Aventura At Assumption Village

administration on the CDR but not documented as administered on the MAR.-12/07/25 at 12:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR.-12/07/25 at 5:42 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR.Interview with LPN #416 on 12/18/25 at 10:13 A.M. revealed Resident #12 complained LPN #480 did not administer her as needed (PRN) Percocet but, gave her Tylenol instead. LPN# 416 notified corporations and LPN #480 was sent home and investigation was initiated.Interview on 12/22/25 at 9:49 A.M. with the Director of Nursing (DON) verified the above findings, and confirmed the nurses were required to administer and document controlled medications using both the MAR and CDR to prevent medication errors. LPN #480 was terminated on 12/25/25 for violation of the facility's drug policy. LPN #480 tested positive for benzodiazepines without active prescription. A police report was filed with the local police department.

Ohio Department of Health, Ohio Board of Nursing and Ohio Board of Pharmacy were notified of investigation findings.Interview with the Administrator on 12/22/25 at 10:10 A.M. revealed LPN #480 had no other violations substantial to medication documentation errors. Resident #12 had complained about LPN #480 taking her medications several months prior after this incident presented itself to facility.Review of the facility policy, Administering Medications, revised April 2019, revealed medication errors are documented, reports, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training and if the drug is withheld, refused, or given at a time other than scheduled time, medication shall be initialed and circled on the MAR.

All medications administered shall be documented on the MAR.This deficiency represents non-compliance investigated under Master Incident Number 2692300.

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