Aviva Hills

Based on interviews, record reviews, review of Ohio Administrative Code, review of the Ohio Board of Nursing, and facility policy revealed the facility failed to ensure licensed practical nurses functioned within their professional capacity and qualified staff pronounced resident deaths. This affected three residents residents (#67, #68, and #69) of three residents reviewed for death.

Findings included:

1. Review of the closed medication record for Resident #67 revealed an admission date of 06/30/25 and date of expiration of 11/02/25. Resident #67's diagnoses included but were not limited to metabolic encephalopathy, cognitive communication deficit, and hypertension.

Review of the 30 day Assessment dated 07/31/25 revealed Resident #67 had intact cognition.

Review of the progress note dated 11/02/25 at 10:14 A.M. authored by Licensed Practical Nurse (LPN) #258 revealed at approximately 7:00 A.M. nursing staff went in to Resident #67's apartment to check her blood sugar. Resident #67 was found to be without pulse or respirations and confirmed by two nurses.

Interview on 02/04/26 at P.M. via phone with Medication Aide (MA) #225 revealed they went into Resident #67's room to obtain her blood sugar and felt the resident might be dead. MA #225 immediately contact Licensed Practical Nurse (LPN) #216.

Interview on 02/03/26 at 8:54 A.M. with LPN#258 confirmed he pronounced death of Resident #67 with LPN #216. He confirmed two LPN'S confirmed all deaths in the facility.

Interview on 02/04/26 at 10:11 A.M. with LPN #216 revealed two LPNs pronounce resident deaths in the facility. LPN #216 revealed facility only has LPNs, and she pronounced death of Resident #67 with LPN #258.

Interview on 02/04/26 at 11:32 A.M. with DON confirmed LPNs pronounce death in facility with two LPNs. DON unable to provide policies or documentation permitting LPNs to pronounce death in the facility. DON confirmed no registered nurses (RNs) work in the facility.

Interview on 02/05/26 at 9:58 A.M. with LPN #213 confirmed two LPNs pronounce resident deaths, and the resident's deceased body does not leave the facility until two LPNs pronounce the death.

Interview on 02/05/26 at 10:03 A.M. with LPN #211 confirmed two LPNs pronounce resident deaths, and the resident deceased body does not leave the facility until two LPNs pronounce the death.

Review of facility policy, Resident Accident, Injury, or Acute Illness, 07/03/24, revealed in the event of a death if under hospice provider to call emergency number for hospice and notify them resident is exhibiting no apparent signs of life. Follow the instructions of the hospice Provider. If the resident is not under the care of hospice provider, call 911 and report there is a resident in the community who is exhibiting no apparent signs of life. Notify the physician, nurse practitioner, hospice, Executive Director, and Resident Care Director of the situation. The policy did not identify the qualifications of staff required to pronounce resident death.

Review of the Ohio Administrative Code/Rule 4731-14-01, revealed the following, Pronouncement of death, revealed only a person holding one of the following current certificates or licenses may pronounce a person dead: certificate to practice medicine, surgery, or osteopathic medicine, certified nurse practitioner or clinical nurse specialist, registered nurse, physician assistant, or podiatric medicine and surgery. A physician holding a current certificate to practice medicine or surgery or osteopathic medicine and surgery issued under section 4731.14 of the Revised Code may pronounce a person dead without personally examining the body of the deceased only if a competent observer has recited the facts of the deceased's present medical condition to the physician and the physician is satisfied that death has occurred. An competent observer shall mean one of the following: licensed practical nurse, EMT-Basic, EMT-Intermediate, EMT-paramedic, chiropractor, or coroner's investigator.

Review of the Ohio Board of Nursing list the following who can pronounce death in an assisted living facility to include the following professionals, certified nurse practitioners, clinical nurse specialist, and registered nurses.

2. Review of the closed medical record for Resident #68 revealed an admission date of 08/28/23 and a discharge date of 10/30/25 with diagnoses including but not limited to dementia, senile, depression and irritable bowel syndrome. Resident #68 received hospice services.

Review of the 09/10/25 Semi-Annual Assessment dated 09/10/25 revealed Resident #68 had moderate impairment and is disoriented.

Review of the progress note dated 10/30/25 at 10:14 A.M., authored by DON, revealed at 8:45 P.M. DON called to resident room and found without vitals at this time, family at bedside. Hospice was called at 8:53 P.M. and message was left. Funeral home was called at 9:02 P.M. Funeral home picked up body at 9:40 P.M. Hospice has not called back.

Interview on 02/04/26 at 11:32 A.M. with DON confirmed LPNs pronounce death in facility with two LPNs. DON confirmed on 10/30/25 Resident #68 passed away and did not have two LPNs pronounce death and Resident #68's body left the facility without two LPNs pronouncing death. DON confirmed no registered nurses (RNs) work in the facility.

Interview on 02/05/26 at 9:58 A.M. with LPN #213 confirmed two LPNs pronounce resident deaths, and the resident's deceased body does not leave the facility until two LPNs pronounce the death.

Interview on 02/05/26 at 10:03 A.M. with LPN #211 confirmed two LPNs pronounce resident deaths, and the resident deceased body does not leave the facility until two LPNs pronounce the death.

Review of facility policy, Resident Accident, Injury, or Acute Illness, 07/03/24, revealed in the event of a death if under hospice provider to call emergency number for hospice and notify them resident is exhibiting no apparent signs of life. Follow the instructions of the hospice Provider. If the resident is not under the care of hospice provider, call 911 and report there is a resident in the community who is exhibiting no apparent signs of life. Notify the physician, nurse practitioner, hospice, Executive Director, and Resident Care Director of the situation.

Review of the Ohio Administrative Code/Rule 4731-14-01, revealed the following, Pronouncement of death, revealed only a person holding one of the following current certificates or licenses may pronounce a person dead: certificate to practice medicine, surgery, or osteopathic medicine, certified nurse practitioner or clinical nurse specialist, registered nurse, physician assistant, or podiatric medicine and surgery. A physician holding a current certificate to practice medicine or surgery or osteopathic medicine and surgery issued under section 4731.14 of the Revised Code may pronounce a person dead without personally examining the body of the deceased only if a competent observer has recited the facts of the deceased's present medical condition to the physician and the physician is satisfied that death has occurred. An competent observer shall mean one of the following: licensed practical nurse, EMT-Basic, EMT-Intermediate, EMT-paramedic, chiropractor, or coroner's investigator.

Review of the Ohio Board of Nursing list the following who can pronounce death in an assisted living facility to include the following professionals, certified nurse practitioners, clinical nurse specialist, and registered nurses.

3. Review of the closed medical record for Resident #69 revealed an admission date of 04/07/25 with diagnoses including end stage renal disease. Resident #69 received hospice services and expired on 11/13/25.

Review of the 11/05/25 Semi-Annual Assessment revealed Resident #69 was alert to person and time with moderate impairment with occasionally disorientation..

Review of the late entry progress note dated 11/14/25 at 6:34 A.M., authored by LPN #213, revealed Resident #69's family stated he may not be breathing. LPN #213 assessed Resident #69 with no signs of life and had another nurse come to room to confirm. Hospice, physician, and management made aware.

Interview on 02/04/26 at 11:32 A.M. with DON confirmed LPNs pronounce death in facility with two LPNs. DON unable to provide policies or documentation permitting LPNs to pronounce death in the facility. DON confirmed no registered nurses (RNs) work in the facility.

Interview on 02/05/26 at 9:58 A.M. with LPN #213 confirmed two LPNs pronounce resident deaths, and the resident's deceased body does not leave the facility until two LPNs pronounce the death.

Interview on 02/05/26 at 10:03 A.M. with LPN #211 confirmed two LPNs pronounce resident deaths, and the resident deceased body does not leave the facility until two LPNs pronounce the death.

Review of facility policy, Resident Accident, Injury, or Acute Illness, 07/03/24, revealed in the event of a death if under hospice provider to call emergency number for hospice and notify them resident is exhibiting no apparent signs of life. Follow the instructions of the hospice Provider. If the resident is not under the care of hospice provider, call 911 and report there is a resident in the community who is exhibiting no apparent signs of life. Notify the physician, nurse practitioner, hospice, Executive Director, and Resident Care Director of the situation.

Review of the Ohio Administrative Code/Rule 4731-14-01, revealed the following, Pronouncement of death, revealed only a person holding one of the following current certificates or licenses may pronounce a person dead: certificate to practice medicine, surgery, or osteopathic medicine, certified nurse practitioner or clinical nurse specialist, registered nurse, physician assistant, or podiatric medicine and surgery. A physician holding a current certificate to practice medicine or surgery or osteopathic medicine and surgery issued under section 4731.14 of the Revised Code may pronounce a person dead without personally examining the body of the deceased only if a competent observer has recited the facts of the deceased's present medical condition to the physician and the physician is satisfied that death has occurred. An competent observer shall mean one of the following: licensed practical nurse, EMT-Basic, EMT-Intermediate, EMT-paramedic, chiropractor, or coroner's investigator.

Review of the Ohio Board of Nursing list the following who can pronounce death in an assisted living facility to include the following professionals, certified nurse practitioners, clinical nurse specialist, and registered nurses.

This violation represents non-compliance investigated under Complaint Number OH00168906.

Based on record review, interview, and facility policy review, the facility failed to properly monitor and assess Resident #67 after a change in condition. This affected one resident (#67) out of three residents reviewed for change in condition. Facility census was 66.

Findings included:

1. Review of the closed medication record for Resident #67 revealed an admission date of 06/30/25 with diagnoses including but not limited to metabolic encephalopathy, cognitive communication deficit, and hypertension. Resident #67 expired on 11/02/25.

Review of the 30 day Assessment dated 07/31/25 revealed Resident #67 had intact cognition.

Review of the untitled document for care plan, revealed a document with Resident #67's picture and on the top of form with basic information to include, allergy, code status, room number, resident name, devices to include walker and eyeglasses, shower days: 6-2 Sunday and Wednesday, Activities of Daily Living (ADL's) remind to set up assist with showers, Incontinence supplies: Family Provides. The remainder of the form included the Month of and blank space, and then the remainder of the form is set up by shift 1, shift 2, and shift 3 with dates and initials. The form and resident's medical record did not contain and individualized comprehensive care plan to address the resident's medical and psychosocial needs.

Review of the progress note dated 10/31/25 at 10:58 A.M. authored by Director of Nursing (DON), revealed the resident had low blood sugar last night of 78 and was given orange juice and peanut butter and medications without difficulty. Morning blood sugar was 43 and Resident stated she didn't feel well. She was given a snack and took her medications without difficulty. Resident #67 had an emesis, and vital signs were within normal limits. Nurse practitioner (NP) was notified and no new orders at this time.

Review of the progress note dated 10/31/25 at 11:24 A.M., authored by DON, revealed a new order from NP to decrease insulin to 30 units at bedtime (HS).

Review of the progress note dated 11/01/25 at 12:33 P.M. authored by Licensed Practical Nurse (LPN) #216 revealed Medication Technician (Med Tech) #217 notified LPN #213 Resident #67's blood sugar (BS) before lunch was 65. She stated the morning BS was 49 and Resident was given juice and peanut butter crackers. Med Tech #217 stated resident has an emesis x 1 and she had complaint of a sore throat. LPN #213 went in to see Resident #67 who stated she did have one emesis but her stomach does not feel upset. She complained of a sore throat. Vital signs were blood pressure (BP) 120/79, pulse (P) 93, temperature (T) 97.2. LPN #213 reported she would leave a note for the physician to assess the sore throat with concerns of her BS readings. LPN gave Resident #67 four (4) packs of regular saltine crackers and advised her to try to snack on those. Resident #67 also stated she will make some hot tea to help her throat. LPN #213 advised Med Tech #217 to give resident some as needed Tylenol to help with the throat pain for now. Resident #67 stated her son is going to bring her some soup.

Review of the progress noted dated 11/01/25 at 1:59 P.M. revealed Med Tech #217 informed LPN #213 Resident #67 had another emesis and as needed (PRN) Zofran was given per standing orders. Resident's son brought in cloraseptic throat lozenges and resident did take one.

Review of the progress note dated 11/01/25 at 5:38 P.M. authored by LPN #213 revealed Resident #67 called nurse to her room with complaints of not feeling well. She complained of tired and sore throat. BS was 131. BP: 99/60, P: 99, and T 97.5. Resident #67 was given evening medications and she was unable to swallow them and she coughed and spit them out. LPN #213 phone NP#277 and was instructed by NP to ask Resident #67 if she wanted to go the Emergency Room (ER). If resident didn't want to go to the ER then give Tylneol 650 milligram (MG) PRN and throat lozenges. NP #277 stated she feels it could be a reaction to the Covid vaccine she received last week. Resident #67 did not want to go to the ER so the Med Tech #225 will give her Tylenol 650 MG whole in applesauce to see if she would be able to swallow them and then give her a throat lozenge.

Review of the blood sugar reading for 11/01/25 at 7:29 P.M. revealed Resident #67's blood sugar was 183 and she was administered her insulin, from the physician order of Toujeo 300 units/ml pen injector inject 30 units sq every night at bedtime.

Review of Resident #67's medical record after the resident declined to go to the hospital revealed no evidence the resident's change in condition was further assessed or monitored.

Review of the progress note dated 11/02/25 at 10:14 A.M. authored by Licensed Practical Nurse (LPN) #258 revealed at approximately 7:00 A.M. nursing staff went into Resident #67's apartment to check her blood sugar. Resident found to be without pulse or respirations and confirmed deceased by two nurses.

Interview on 02/04/26 at 10:35 A.M. with LPN #200 revealed she worked on 11/01/25 from 6:00 P.M. to 6:00 A.M., saw Resident #67 beginning of shift then peeked in around 4:00 A.M. in her room and reported she was sleeping and alive because she heard her breathing. LPN #200 reported she did not document this.

Interview on 02/04/26 at 11:56 A.M. via phone with Medication Aide (MA) #225 revealed they went into Resident #67's room to obtain her blood sugar in the morning and felt the resident might be dead. MA #225 immediately contacted LPN #216.

Interview on 02/05/26 at 12:23 with DON revealed staff do need to round every two hours on Resident #67 who is independent in her care. DON revealed independent residents with change in condition staff are not expected to round on them throughout the day or night. DON confirmed care plans are in a binder and aides use them to initial care was provided, but they are not comprehensive or individualized.

Interview on 02/09/26 at 8:01 A.M. with NP #277, who was notified on 11/01/25 of Resident #67's change in condition, confirmed for a resident not feeling well, she would have given an order to monitor the resident and call with any changes.

Interview on 02/09/26 at 9:04 A.M. with NP #276 confirmed for a change in condition, even for independent residents, if a resident isn't feeling well it is reasonable expectation of staff to monitor and check on them throughout the night.

Interview on 02/09/26 at 9:05 A.M. with Resident #67's son revealed he was concerned on the day she passed away. Resident #67's son reported when he was there was told her BS was high and she was throwing up and couldn't keep anything down. Resident #67's son reported he asked the nurse to test for strep and she said she would put it on the physician list.

Interview on 02/09/26 at 1:44 P.M. with Care Giver (CG) #237 revealed she worked the night shift on 11/01/25 to 11/02/25 from 10:00 P.M. to 6:00 A.M. and she did not check on Resident #67 through her shift because she was not aware she had a change in condition.

Interview on 02/10/26 at 1:33 P.M. with Med Tech #217 confirmed she worked 11/01/25 and 11/02/25 from 4:00 P.M. to 10:00 P.M. Med Tech #217 revealed Resident #67 wasn't feeling good, and didn't look good and she notified LPN #200. Med Tech #217 reported Med Tech's administer medications and that was all.

Review of facility policy, Resident Accident, Injury, or Acute Illness, 07/03/24, revealed it is the policy to respond to all residents' accidents, injuries, or acute illnesses promptly. The policy addressed accidents or injuries that require emergency treatment and death. The policy doesn't address a change in condition.

Review of the policy, Resident Evaluations and Service Plans, revised 08/14/2024, revealed Service Plans/Care Plans, the following completion of an evaluation, the Resident Care Director/designee shall develop the plan ensuring it includes the following, services offered to the individual resident to be appropriate to scope, frequency, need, and preference of the resident, and will list who is responsible for completing each service, service offered shall be reviewed and revised as appropriate and discussed by the resident and community as needs or desires change, the agreed upon service plan shall be signed and dated by resident or resident POA, and administration of medications or provision of residential nursing services or both is needed, a licensed nurse shall be involved in identification and documentation of the services provided.

Review of the Resident Risk Agreement, undated, revealed under B - Assessment, letter F Resident Service Plan, an individualized service plan will be developed based on resident interview, physician's report and mental health screening.

This violation represents non-compliance investigated under Complaint Number OH00168906.

Based on record review, interviews, and facility policy, the facility failed to timely report and thoroughly investigate and allegation of abuse to ensure Resident #59 was free from abuse. This affected one (Resident #59) of three residents reviewed for abuse. The facility census was 66.

Findings included:

Review of medical record for Resident #59 revealed an admission date of 4/21/25 with diagnoses including but not limited to Parkinson's disease and neurocognitive disorder with lewy bodies.

Review of the 04/21/25 admission assessment revealed Resident #59 had severe impaired cognition.

Review of the investigation provided by Director of Nursing (DON) revealed a timeline to include on 11/22/25 three witness statements were collected related to an allegation of a family member abusing Resident #59. On 11/24/25 an investigation was started. The investigation included only three witness statements.

Interview on 02/02/26 at 9:02 A.M. with Certified Nursing Assistant (CNA) #236 revealed she witnessed Resident #59's daughter potentially forcibly feeding resident and being verbally abusive. CNA #236 revealed she notified Licensed Practical Nurse (LPN) #273, who was an agency nurse. CNA #236 reported LPN #273 instructed her to write a witness statement regarding what happened. .CNA #236 wrote the witness statement and gave it to LPN #273.

Interview on 02/02/25 at 11:45 A.M. with Administrator revealed an incident of alleged/suspected abuse should be reported immediately and an investigation should start immediately.

Interview on 02/03/26 at 9:44 A.M. with Caregiver (CG) #264 revealed she was instructed to do a witness statement regarding Resident #59's daughter potentially force feeding and being verbally abusive.

Interview on 02/03/26 at 10:13 A.M. with DON revealed she wasn't notified of the alleged abuse allegation towards Resident #59 until Monday 11/24/25 when she came into work and found witness statements in her mailbox. DON confirmed the allegation was not immediately reported to management an investigation was not initiated immediately. DON confirmed a thorough investigation was not completed timely.

Interview on 02/04/26 at 8:42 A.M. with LPN #273, via phone, revealed on 11/22/25 she was notified by several staff members Resident #59's daughter was allegedly physically and verbally abusive to her mother. LPN #273 revealed she contacted the Director of Nursing (DON) via text message on 11/22/25 regarding the alleged abuse and was instructed to get statements and she would take care of it. LPN #273 revealed she had CG's #236, #264 and #266 write statements and put in DON mailbox.

Review of the facility policy, Resident Abuse, revised 7/24/24, revealed right of resident to live in a safe and secure environment free of any type of abuse by staff, volunteers, visitor and other residents. Further states to investigate any alleged abuse to include abuse prevention identification, investigation, resident protection, and reporting. Further states the Executive Director or designee will conduct a thorough and confidential investigation and will immediately contact local police department, the Department of Health/Regulatory Agency/Adult Protective Services as required by state regulation.

This violation represents non-compliance investigated under Complaint Number OH00168956.

Based on record review and interviews, the facility failed to maintain comprehensive care plans and Hospice notes to ensure continuity of care. This affected two Residents (#68 and #69) and had the potential to affect all residents. Facility census was 66.

Findings included:

1. Review of the closed medical record for Resident #68 revealed an admission date of 08/28/23 and a discharge date of 10/30/25. Diagnoses included but were not limited to dementia, senile, depression and irritable bowel syndrome. Resident #68 received Hospice services.

Review of the 09/10/25 Semi-Annual Assessment dated 09/10/25 revealed Resident #68 had moderate impairment and is disoriented.

Review of the closed medical records for Resident #68 revealed no Hospice notes. The facility requested the faxed hospice notes dated 02/04/26 after this surveyor asked for Hospice notes.

Review of the care plan for Resident #68 revealed the plan did not specify the care and services the resident received from Hospice or individualized interventions related to medical and psychosocial needs.

Interview on 2/04/26 at 1:29 P.M. with Director of Nursing (DON) confirmed they do not keep hospice notes or binder at facility. DON reported we are not required to keep these records at the facility. DON reported if hospice sends the notes they will put in resident charts. DON confirmed she requested Hospice notes on Resident #68 after surveyor request.

Interview on 2/04/26 at 2:33 P.M. with Hospice Registered Nurse (RN) #300 revealed there were no hospice notes kept at the facility because facility refused to permit them to keep their hospice binder at facility with communication and hospice notes. Hospice RN #300 reported every other facility permits them to keep their hospice binder with notes at the facility.

Interview on 02/05/26 at 12:23 with DON revealed care plans are located in the binder for aides and confirmed care plans were not comprehensive or individualized.

2. Review of the closed medical record for Resident #69 revealed an admission date of 04/07/25 with diagnoses including end stage renal disease. Resident #69 received Hospice services and expired on 11/13/25.

Review of the 11/05/25 Semi-Annual Assessment revealed Resident #69 was alert to person and time with moderate impairment with occasionally disorientation.

Review of the care plan for Resident #68 revealed the plan did not specify the care and services the resident received from Hospice or individualized interventions related to medical and psychosocial needs.

Interview on 2/04/26 at 1:29 P.M. with DON confirmed they do not keep hospice notes or binder at facility. DON reported we are not required to keep these records at the facility. DON reported if hospice sends the notes they will put in resident charts. DON confirmed she requested Hospice notes on Resident #68 after surveyor request.

Interview on 2/04/26 at 2:33 P.M. with Hospice RN #300 revealed there were no hospice notes kept at the facility because facility refused to permit them to keep their hospice binder at facility with communication and hospice notes. Hospice RN #300 reported every other facility permits them to keep their hospice binder with notes at the facility.

Interview on 02/05/26 at 12:23 with DON revealed care plans are located in the binder for aides and confirmed care plans were not comprehensive or individualized.

Review of the facility policy, Resident Third Parry Services, undated, revealed a planned procedure is in place to require reporting from any agency in order to assure the community is kept appraised of the resident's condition. Further states, any agency providing care for a resident must maintain a communication/treatment record in a binder or folder. This will enable staff to review resident service planned/interventions periodically and assist with improved communication regarding the resident's care and health status.

Review of the policy, Resident Evaluations and Service Plans, revised 08/14/2024, revealed Service Plans/Care Plans, the following completion of an evaluation, the Resident Care Director/designee shall develop the plan ensuring it includes the following, services offered to the individual resident to be appropriate to scope, frequency, need, and preference of the resident, and will list who is responsible for completing each service, service offered shall be reviewed and revised as appropriate and discussed by the resident and community as needs or desires change, the agreed upon service plan shall be signed and dated by resident or resident POA, and administration of medications or provision of residential nursing services or both is needed, a licensed nurse shall be involved in identification and documentation of the services provided.

Review of the Resident Risk Agreement, undated, revealed under B - Assessment, letter F Resident Service Plan, an individualized service plan will be developed based on resident interview, physician's report and mental health screening.

Based on record review, staff interview, review of facility policy and facility Tuberculosis (TB) risk assessment the facility failed to ensure employees had annual TB screenings completed. This had the potential to affect all of the residents residing in the facility. The census was 75 residents.

Findings include:

Review of the personnel files for Licensed Practical Nurse (LPN) #4 and LPN #6 revealed a hire date of 10/17/23 for LPN #4 and a hire date of 04/29/15 for LPN #6. Further review of the files revealed no evidence of an annual TB screening for LPN #4 or LPN #6.

Interview on 10/06/25 at 2:00 P.M. with the Executive Director confirmed the facility had not completed an annual TB screening for LPN #4 and LPN #6.

Review of the facility policy titled TB Testing of Staff dated 12/07/22 revealed each staff person will be screened annually for Tuberculosis using the Tuberculosis Screening Tool unless otherwise specified by state regulations.

Review of the facility TB risk assessment worksheet, Section 3, dated 07/09/25 revealed How frequently are HCW's tested for M. tuberculosis infection? Upon hire- 2 step Mantoux and annual- symptoms screening.

Based on observation, interview, kitchen cleaning schedule review and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 75 residents residing in the facility.

Findings include:

On 10/06/25 at 9:16 A.M. observation of kitchen during the initial tour with Kitchen Director #2 revealed a half of loaf of bread with a best if used by date of 08/11/25, one open bag of spaghetti noodles in the dry food pantry, no open date on the bag. The deep fryer oil had particles of food remnants built up in the four corners and on the sides and the top of the fryer.

Interview with Kitchen Director #2 stated the oil is changed every 2-3 weeks or when it looks dark and there is no set cleaning schedule and verified the bread should have been thrown out and the spaghetti noodles should have been sealed and dated.

Review of facility policy titled Food Receiving and Storage dated 02/20/24 revealed food is stored under sanitary conditions and away from the risk of contamination and food is labeled according to date marking guidelines.

This violation is a recite to annual survey completed 12/05/24.

Based on record review and interview, the facility failed to ensure a menu substitution log was maintained. This had the potential to affect all 75 residents residing in the facility.

Findings include:

Record review of the kitchens menu substitution logs revealed no documented evidence that a food substitution log was available prior to the month of September 2025.

Interview on 10/06/25 at 10:30 A.M. with Kitchen Director #2 verified the facility did not keep track of substitutions from the menu.

This violation is a recite to annual survey completed 12/05/24.

Based on medical record review, review of accounts, review of a police department request, review of internal facility memos, policy review and interview, the facility failed to adhere to their Abuse policy regarding allegations of misappropriation of residents' money. This affected two (Residents #47 and #58) of three residents reviewed for misappropriation.

Findings include:

1. Review of Resident #47's medical record revealed diagnoses including hypertension, depression and hyperthyroidism. A Health and Service Evaluation dated 03/19/25 indicated Resident #47 was oriented to person, place, time and situation. Resident #47 did not have current or history of issues with exploitation. Resident #47 did not require assistance with ambulation, transferring, bathing, grooming/hygiene, dressing, toileting, meal consumption, or medication administration. Staff completed all housekeeping tasks.

A memo dated 01/06/25 at 9:00 A.M. indicated Jackson Police department was called to report Resident #47's missing money. The memo indicated Resident #47 stated $600.00 was missing from her room on Christmas Eve. The money would be refunded.

On 07/22/25 at 9:55 A.M., Resident #47 stated she had $600.00 taken from her apartment around Christmas and stated she knew other residents who also had money taken but would not provide names. Resident #47 stated the money was never found but she was given a $600.00 credit on her bill. Resident #47 stated with all the cameras in the facility she did not understand why the facility could not determine who was responsible.

On 07/22/25 at 10:36 A.M., the Executive Director verified there was no reason for the facility to doubt Resident #47's claims of missing money because she was alert and oriented. The Executive Director provided account information indicating $600.00 was credited to Resident #47's account on 01/07/25. The Executive Director reported Resident #58 had also reported missing money which was unable to be located and was credited to his account. Resident #58 was also alert and oriented. Although the facility did have cameras, residents were unable to state with certainty when they last saw the money to narrow the time frame.

2. Review of Resident #58's medical record revealed diagnoses including malignant melanoma of the scalp and neck, generalized muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, sleep apnea, heart disease, chronic kidney disease, congestive heart failure, chronic atrial fibrillation, presence of prosthetic heart valve, chronic peripheral venous insufficiency, hypertension, hyperlipidemia, glaucoma, history of malignant neoplasm of the large intestine and constipation. A Health and Service Evaluation dated 04/02/25 indicated Resident #58 was alert and oriented to person, place, time and situation. Resident #58 used eyeglasses. Resident #58 was independent with mobility, bathing, hygiene/grooming, dressing, toileting, meal consumption, medication administration and housekeeping. Resident #58 needed verbal cues during transfers.

A memo dated 01/02/25 at 8:00 A.M. indicated Resident #58 reported he had $260.00 missing from his room.

On 07/22/25 at 11:05 A.M., the Executive Director stated Resident #58 was unable to state when he last saw the money. Locks to residents' doors were digital but when reports were read it was determined if someone with a key was within 6-8 room range of a particular resident's room it registered on the report for all residents although the key only unlocked one individual room so it was difficult to determine who was in a particular room at any given time.

On 07/22/25 at 11:57 A.M., the Executive Director reported she was unable to locate a comprehensive investigation into allegations of stolen money for Residents #47 or #58. The Executive Director stated she requested a police report regarding Resident #47 on 07/22/25 but was told it could take two days to provide but did provide a request (undated) from the police department requesting video recordings as available evidence in a crime committed on 12/22/24 to 12/24/24. The Executive Director verified she was unable to locate any investigation completed for Resident #47 or #58 regarding allegations of stolen money. The Executive Director acknowledged no Facility Reported Incident was filed with the State Survey Agency. The Executive Director stated during the time frame when the residents reported the missing money the facility had multiple agency staff working, some would only work one day and it was difficult to interview those agency staff.

Review of the facility's Resident Abuse policy (dated 01/22/21) indicated it was the policy of the facility to ensure misappropriation of personal property did not occur. Exploitation was defined as use of a resident or their belongings for personal gain. Misappropriation was defined as the intentional and unauthorized use of someone else's funds, property or resources for one's own personal gain or benefit. Financial misappropriation was further described as illegally using or diverting funds entrusted to one's care, such as misuse of resident checks or debit/credit cards or misusing a resident's bank accounts. Upon witnessing or hearing a report of complaints of an act of misappropriation, staff were required to immediately report the allegation to the executive director and/or supervisor who would follow State specific reporting requirements. The Executive Director and/or designee would immediately contact the local police department and the Department of Health/Regulatory Agency/Adult Protective Services as required. The Executive Director and/or designee were responsible for conducting an investigation by obtaining statements from the alleged victim, the alleged perpetrator(s), the person making the report and any and all witnesses involved, including those who might have information from before and after the alleged occurrence. The investigation contents were to be maintained confidentially and securely in the Executive Director's office.

This violation represents non-compliance investigated under Complaint Number OH00166310.