Deer Creek Lodge

Based on review of personnel files and staff interview, the facility failed to request a criminal background check on a newly hired employee not later than five business days after the individual began conditional employment. This had the potential to affect all 102 residents residing in the facility. The facility census was 102.

Findings Include:

Review of the personnel file for Dietary Manager (DM) #504 revealed a hire date of 10/27/25. Further review of the personnel file revealed no evidence of any completion of a criminal background check completed as required.

Interview with the Executive Director (ED) on 04/14/26 at 9:33 A.M. verified no evidence of a background criminal background check was present in DM #504's personnel file.

This deficiency represents non-compliance investigated under Master Complaint Number OH00170272.

Based on review of the facility background check log and staff interview, the facility failed to ensure the criminal background check log contained all required information. This had the potential to affect all 102 residents residing in the facility. The facility census was 102.

Findings Include:

Review of the facility criminal background check log revealed the log did not contain information regarding the type of background check (Bureau of Criminal Identification and Investigation (BCII) or Federal Bureau of Investigation (FBI) performed on perspective applicants.

Interview with the Executive Director (ED) on 04/14/26 at 9:33 A.M. verified the facility criminal background check log did not contain information regarding the type of background check (BCII or FBI) performed on perspective applicants as required.

This deficiency represents an incidental finding investigated under Master Complaint Number OH00170272 and continued non-compliance from the annual survey dated 07/29/25.

Based on review of personnel files, staff interview, and policy review, the facility failed to ensure employees were screened for findings of abuse, neglect, or misappropriation through the state nurse aide registry as required. This had the potential to affect all 102 residents residing in the facility. The facility census was 102.

Findings Include:

Review of the personnel files for Dietary Aide (DA) #500, DA #501, Receptionist #503, Dietary Manager (DM) #504, and the Executive Director (ED) revealed no evidence any of the employees were reviewed for findings of abuse or neglect of a resident or misappropriation of resident property through the state nurse aide registry.

Interview with the ED on 04/13/26 at 2:10 P.M. verified DA #500, DA #501, Receptionist #503, DM #504, and the ED were not reviewed for findings through the state nurse aide registry.

Review of the undated policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property

Based on the review of facility records, and staff interview, the facility failed to ensure the maintenance of an applicant or employee criminal record log to verify when checks where sent and results were received from the Bureau of Criminal Identification and Investigation (BCII) and or the Federal Bureau of Investigation (FBI). This had the potential to affect all 93 residents residing in the facility. The facility census was 93.

Findings include:

Requested facility records on 07/28/25 at approximately 8:30 A.M., 11:30 A.M., and 3:00 P.M. revealed there was no applicant criminal record verification log maintained by the facility separate from the personnel file.

Interview of the Executive Director (ED) on 07/28/25 at 11:30 A.M., revealed the facility does not keep a log of criminal records check requests sent to BCII or the FBI for the assisted living facility location.

Interview of the Director of Human Resources (DHR) #689 on 07/29/25 at 11:30 A.M. confirmed facility does not maintain a log of applicant or employee BCII and FBI information.

Based on the review of the facility personnel records, and staff interview, the facility failed to ensure physical examinations were completed for new employees. This affected two of eight employee files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 93.

Findings include:

Review of the facility personnel record on 07/29/25 at approximately 9:40 A.M. for Licensed Practice Nurse (LPN) #682 revealed no evidence of a physical examination. LPN #682 was hired on 07/03/25.

Review of the facility personnel record for Cook (CK) #624, revealed no evidence of physical examination. CK #624 was hired on 03/25/25.

Interview with the Director of Human Resources (DHR) #689 and the Human Resource Assistant (HRA) #690, at the time of the record review confirmed neither LPN #682 or CK #624 had a pre-employment physical examination completed.

Based on review of the personnel records, and staff interview, the facility failed to complete the verification of a current Ohio nursing license. This affected one of one employee files with a license. This had the potential to affect all residents residing in the facility. The facility census was 93.

Findings include:

Review of the facility personnel file on 07/29/25 at approximately 10:52 A.M. for Licensed Practical Nurse (LPN) #682 revealed a hire date of 07/03/25. There was no record of verification of an active Ohio nursing license in the file for LPN #682.

Interview with the Director of Human Resources (DHR) #689 at the time of the observation verified a licensure check had not been completed for LPN #682.

Based on review of facility records, and staff interview, the facility failed to ensure checks were completed and responses were received from the Ohio Sex Offender Registry prior to the admission of a new resident. This affected two (#418 and #468) of five resident records reviewed. This had the potential to affect all 93 residents residing in the facility. The facility census was 93.

Findings include:

Review of the resident medical record for Resident #418 revealed an admission date of 08/26/24. The medical record contained a signed consent for the Ohio Sex Offender Registry check, however, the medical record contained no evidence that the Ohio Sex Offender Registry was checked prior to Resident #418's admission.

Review of the resident medical record for Resident #468 revealed an admission date of 06/02/25. The medical record contained a signed consent for the Ohio Sex Offender Registry check, however, the medical record contained no evidence that the Ohio Sex Offender Registry was checked prior to Resident #468's admission.

Review of the facility's Ohio Sex Offender binder for all admitted residents revealed no evidence of a check being completed for either Resident #418 or #468.

Interview on 07/29/25 with the Sales and Admissions Director (ADM) #688 verified the facility did not conduct a check with the Ohio Sex Offender list for either Resident #418 and #468 prior to their admission.

Based on record review, and staff interview, the facility failed to conduct monthly fire drills, failed to conduct resident evacuations, and failed to confirm with monitoring company the transmitted fire alarm signal was received. This had the potential to affect 93 residents. The facility census was 93.

Findings include:

Record review conducted on 07/28/25 at 10:30 A.M. of the facility fire drills revealed fire drills were conducted on 08/28/24, 09/30/24, 11/24/24, 12/30/24, 01/20/25, 02/25/25, 03/03/25, 04/09/25 and 05/25/25. Further review of the fire drills revealed residents were not evacuated from the alarmed area, and the facility did not document the signal was received from the monitoring company for any of the drills completed.

Interview with the Administrator on 07/28/25 at 11:20 A.M. confirmed the facility did not complete fire drills in October 2024 or June of 2025. The Administer also verified no resident evacuations occurred with any of the fire drills conducted in the last year and further verified the facility had no documentation of the monitoring company receiving the transmitted signal.

Based on record review, and staff interview, the facility failed to conduct a tornado drill between the months of March 2025 to July of 2025, as required. This had the potential to affected all residents. The facility census was 93.

Findings include:

Record review conducted on 07/29/25 at 1:45 P.M. revealed that the facility did not conduct the required tornado disaster preparedness drill between the months of March 2025 and July 2025.

Interview with the Administrator on 07/29/25 at 2 P.M. confirmed a tornado drill had not been completed.

Based on record review, and staff interview, the facility failed to conducted monthly fire inspections. This had the potential to affected 93 residents. The facility census was 93.

Findings include:

Review on 07/29/2025 at 1:50 P.M. of the facilities monthly fire safety self inspection form revealed the facility did not conducted the monthly fire inspections.

Interview with Administrator on 07/29/2025 at 2 P.M. confirmed that the monthly inspections were not completed.

Based on record review, and staff interview, the facility failed to maintain a valid transfer agreement. This had the potential to affect 93 residents. The facility census was 93.

Findings include:

Review of the facility's current active transfer agreement on 07/29/25 at 8:50 A.M. revealed the facility transfer agreement listed facilities that no longer exist in the area.

Interview with the Administrator on 07/29/25 at 8:55 A.M. confirmed that the transfer agreement had names of buildings that no longer existed. At 8:56 A.M. Administrator indicated she was working on getting an updated transfer agreement.

Based on medical record review, review of the facility Self-Reported Incident (SRI), staff and resident interviews and police report the facility failed to ensure residents were free from misappropriation and allegations of misappropriation were thoroughly investigation. This affected seven residents (#15, #55, #56, #78, #90, #91 and #92) of seven residents reviewed for misappropriation. This had the potential to affect all 96 residents residing in the facility.

Findings include:

Review of the facility Self-Reported Incident (SRI) dated 03/21/25 revealed the daughter of Residents #55 and #56 contacted the facility on 03/17/25 around 11:45 A.M. stating someone was in their apartment who they did not know. The facility contacted the local police and obtained statements from staff and any witnesses. Residents #55 and #56's daughter sent a video from an in-room camera showing the unknown person in the room. The video was shared with the Administrator who identified the unknown individual as Housekeeper #308. Housekeeper #308 was not scheduled to clean that room, and upon investigation, was found to have $2312 in her possession which was confiscated by the police. The facility terminated Housekeeper #308, and she was taken into police custody on 03/17/25 around 3:45 P.M. It was later found that Housekeeper #308 was charged with theft. The facility SRI listed the staff notified residents of the allegation of theft in the facility. Residents were reminded to lock the door of their apartment when not inside and keep valuable belongings safe.

Review of the witness statement dated 03/17/25 from the Director of Nursing (DON) revealed an unidentified private caregiver for Residents #55 and #56 notified the DON that a staff member had stolen money from her. The private caregiver had reported there was a camera in the room and Resident #55 and #56's daughter emailed the video to the DON. When asked if she could identify the staff member, the caregiver discreetly identified the staff member as Housekeeper #308, who was seated near facility mailboxes. The DON then asked the Housekeeper #308 to come to an office and sit. The DON then went to view the video. After viewing the video, the DON went to the housekeeper's closet and found a purse/lunchbox on the shelf with money sticking out of it. The DON alerted the Administrator who called the police. The DON and Administrator briefed the police on the situation upon their arrival. The DON began gathering staff statements.

Upon further investigation, the facility identified seven total residents (#15, #55, #56, #78, #90, #91, and #92) were affected by the misappropriation.

1. Review of the medical record for Resident #15 revealed an admission date of 08/08/21. Diagnoses included but were not limited to gastro-esophageal reflux disease, hypertension and osteoarthritis.

Review of the Assessment for Assisted Living dated 08/26/24 for Resident #15 revealed she was oriented to person and was noted to have short- and long-term memory issues. Resident #15 was noted to be independent with activities of daily living (ADLs) and used a cane or walker for mobility.

2. Review of the medical record for Resident #55 revealed an admission date of 08/29/22. Diagnoses included but were not limited to atrial fibrillation, osteoporosis, and hypercholesterolemia.

Review of the Assessment for Assisted Living dated 08/26/24 for Resident #55 revealed he was alert to person, place and time and was independent for ADLs.

3. Review of the medical record for Resident #56 revealed an admission date of 08/29/22. Diagnoses included but were not limited to hypertension, mild cognitive impairment, and osteoporosis.

Review of the Assessment for Assisted Living dated 08/16/24 for Resident #56 revealed the resident was alert to person, place and time with no noted memory issues. Resident #56 required supervision and transfer assistance for toileting, mobility, and dressing. Resident #56 required complete assistance with bathing.

4. Review of the medical record for Resident #78 revealed an admission date of 07/07/21. Diagnoses included but were not limited to atrial fibrillation, chronic kidney disease and type I diabetes mellitus.

Review of the Assessment for Assisted Living dated 08/01/24 for Resident #78 revealed he was oriented to person, place and time and was independent for ADLs.

5. Review of the medical record for Resident #90 revealed an admission date of 07/19/23. Diagnoses included but were not limited to anxiety, depression and pulmonary hypertension.

Review of the Assessment for Assisted Living dated 07/25/24 for Resident #90 revealed the resident was alert to person, place and time and was independent for ADLs.

6. Review of the medical record for Resident #91 revealed an admission date of 07/19/23. Diagnoses included but were not limited to hypertension, osteoarthritis and macular degeneration.

Review of the Assessment for Assisted Living dated 07/25/24 for Resident #91 revealed he was alert to person, place and time and was independent for ADLs.

7. Review of the medical record for Resident #92 revealed an admission date of 03/29/24. Diagnoses included but were not limited to hypertension, hypothyroidism and history of breast cancer.

Review of the Senior Living Assessment dated 03/29/24 for Resident #92 revealed she was alert to person, place and time and was independent for ADLs.

Review of the witness statement dated 03/17/25 from Private Caregiver (PC) #301 revealed Housekeeper #308 came around Resident #15's room 9:30 A.M. asking if she could clean the room on Tuesday or Wednesday. PC #301 stated she left the room on 03/17/25 at approximately 1:15 P.M. on 03/11/25 and then realized she was missing $20. When she returned to Resident #15's room later that day, she realized Resident #15 was additionally missing $45 from her purse. PC #301 stated she reported the missing money to the facility's security guard.

Review of the witness statement from Resident #92 dated 03/23/25 revealed on 03/20/25 after being told about the robbery, Resident #92 checked her wallet and discovered she was missing $60 from her wallet. She also checked her second money storage spot and realized there was an additional $100 missing, so she was missing a total of $160.

Review of the undated witness statement from PC #307 revealed Housekeeper #308 was in Resident #93's room without permission on 03/10/25 and 03/13/25. PC #307 stated she observed Housekeeper #308 outside the resident's room in the hallway with no cleaning supplies. PC #307 recalled she had seen Housekeeper #308 multiple times on other floors with no cleaning supplies, just standing around.

Review of the undated witness statement from PC #300 revealed she and Residents #55 and #56 left their apartment on 03/17/25 at 10:20 A.M. to go to an appointment. PC #300 stated she left her purse in the walk-in closet on the top shelf in the apartment before leaving. Upon return, she noted she had missing money from her purse. The amount missing was $300.

Review of the Resident Concern Log for March 2025 revealed on 03/17/25 Resident #93's aide felt someone had been in the apartment without permission. The resolution was listed that the facility permission list revealed no entry is allowed without resident present. No additional listings were found related to the additional residents who reported stolen money.

Interview on 04/09/25 at 2:41 P.M. with PC #300 recalled two days prior to the incident, Housekeeper #308 came to the room of Residents #55 and #56 and stated she was checking to see if residents lived in the room as she was supposed to clean them if they were vacant. PC #300 stated she was out of the facility on 03/17/25 for an appointment with Residents #55 and #56. Upon their return, PC #300 stated Resident #55 and #56's daughter called her about seeing someone in their room on the video camera. PC #300 checked her purse and noted she was missing $300 out of her purse.

Interview on 04/09/25 at 3:08 P.M. with PC #302 revealed she and Resident #15 were out of Resident #15's room from on 03/17/25 at 10:50 A.M. till 1:00 P.M. When they returned at 1:00 P.M., PC #302 left to go help Resident #65. PC #302 went to get something out of her purse and noticed $20 missing. Upon checking again with Resident #15, it was noted that Resident #15 was also missing $45 from her purse. Private Caregiver #302 went down to security and reported the missing money.

Interview on 04/09/25 at 3:21 P.M. with Resident #90 and #91 revealed they were told by other residents about the robbery and after checking their belongings, they noticed they had money missing. Resident #90 stated the facility did not send an email or letter to residents about the incident, they had only heard it from other residents. Resident #90 stated the Administrator announced it at a meeting on 03/21/25 but they had already heard it from other residents. Resident #90 stated about $450 was in a money clip in his top drawer of his nightstand. Resident #90 reported the missing money to the Administrator on 03/17/25. Resident #90 stated they had been out of their room from approximately 6:00 P.M. until 9:00 P.M. on 3/13/25 and 03/14/25 prior to the discovery of missing money.

Interview on 04/09/25 at 3:49 P.M. with Resident #92 revealed that while she was in the second-floor lobby, an unidentified caregiver told her some residents were missing some money. Resident #92 checked her purse which was sitting on her bookcase in her room and found $50 was missing. Resident #92 went to the receptionist who informed her the Administrator was not in his office. Resident #92 wrote a statement and gave it to the Administrator the following day.

Interview on 04/09/25 at 4:13 P.M. with the Administrator and DON revealed the DON was told by PC #300 that a staff member stole money from her. Resident #55 and #56's daughter sent a video from their room camera and after viewing the video, she brought Housekeeper #308 to a room in the front office. The DON went to tell the Administrator, but he was already on the phone with Residents #55 and #56's daughter. The DON went to search Housekeeper #308's housekeeping closet and found money sticking out of a purse. The DON took the purse to the Administrator, and they called the police. Upon the arrival of the police, two officers spoke with the DON and Administrator and two officers spoke with Housekeeper #308. The money from the purse totaled $2312. The police officers arrested Housekeeper #308 for theft. The Administrator stated he communicated the concerns to the residents at the weekly morning meeting on 03/21/25 but was unable to confirm all residents attended the meeting. The Administrator also confirmed during the facility investigation, additional residents were identified to be missing money. The Administrator confirmed he did not have evidence of all residents being notified either in person or in writing to alert them of the robbery concerns and to check their apartments for missing money or items.

Interview on 04/10/25 at 10:26 A.M. was attempted with Resident #15 but was unable to be completed due to hospitalization.

Interview on 04/10/25 at 10:29 A.M. with Resident #78 revealed he noticed missing money on two separate occasions but was unsure of the dates. The first time $150 was missing and the second time $95 was missing. The money was sitting on top of Resident #78's dresser. After the first time, he thought the money had fallen out of his pocket and after the second time he reported it to the Administrator. Resident #78 stated he usually goes to the weekly meeting with the Administrator but was unsure if he attended on 03/21/25. Resident #78 stated no other staff or residents told him about the alleged incidents, he just reported it upon discovering the missing money.

Interview on 04/10/25 at 10:41 A.M. with Resident #55 stated their caregiver was out to an appointment on 03/17/25 with them. Resident #55 stated his daughter had seen someone in their apartment while they were out on their in-room camera. Resident #55's daughter called the Administrator to alert him. Resident #55 did not recall any further details.

Interview on 04/10/25 at 10:54 A.M. with Resident #32 revealed he was not affected by missing items. Resident #32 stated he was not told by anyone from the facility but heard about a robbery from other residents. Resident #32 stated he does not always go to the weekly meeting with the Administrator.

Interview on 04/10/25 at 10:59 A.M. with Resident #31 stated she was unaware of any concerns related to missing money and was not told by any facility staff. Resident #31 stated she sometimes attends the weekly Administrator meeting but not always.

Interview on 04/10/25 at 11:05 A.M. with Resident #54 revealed she was not aware of any recent concerns with missing money and stated she sometimes attends the weekly Administrator meeting but not always.

Interview on 04/10/25 at 12:06 P.M. with Resident #13 confirmed she was not told by the facility about the recent theft but was told by other residents. Resident #13 stated she does not always attend the weekly Administrator meeting.

Phone interview on 04/10/25 at 12:35 P.M. with Resident #55 and #56's daughter revealed following seeing someone in her parent's room on their room camera on 03/17/25, she called the Administrator, and the Administrator called the police. Resident #55 and #56's daughter stated she did not receive an email or letter notifying her of a recent robbery.

Review of the videos (part 1 and part 2) dated 03/17/25 provided by Resident #55 and #56's family revealed Housekeeper #308 in their room. Housekeeper #308 appeared to rummage through various drawers and cabinets.

Review of Housekeeper #308 employee file revealed she was hired on 02/12/25 and terminated on 03/17/25 related to attendance.

Review of the staff schedules from 02/12/25 to 03/17/25 revealed Housekeeper #308 worked 21 days in the facility prior to her termination.

Interview on 04/10/25 at 1:06 P.M. with the Administrator confirmed he was unable to provide a complete employee file with a signed orientation check sheet for Housekeeper #308 which included training on the facility's abuse and misappropriation policy and procedure.

Review of the police report for CR-25-700557-A involving Housekeeper #308 revealed on 03/25/25 indictments were issued for burglary and aggravated theft.

Review of the 12/23 facility policy called Abuse-Reportable Events revealed it is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belonging or money without the resident's consent.

This violation represents non-compliance investigated under Complaint Number OH00164122.