Aventura at Walton Hills

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to notify the guardian of Resident #77's elopement. This affected one resident (#77) of three residents reviewed for elopement. The facility census was 79.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to timely develop care plans relative to elopement risk. This affected one resident (#77) of three residents reviewed for elopement. The facility census was 79.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure the staff prepared food that was palatable with seasoning and had the ingredients to prepare the food according to the dietitian approved recipes. This affected 72 out of 75 residents who ate their meals in the facility. The facility identified three residents (#4, #9, #29) who received no food by mouth. The facility census was 75.

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to ensure food items were stored in a safe and clean manner to prevent cross contamination, exposure to air, and failed to ensure the kitchen work areas were clean and free of debris and grease buildup. This had the potential to affect all residents who received food from the kitchen. The facility identified three residents (#4, #9 and #29) who received no food by mouth. The facility census was 75.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a clean and sanitary environment. This affected six residents (#08, #24, #39, #53, #65 and #82) of 11 residents reviewed for environment and had the potential to affect all the residents residing in the facility. The facility census was 75.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure dependent residents could reach their call lights. This affected one resident (#37) of eleven residents reviewed for environmental concerns. The facility census was 75.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure the physician orders were implemented in a timely manner for Resident #38 and Resident #43. This affected two residents (#38 and #43) out of five residents reviewed for unnecessary medications. The facility census was 75.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure staff followed infection control practices to prevent cross contamination of germs during Resident #42's incontinence care. This affected one resident (#42) out of three residents reviewed for bowel and bladder incontinence. The facility census was 75.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed prevent Resident #58 from developing an in-house pressure ulcer and failed to ensure timely identification, proper treatment and interventions were initiated to promote healing. Additionally, the facility failed to ensure nursing staff completed accurate and comprehensive weekly skin assessments/checks as ordered. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to ensure infection control measures were maintained during medications administration, which included hand washing/hand hygiene. This affected three residents (#4, #20, and #71) out of six residents observed for medication administration and had the potential to affect 16 additional residents (#3, #5, #10, #22, #23, #24, #28, #30, #31, #35, #39, #41, #44, #46, #66, and #67) on Licensed Practical Nurse (LPN) #215's assignment. The facility census was 71.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure care plans were individualized for Resident #33. This affected one resident (#33) out of three residents reviewed for care plans. The facility census was 71.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure weekly skin observations were accurately completed as ordered for Residents #33 and #72. This affected two residents (#33 and #72) out of three residents for wounds. The facility census was 71.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure staff followed enhanced barrier precautions during catheter care. This affected one (Resident #15) of three residents reviewed for catheters. The facility census was 72.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure residents were treated in a respectful and dignified manner. This affected three residents (#31, #68, and #70) of six observed for dignified treatment. The facility census was 71.

Inspectors wroteBased on record review, staff and family interview, and review of the facility policy, the facility failed to ensure residents and their responsible parties were included in the development and implementation of the plan of care. This affected one resident (Resident #11) of three residents reviewed for care planning. The facility census was 71.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to timely address resident and family concerns. This affected two residents (#11 and #67) of four residents reviewed for concerns. The facility census was 71.

Inspectors wroteBased on record review, interview, review of facility policy, and review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), the facility failed to timely report an allegation of staff to resident verbal abuse to the State Agency as required. This affected one resident (Resident #72) of three residents reviewed for abuse. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate urinary catheter care had been performed. This affected one Resident (#11) of three observed for catheter care. The facility identified five residents with indwelling urinary catheters. The facility census was 71.

Inspectors wroteBased on record review, Self-Reported Incident (SRI) review, police report review, policy review, and interview, the facility failed to prevent the exploitation of Resident #33 by an employee. This affected one (Resident #33) of three residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #50's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #50) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety when not returning from a leave of absence. This affected one Resident (#27) of three reviewed for safety hazards. The facility census was 72.

Inspectors wroteBased on medical record review, review of a Self-Reported Incident (SRI), facility investigation interviews, police report and facility policy review, the facility failed to ensure Resident #22 was free from suspected resident-to-resident sexual abuse by Resident #63. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 69.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This affected four (Residents #24, #25, #33, and #49) of four residents reviewed for personal funds. This had the potential to affect 22 additional residents (Residents #1, #3, #6, #7, #8, #10, #13, #14, #18, #23, #26, #29, #32, #36, #37, #38, #47, #50, #53, #55, #56, and #58) who also had personal needs bank accounts at the facility. The facility census was 60.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect 58 out of 60 residents receiving food from the facility. Two residents (Residents #2 and #4) out of 60 residents received nothing by mouth. The facility census was 60.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually. This had the potential to affect all residents. The facility census was 60. Findings Include: Review of the facility assessment revealed the facility assessment was completed on 10/09/17 and reviewed on 11/21/17, 11/24/18, 02/06/19, 06/24/19, 07/30/19, 11/25/19, 03/23/20, 05/18/20, and 06/14/21. Review of the facility assessment revealed it had not been reviewed or updated since 06/14/21. Interview with the Administrator on 11/22/22 at 3:40 P.M. verified the above findings.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Resident #6 and Resident #11. This affected two of two residents reviewed for call light placement. The facility census was 60. Findings Include: 1. Review of the medical record for the Resident #6 revealed an admission date of 07/07/18. Diagnoses included epilepsy, diabetes, and a history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/22, revealed the resident had intact cognition. Resident #6 was independent for bed mobility, transfers, walking, locomotion, dressing, eating, and toilet use. Resident required supervision for personal hygiene. Observation of the resident on 11/20/22 at 9:46 A.M. revealed his call light not within reach. [...]

Inspectors wroteBased on record review and interview, the facility failed to honor resident preferences regarding getting out of bed to participate in activities and or socialize, and going back to bed. This affected one resident, Resident #1, of one resident reviewed for choices. The facility census was 60.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Pre admission Screen and Resident Review (PASRR) forms were completed timely as required and addressed all applicable mental health and developmental disability diagnoses. This affected one of one resident reviewed for PASRR compliance. The facility census was 60. Findings Include: Resident #54 was admitted to the facility on [DATE] diagnoses that included schizoaffective disorder, intrahepatic bile duct carcinoma , hypertension and severe protein-calorie malnutrition. Further review of the medical record revealed Resident #54 was admitted to the facility on a hospital exemption form which in turn required the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #54 PASRR was completed on 11/07/22. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure timely nail care was provided for Resident #6, Resident #26, and Resident #42. This affected three of three residents reviewed for providing assistance with nail care. The facility census was 60. Findings Include: Review of the medical record for the Resident #6 revealed an admission date of 07/07/18. Diagnoses included epilepsy, diabetes, and a history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/22, revealed the resident had intact cognition. The Resident required supervision for personal hygiene. Observation on 11/20/22 at 9:22 A.M. and 09:46 A.M. revealed Resident #6's nails were long, jagged, and split. Interview on 11/20/22 at 9:46 A.M. Resident #6 said he usually cut his own nails but had lost his clippers. Interview on 11/20/22 at 12:20 P.M. [...]

Inspectors wroteBased on interview and record review, the facility did not provide ongoing activities to meet the interest and needs for one resident, Resident #1, of one resident reviewed for activities. The facility census was 60.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure an effective bowel regimen was implemented for Resident #52 after the resident did not have a bowel movement for nine days and failed to ensure Resident #52's left elbow cushion was available and applied at all times per the physician orders. This affected one resident (Resident #52) of one resident reviewed for bowel monitoring and interventions for pressure wounds. The facility census was 60.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the physicians order for splints was followed for residents #3 and #9. This affected two of two residents reviewed for splint placement. The facility census was 60. Findings Include: 1. Diagnoses included aphasia, hemiplegia and hemiparesis, and contracture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/08/22, revealed the resident had impaired cognition. The resident was totally dependent for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was independent for eating. Review of physician orders for 11/22 revealed an order dated 09/22/22 for Resident #3 to wear a right resting hand splint daily as tolerated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered/dietary recommended nutritional supplements for one resident, Resident #29, of three residents reviewed for nutrition. The facility census was 60.

Inspectors wroteBased on staff interview, observation, medical record review, and facility policy review, the facility failed to ensure Resident #266 Continuous Positive Airway Pressure (CPAP) machine was maintained in functional order. The facility identified one resident (#266) who utilized a CPAP machine. The facility census was 60.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure residents request and preferences for meals were honored. This affected two (Resident #40 and #41) of 58 residents who received meals from the kitchen. Residents #2 and #4 received no food by mouth. The facility census was 60. Findings Include: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, chronic kidney disease obesity, and other intestinal obstruction unspecified as to partial versus complete obstruction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was alert and oriented to person, place, and time and required two-person physical assist for activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices during wound care provided for one Resident, Resident #52, of one resident reviewed for pressure ulcers. The facility census was 60.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #54, who was cognitively impaired and required extensive assistance from two persons for transfers was transferred safely via a mechanical (Hoyer) lift to prevent a fall with injury. Actual Harm occurred on 12/12/19 when Resident #54 sustained a fall from the Hoyer lift resulting in a laceration to her head requiring transport to the emergency room. This affected one resident (#54) of one resident review for accidents. Findings Include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, type two diabetes and unspecified intellectual disabilities. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent contamination and/or food borne illness. This affected all 63 of 63 residents who received meal trays from the kitchen. The facility identified one resident (#24) who received nothing by mouth. The facility census was 64.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure pureed foods were served at a palatable and smooth consistency for safe swallowing. This affected eleven residents (#3, #7, #24, #26, #28, #30, #37, #39, #41, #53 and #216) who were prescribed a pureed diet of 63 residents who consumed meals from the facility's kitchen.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #62 and Resident #214 had accurate advance directive orders and information in place throughout their medical records. This affected two residents (#62 and #214) of two residents reviewed for advanced directives.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a seat belt device was properly assessed as a restraint for Resident #25 and failed to ensure the device was the least restrictive device for the resident. This affected one resident (#25) of two residents reviewed for seat belt devices.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the physician's diet order for Resident #59 was followed. This affected one resident (#59) of four residents reviewed for nutrition.