Finding Text
Reference Number (S3800-010) 2022-001 Title and Federal Assistance Listing Number of Federal Program (S3800-011) Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities ? Federal Assistance Listing Number 14.129 Criteria (S3800-020) The affiliated lessee (Traditions at Chillicothe) received a level K deficiency during a complaint/infection control survey conducted by the Ohio Department of Health (ODH) completed on February 8, 2022. A level K deficiency is considered a pattern of immediate jeopardy to resident health or safety. The level K deficiency was not reported to HUD and the lender within the required 2 business days of receiving notice of the violation. Cause (S3800-0032) National Church Residences Chillicothe Land Holdings, Inc. is required to be in compliance with the borrower regulatory agreement that requires the level K deficiency to be reported to HUD and the lender within 2 business days of receiving the notice of the violation. Effect or Potential Effect (S3800-033) A level K deficiency was noted during a complaint/infection control survey conducted by ODH and was not reported to HUD and the lender within 2 business days of receiving the notice of the violation which is required by the borrower regulatory agreement. Recommendation (S3800-080) Management is required to notify HUD and the lender, which was completed on March 23, 2023. Auditor?s Summary of the Auditee?s Comments on Findings and Recommendations (S3800-090) Management of the affiliated lessee (Traditions at Chillicothe) agrees with the finding. The deficiency is an isolated incident and is not reoccurring. The affiliated lessee has implemented a sufficient plan of correction in order to mitigate the deficiency and all situations alike moving forward.