Health inspection·January 22, 2026

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete attended Food Committee meetings, and nothing changed. Resident #249 was disgusted with the options and choices provided. He voiced concerns about plastic silverware, wants real silverware, and too many sandwiches being served. Food was sometimes so tough, he could not even cut it. Resident #249 would just like the facility to listen to concerns; it could be much better. The snack cart was not consistent, sometimes it was passed on this unit and sometimes it was not. It's all the same snacks, no variety.This deficiency represents noncompliance investigated under Master Complaint Number 2717130 and Complaint Number 2655827. Event ID: Facility ID: 366186 If continuation sheet Page 2 of 4 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 01/22/2026 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, review of photographs and facility policy review, the facility failed to follow its planned and posted menu and failed to serve meals in a manner consistent to meet the nutritional value for Resident #222. This affected two residents (#222 and Resident #249) of three residents reviewed for palatable and nutritional food. This had the potential to affect all residents receiving meals at the facility . The facility census was #65.Findings include:1. Review of the medical record revealed Resident #222 was admitted to the facility on [DATE] with diagnoses of aftercare following surgery for neoplasm, acquired absence of left breast and nipple, malignant neoplasm of overlapping sites of left female breast, acquired absence of other specified parts of digestive tract, type II diabetes mellitus with diabetic chronic kidney disease, presence of other specified functional implants, essential (primary) hypertension, chronic kidney disease, unspecified, muscle weakness (generalized), need for assistance with personal care, sick sinus syndrome, idiopathic gout, unspecified site, cardiac arrhythmia, unspecified presence of cardiac pacemaker, primary generalized osteoarthritis, embolism and thrombosis or renal vein, orthostatic hypotension, long term use of anticoagulants, and obstruction of bile duct.Review of the quarterly [NAME] Data Sheet (MDS) assessment dated [DATE] indicated Resident #222 was not cognitively impaired, required setup or clean-up assistance for all activities of daily living (ADL).Review of a photograph dated 11/25/25 revealed Resident #222 was served burnt lasagna, mashed potatoes, and gray-green colored green beans instead of the planned lasagna, tossed salad and mixed fruit. The substituted food items were not documented on the menu, nor was there evidence of a planned or approved menu substitution. The substitution log did not reveal any substitutions on 11/25/25.Interview on 01/21/26 at 9:34 A.M. with the Ombudsman revealed Resident #222 received burnt lasagna, mashed potatoes and gravy, and gray-colored green beans on 11/25/25. Resident #222 had not asked for the mashed potatoes and green beans instead of the tossed salad and fruit. She stated residents complained of food substitutions without notification, and using Styrofoam plateware. The Ombudsman revealed she exhausted all avenues with management.Interview with the Dietary Manager #497 on 01/22/26 at approximately 8:19 A.M. confirmed that the posted menu was not followed for Resident #222 for the lunch meal on 11/25/25 and that no documentation of the substitution was completed. Dietary Manager #497 confirmed the picture verified Resident #222 received burnt lasagna and mashed potatoes and gravy on 11/25/25, instead of the planned tossed salad and mixed fruit listed on the menu. Dietary Manager #497 was shown image of burnt lasagna and confirmed he would not eat it, and it was served to Resident #222. Interview on 01/22/26 at 9:06 A.M. with Resident #222 revealed she was served a piece of burnt lasagna with a side of mashed potatoes and gravy on 11/25/25. Resident #222 revealed she did not order any substitutions of mashed potatoes and gravy with lasagna. Resident #222 stated the facility had no fresh bread on site. Food was sometimes cold by the time it was served. Resident #222 stated she had attended Resident Council and Food Committee meetings to voice her concerns with no improvement. 2. Review of the medical record revealed Resident #249 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified, pneumonia due to coronavirus disease 2019, presence of left artificial hip joint, type II diabetes mellitus with diabetic polyneuropathy, tremor, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, unspecified, gastro-esophageal reflux disease without esophagitis, schizoaffective disorder, bipolar type, essential (primary) hypertension, major depressive disorder, single episode, severe with psychotic features, hypothyroidism, unspecified, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, benign Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366186 If continuation sheet Page 3 of 4 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 01/22/2026 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete prostatic hyperplasia without lower urinary tract symptoms, other bipolar disorder, cerebrovascular disease, unspecified, obstructive sleep apnea (adult) (pediatric), syncope and collapse, tachycardia, unspecified, right lower quadrant pain, pain in the left knee, retention of urine, unspecified, and unilateral primary osteoarthritis, left hip. Review of the quarterly MDS assessment dated [DATE] revealed Resident #249 was not cognitively impaired and was independent in all ADL.Interview on 01/21/26 at 9:34 A.M. with the Ombudsman revealed multiple food complaints from several residents, including burnt lasagna, no fresh bread available in the facility, food substitutions without notification, and Styrofoam plateware. The Ombudsman stated revealed she exhausted all avenues with management.Interview with the Administrator on 01/21/26 at 2:50 P.M. confirmed there was no tracking system in place to ensure food-related complaints raised through Food Council were followed up and resolved.Interview on 01/22/26 at 10:17A.M. with Resident #249 revealed the food sucked. The facility doesn't listen to his concerns. He attended Food Committee meetings, and nothing changed. Resident #249 was disgusted with the options and choices provided. He voiced concerns about plastic silverware, wants real silverware, and too many sandwiches being served. Food was sometimes so tough, he could not even cut it. Resident #249 would just like the facility to listen to concerns; it could be much better. The snack cart was not consistent, sometimes it was passed on this unit and sometimes it was not. It's all the same snacks, no variety.This deficiency represents noncompliance investigated under Master Complaint Number 2717130 and Complaint Number 2655827. Event ID: Facility ID: 366186 If continuation sheet Page 4 of 4