Health inspection·January 11, 2024

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Some Based on personnel record review, review of staff timecards, review of staff assignments, review of court documents, policy review and staff interview, the facility failed to ensure all staff working at the facility had a completed background check and did not have a disqualifying offense. This had the potential to affect 16 (#6, #7, #8, #11, #13, #14, #17, #19, #28, #35, #36, #46, #47, #48, #67 and #72) residents identified by the facility as residing on the South Unit of the facility. The facility census was 70. Findings include: Review of State Tested Nurse Aide (STNA) #205's personnel record revealed the STNA was employed by a staffing agency, with a hire date of 05/03/22. Review of STNA #205's timecards revealed she worked in the facility 18 days in October 2023 and five days in November 2023, with the last day being 11/08/23 when the facility removed STNA #205 from the facility after being alerted to a potentially disqualifying offense. Review of staff assignment sheets from 10/01/23 through 11/08/23 confirmed STNA #205 was assigned to the South Unit on each of the scheduled work days. Interview on 01/10/24 at 8:25 A.M. with the Administrator verified STNA #205 was a former agency staff who picked up shifts through a local staffing agency the facility had a contract with. The facility was notified the STNA had a criminal record, verified this on research, and placed STNA #205 on the Do Not Return (DNR) list. The Administrator stated the contract with the staffing agency identified the agency as responsible for ensuring background checks were completed and maintenance of those records. Interview on 01/10/24 at 10:56 A.M. with Human Resources Manager (HRM) #301 revealed all facility staff received criminal background checks, abuse training, and nurse aide registry checks upon hire. On 11/07/23, HRM #301 stated the facility received a verbal tip STNA #205 had criminal charges. The facility investigated, found the claim was substantiated, removed STNA #205 from the schedule and notified the staffing agency. Interview on 01/11/24 at 11:03 A.M. with the staffing agency [NAME] President of Marketing (VPM) #701 revealed his agency could not find evidence STNA #205 had a completed criminal background check when she began employment with them. (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 3 Event ID: 366186 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 366186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Humility House 755 Ohltown Road Austintown, OH 44515 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)