Health inspection·September 3, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, staff interview, review of witness statements, review of a facility Self-Reported Incident (SRI) and policy review, the facility failed to ensure misappropriation of resident funds. This affected three (#21, #22, and #23) residents of the six Residents (#11, #14, #15, #21, #22, and #23) reviewed for resident funds. The facility census was 57. Findings include: Review of the medical record for Resident #21, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, acute respiratory failure, paranoid schizophrenia, anxiety, cerebrovascular disease, and acute kidney failure. Resident #21 expired in the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of the medical record for Resident #22, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, bipolar, anxiety, paraplegia, pain, and cerebrovascular disease. Resident #22 expired in the facility on [DATE]. Review of the most recent MDS assessment dated [DATE] revealed Resident #22 had mild to moderated cognitive deficits. Review of the medical record for Resident #23, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, heart failure, depression, dry eye syndrome, kyphosis, and anxiety. Resident #23 expired in the facility on [DATE]. Review of the most recent MDS assessment dated [DATE] revealed Resident #23 had moderate to severe cognitive deficits. Review of a check dated [DATE], revealed the check was made out to Petty Cash in the amount of $300.00 signed and endorse by Former Business Office Manager (BOM) #61. The memo indicated the check was for account closure (Resident #23). Review of a check dated [DATE], revealed the check was made out to Former BOM #61 in the amount of $567.49 signed and endorsed by former BOM #61. The memo indicated the check was for account closure (Resident #21). Page 1 of 4 365603 365603 09/03/2024 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of check dated [DATE], revealed the check was made out to Receptionist #64 in the amount of $1,548.58 signed by former BOM #61 and endorsed by Receptionist #64. The memo indicated the check was for account closure (Resident #22). Review of a facility SRI dated [DATE] categorized for misappropriation, revealed while the facility was completing a resident trust audit, the facility discovered an employee had written check to themselves out of a residents account who was deceased . Receptionist #64 notified the Administrator about concerns she had with missing resident trust account money. The Administrator began a full comprehensive investigation. Former BOM #61 was suspended while the facility conducted an audit of Resident #21's resident trust account. During the audit, the facility discovered former BOM #61 wrote out a check to herself on [DATE] from Resident #21's trust account in the amount of $567.49 and signed the check. Former BOM #61 then took the check to the bank and endorsed it. Resident #21 was deceased [DATE]. The memo on the check stated account closure. When the Administrator questioned former BOM #16 about the process to close an account, former BOM #61 was not able to give the appropriate steps. The Administrator reminded former BOM #61 that an account needs to be closed and sent to either the funeral home or to the Attorney General's Office in a check format and closed account checks should not be written out to yourself or another employee, cashed and be given to anyone. Former BOM #61 stated understanding. Former BOM #61 has since been terminated from her position. Receptionist #64 was interviewed, but she noted she doesn't touch the checks, so she was not aware of this incident. The [NAME] President of Revenue Operations (VPRO) #60 completed a whole house audit on the resident accounts that were deceased back to [DATE] and there were no further incidents discovered. On [DATE] the Administrator was educated by VPRO #60 on the need to audit resident funds accounts. All staff were educated by the Administrator on abuse and misappropriation. The police were called, and they would conduct an investigation also. The facility substantiated abuse, neglect or misappropriation verified by evidence. After completing a full investigation, the incident was substantiated due to finding a check written to the employee from a deceased resident's account. The local Police Department was called, and a copy of the check was provided to the Police and was instructed a detective would be investigating. An addendum to the SRI was uploaded on [DATE] to indicate the Administrator was informed by VPRO #60 that two more Residents (#22 and #23) had concerns with their closed accounts. Resident #22's account was opened with a personal check on [DATE] and closed on [DATE]. Former BOM #61 issued and signed a check made out to Receptionist #64 for $1,548.58. Receptionist #64 stated the cash was handed to former BOM #61 who was taking it to meet Resident #22's daughter at Walmart. Resident #22 was on Medicaid at time of death. The Administrator called Resident #22's daughters and neither had received any money or met anyone in the Walmart parking lot. Resident #23 expired [DATE] and the account was closed on [DATE] with two checks issued. One check for $330.00 issued to Resident #23's niece and has not been cashed as of yet. VPRO #60 will be putting a stop payment on the check and issuing to estate recovery. The second check was issued to Petty Cash for $300.00, signed and endorsed by former BOM #61. Remaining $1.44 left in the account and need checks issued to estate recovery. Review of a facility documented titled Employee Discipline Notice dated [DATE] revealed former BOM #61 was in violation of the facility's progressive discipline policy. Group IV-Theft, attempted theft, or misuse of facility, employee, resident or visitor property. On [DATE], BOM #61 wrote a check out to herself, and cashed it out of deceased Resident #21's account. Former BOM #61 was terminated. Review of a witness stated dated [DATE] by Receptionist #65, revealed former BOM #61 never asked her to go to the bank to cash any checks at any time. She indicated that she never had checks made out to her for cash, and as of 01/2024 she no longer entered transactions into the Resident Fund Management Service. 365603 Page 2 of 4 365603 09/03/2024 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of undated witness statement revealed Receptionist #64 had been the payee at times. Receptionist #64 would go to the bank and bring the money back to the facility. Receptionist #64 had concerns that the resident trust accounts in general were not accurate, so she brought it to the Administrator's attention. Review of an undated witness statement from Receptionist #66 and narrated by the Administrator revealed the Administrator spoke to Receptionist #66 over the phone and she indicated she would only give the residents cash out of the petty cash box and then turn the receipts into the Business office manager. Interview with the Administrator on [DATE] at 3:00 P.M. revealed the former BOM #61 had taken the money, and it has never been recovered. The Administrator stated that the police were notified, and she is still in contact with them on a weekly basis and they going to press charges on former BOM #61. The Administrator stated the money for all three Residents (#21, #22, and #23) has been put back into their accounts and they are waiting for the check signers from the bank so they can sign the checks and sent them where they need to go. Resident #21's money goes to the estate, and Residents #22 and #23 are to be sent to the Attorney General due to being Medicaid. Review of the Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures (dated 2023) revealed to ensure that all of the facility's residents are free from abuse, neglect, misappropriation of their property, and exploitation. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], an SRI was submitted to the State Agency for the allegations of misappropriation. The SRI was completed on [DATE] and the allegations of misappropriation were substantiated. On [DATE], former BOM #61 was terminated. On [DATE], all staff were educated by the Administrator on abuse and misappropriation. On [DATE], the Police were notified and were given a copy of the check. The Police are in the process of investigation and possibly filing formal charges against former BOM #61. On [DATE], An Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, the Director of Nursing (DON) and the Medical Director. A Root Cause Analysis (RCA) was determined that the former BOM #61 was doing illegal activity with the resident accounts and a working system was not in place. A house wide audit for resident accounts were started on [DATE] and to be completed on [DATE]. Additional QAPI meetings were held on [DATE], [DATE], and [DATE]. Attendees included Administrator, Assisted Living (AL) Director #106, Staffing Coordinator #102, MDS Coordinator#103, Unit Manager / Licensed Practical Nurse (LPN) #104, Activities Supervisor #100, Registered Nurse (RN) #105, and the Medical Director. No additional issues were identified. On [DATE], the Administrator, and two Receptionists (#64 and #65) were educated by VPRO #60 on the need to audit resident fund accounts. On [DATE], a whole house audit of the resident's fund accounts was completed by the Administrator 365603 Page 3 of 4 365603 09/03/2024 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0602 with no issues being identified. Level of Harm - Minimal harm or potential for actual harm On [DATE], the Administrator started weekly audits of five resident fund accounts to ensure that no misappropriation was occurring. The audits will be completed weekly for four weeks then monthly and reported to the QAPI committee to determine the need for further formal audits. Additional audits from [DATE] and [DATE] were reviewed with no issues being identified. Residents Affected - Few 365603 Page 4 of 4