F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to ensure resident funds were conveyed timely upon
discharge from the facility. This affected one resident (#337) of one resident reviewed for conveyance of
funds. The facility census was 90.
Residents Affected - Few
Findings include:
Review of the closed medical record for Resident #337 revealed an admission date of 05/26/22 and date of
death of [DATE].
Review of the letter from Collections Enforcement Section of the Attorney General's office dated 01/06/23
revealed resident funds for Resident #337 were not dispersed within 30 days of death.
Review of the business records for Resident #337 revealed a check for $610.24 was dispersed to the
treasurer of the state dated 01/06/23 to close Resident #337's account.
Interview on 08/24/23 at 11:45 A.M. with Accounting #592 revealed he was unsure why the funds for
Resident #337 were not dispersed within 30 days following her death.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
365072
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365072
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Anna Maria of Aurora
889 North Aurora Road
Aurora, OH 44202
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and facility policy review the facility failed to securely store medications. This had the
potential to affect the four independently ambulatory residents (#59, #53, #24, and #48) in non-secured
units. The facility census was 90.
Findings include:
On entry into the facility on [DATE] at 8:00 A.M., the surveyor observed a large, full paper bag on a table in
the unmonitored breezeway inside the unlocked main entrance. The bag was stapled shut and labeled
'return to pharmacy.'
Observation on 08/21/23 at 8:30 A.M. alongside the interim Director of Nursing revealed the bag contained
43 medication cards and one medication bottle. All of these items contained at least one remaining pill.
Interview with the Interim Director of Nursing on 08/21/23 at 8:39 A.M. confirmed the above observations.
She confirmed there was no electronic monitoring of the entryway and that medications should be in locked
storage when not in use.
Review of the facility medication storage policy, dated 04/01/2013, revealed medications were to be stored
securely in locked or monitored areas, and only pharmacy staff and those authorized to administer
medications were to have access to them.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365072
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365072
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Anna Maria of Aurora
889 North Aurora Road
Aurora, OH 44202
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and facility policy review the facility failed to maintain a clean and sanitary
kitchen. This had the potential to affect all residents except one resident (#51), who received nothing by
mouth. The facility census was 90.
Findings include:
Observations on 08/21/23 from 9:22 A.M. through 9:41 A.M., with Dietary Manager (DM) #540 revealed
underneath a prep table in area where the juice machine was located was a bulk container of sugar with a
scoop stored inside. There was also sticky food splatter observed on the clear lid and the white portion
under the lid of the container. Next to the sugar container was bulk flour container that had a cup stored
inside of it. The clear lid also had sticky food splatter. Observed in the next room over was a rack that the
juice containers were stored, underneath the rack the floor was dirty, sticky, and also with a moderate
amount of black specks in the sticky spillage. Observation of the steam table revealed streaks of grease
that were solidified drippings down the front of it under the white ledge/table portion, the side facing the
stove. Observed underneath the steam table was a shelf where several pans were stored was various food
debris. Observed various food debris and splatter along the side of the plate warmer which was located
next to the steam table. Across from the steam table was the stove, observed streaks of dried grease with
food stains on the front of it. Observation of the steamer next to the stove on the bottom shelf were several
stacked pans with various food debris and crumbs on the shelf. Across from the steamer and next to the
plate warmer was a prep table, the bottom shelf had several long sheet pans and cutting boards stored
there with various food debris and crumbs on this shelf. Observation of the dish machine revealed a
moderate amount of lime buildup.
Interview on 08/21/23 between 9:22 A.M. through 9:41 A.M., with DM #540 verified all the above findings.
Review of the facility policy titled Food Receiving and Storage, revised 2014, revealed Food Services, or
other designated staff, will maintain clean food storage areas at all times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365072
If continuation sheet
Page 3 of 3
