Health inspection·December 23, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-reported incident (SRI) and facility policy review, the facility failed to accurately document controlled drug administration for Resident #12 to prevent a potential significant medication error and/or misappropriation. This affected one resident (#12) of two residents reviewed for controlled drug administration. The facility identified 27 residents (#1, #4, #6, #7, #8, #12, #16, #19, #23, #25, #26, #30, #31, #32, #33, #34, #35, #37, #40, #44, #,45 #48, #49, #51, #64, #66, and #78) who received controlled medications. The facility census was 98.Findings include:Review of the medical record for Resident #12 revealed an admission date of 04/19/25 with diagnoses of hereditary motor and sensory neuropathy, morbid (severe) obesity due to excess calories, type II diabetes mellitus with diabetic neuropathy, essential primary hypertension, hyperlipidemia, unspecified muscle weakness (generalized), low back pain, gastro-esophageal reflux disease without esophagitis, anemia, generalized anxiety disorder, chronic pain syndrome, major depressive disorder, recurrent, post-traumatic stress disorder, neuralgia and neuritis, and peripheral vascular disease.Review of the facility SRI tracking number 268375 created by the Administrator on 12/08/25 revealed an allegation of misappropriation of medication. On 12/08/25, Resident #12 alleged that on 12/06/25, Licensed Practical Nurse (LPN) #480 gave her the wrong medication and stole her medication, a Percocet (opioid pain medication). LPN #480 was suspended immediately. LPN #480 was drug screened, tested positive for benzodiazepines, alleged stolen medication was an opioid. LPN #480 had a prior prescription for Ativan that was now outdated. Facility cameras were reviewed, LPN #480 did administer a medication during the allegation; however, camera footage was not detailed enough to confirm if the medication was correct or not. No camera footage shows LPN #480 taking medication. The facility unsubstantiated the allegation as the evidence was inconclusive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment and required assistance with medications, activities of daily living, self-care, and mobility.Review of Resident #12's December 2025 physician orders revealed an order dated 10/01/25 for oxycodone-acetaminophen (Percocet) (opioid pain medication) 5-325 milligram (mg) per tablet take one tablet by mouth every eight hours as needed (PRN) for pain.Review of the medication administration record (MAR) and controlled drug records (CDR) for Resident #12's Percocet from 10/01/25 to12/08/25 revealed administration of Percocet was documented as follows:-10/24/25 at 8:15 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR-11/14/25 at unknown time it was removed for PRN administration on the CDR but not documented as administered on the MAR.-12/01/25 at 8:00 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR.-12/06/25 at 7:15 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR.-12/06/25 at 9:10 P.M. it was removed for PRN (continued on next page) 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 2 Event ID: 365783 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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)