Middleburg Heights Assisted Living

Based on observation, medical record review, review of the call light history report, interview, and facility policy review the facility failed to timely respond to call pendants for Resident's #65 and #4. This affected two residents (#65 and #4) of four residents interviewed for call pendant response time. The facility census was 66.

Findings include:

Observation on 09/23/24 at 8:20 A.M. revealed Resident #65 was sitting in the dark in the recliner in his room. Resident #65 had his call pendent hanging around his neck on a lanyard. Interview, during the observation, with Resident #65 revealed the staff didn't answer his call pendent timely. Resident #65 revealed he pressed the call light last night at 9:00 P.M. because he needed a staff member to assist him with removing his compression stockings on his legs; however, no staff member answered his call pendent. Resident #65 pressed his call pendent again at 2:15 A.M., 3:15 A.M. and 5:00 A.M. At 5:00 A.M., Resident Care Associate (RCA) #6 stopped in to check on him; however, RCA #6 stated she was doing her rounds and hadn't seen the call pendant notification on the computer.

Interview on 09/23/24 at 8:45 A.M. with Medication Technician (MT) #1 revealed the staff used to have pagers that alerted when a resident pressed their call pendent; however, the pagers had been broken or stolen, so the staff must check the computer screen near the front entrance desk to check for resident call pendants.

Interview on 09/23/24 at 9:48 A.M. with RCA #4 revealed her pager was in her car, so she checked the computer screen near the front entrance desk every 20 minutes to check for resident call lights.

Interview on 09/23/24 at 10:55 A.M. with Resident #4 revealed the staff didn't answer her call pendent in a timely manner.

Review of the call light history report from 09/22/24 to 09/23/24 revealed Resident #65 pushed his call pendent the following date and time with this alert:

On 09/22/24 at 8:31 P.M. response required by not received as of 9:41 P.M. This alert was never responded to.

On 09/22/24 at 9:48 P.M. response required but not received as of 10:58 P.M. This alert was never responded to.

On 09/23/24 at 2:49 A.M. response required but not received as of 3:59 A.M. This alert was never responded to.

On 09/23/24 at 4:58 A.M. response required but not received as of 6:08 A.M. This alert was never responded to.

Interview on 09/23/24 at 12:15 P.M. with Former Executive Director (FED) #5 revealed the staff had pagers that alerted for resident call pendants.

Interview on 09/23/24 at 3:35 P.M. with the Director of Nursing (DON) verified Resident #65's call light history report revealed Resident #65 pushed the call pendent on 09/22/24 at 8:31 P.M and at 9:48 P.M. and on 09/23/24 at 2:49 A.M. and 4:58 A.M. and the call pendant was not answered.

Review of the facility's undated Nurse/Call Bell System policy revealed timely assistance will be provided to residents' alert buttons; emergency pull cords or pendants to ensure prompt response to urgent or emergency needs. When the alarm button has been activated by a resident or another individual for that resident, the team member will be notified on their pager, mobile device or other systems as per the specific hardware/software system used in the community.

This violation represents non-compliance investigated under Complaint Number OH00157338.

Based on observation, medical record review, review of manufacturer's recommendations and interview, the facility failed to ensure Resident #62'smedications were administered as recommended by the manufacturer. This affected one resident (#62) of two residents observed for medication administration. The facility census was 66.

Findings include:

Review of the medical record for Resident #62 revealed an admission date of 05/26/22 with diagnoses of diabetes, syncope and collapse, chronic kidney disease, and glaucoma.

Review of the Senior Living Standard Level of Care and Service Plan assessment dated 05/30/24 revealed Resident #62 wasn't always oriented, needed reminders for redirection and orientation, and wasn't capable of independent decision making.

Review of the September 2024 physician's orders revealed Resident #62 was ordered Brimonidine solution 0.15% (reduces intraocular pressure in patients with open-angle glaucoma or ocular hypertension) one drop in both eyes three times a day, and Betoptic-S 0.25% (reduces intraocular pressure in patients with open-angle glaucoma) instill one drop into each eye twice daily for glaucoma.

Review of the undated manufacturer's recommendations pamphlet within the Brimonidine Tartrate ophthalmic solution 0.15% eye drop box for Resident #62 revealed Brimonidine Tartrate ophthalmic solution may be used concomitantly with other typical ophthalmic drug products to lower intraocular pressure (IOP). If more than one topical ophthalmic product is to be used, the different products should be installed at least five minutes apart.

Review of the undated manufacturer's recommendation pamphlet from the manufacturer's website (www.novartis.com) revealed Betoptic-S may be used alone or in combination with other IOP lowering medications. Advise patients requiring concomitant topical ophthalmic medications to administer these at least 10 minutes before instilling Betoptic-S.

Observation on 09/23/24 at 9:45 A.M. of medication administration revealed Medicine Technician (MT) #1 instilled Betoptic-S one drop into each of Resident #62's eyes and MT #1 asked the resident to blink a couple of times. At 9:46 A.M., MT #1 instilled Brimonidine one drop into each of Resident #62's eyes.

Interview on 09/23/24 at 2:30 P.M. with the Director of Nursing (DON) verified MT #1 incorrectly administered Betoptic and Brimonidine eye drops into Resident #62's eye since MT #1 did not wait the recommended five to 15 minutes between each eye drop administration.

This violation represents non-compliance investigated under Complaint Number OH00157338.

Based on personnel file review and staff interview, the facility failed to ensure all employees had a physical examination within 30 days prior to or on day of hire as required. This had the potential to affect all 67 residents residing at the facility.

Findings include:

Review of the personnel file for the Executive Director (ED) revealed a start date of 11/22/23. Further review of the personnel file revealed no evidence of a physical examination within 30 days prior to or on the day of hire.

Review of the personnel file for Medication Technician (MT) #12 revealed a start date of 05/14/24. Further review of the personnel file revealed no evidence of a physical examination within 30 days prior to or on the day of hire.

Interview with Business Office Manager #10 on 05/29/24 at 7:10 A.M. confirmed she did not have evidence of a completed physical for the ED or MT #12.

This violation is a recite to the annual survey completed 03/25/22.

Based on medical record review and staff interview the facility failed to ensure physician orders for daily weights were completed as ordered. This affected one (Resident #129) of three residents reviewed for weights. The facility also failed to ensure residents were provided showers as scheduled and per their preference. This affected three (Resident #138, #151, and #160) of three residents reviewed for showers and had the potential to affect all 67 residents residing at the facility.

Findings include:

1. Review of the medical record for Resident #129 revealed an admission date of 06/05/23. Diagnoses included but were not limited to heart failure, atrial fibrillation, stroke with residual aphasia and vision change.

Review of Resident #129's assisted living service plan dated 06/01/23 revealed Resident #129 had mild cognitive impairment, required stand by assistance for showering, and assistance of one for dressing. Resident #129 was independent for toileting and ambulation. Resident #129 was on a two-gram sodium diet related to increased edema.

Review of the physician orders dated 09/20/23 for Resident #129 revealed an order for daily weights in the morning related to diagnosis of congestive heart failure.

Review of the May 2024 Medication Administration Record (MAR) for Resident #129 revealed daily weights were marked as being completed but no weights were recorded to review for comparison.

Review of the medical record under the weights section for Resident #129 revealed the last weight completed was 05/02/24.

2. Review of the medical record for Resident #138 revealed an admission date of 01/22/24. Diagnoses included but were not limited to hyperlipidemia, hypertension, and Alzheimer's dementia.

Review of the 01/22/24 service plan for Resident #138 revealed Resident #138 had moderate cognitive impairment and required assistance with dressing, grooming, and showering. Resident #138 was independent for eating and mobility.

Review of Resident #138's physician orders revealed an order dated 02/27/24 for weekly weights related to diagnosis of hypertension.

Review of Resident #138's May 2024 Medication Administration Record revealed the last weekly weight was completed on 05/07/24. No weights were recorded for 05/14/24, 05/21/24 or 05/28/24.

Review of the facility shower schedule revealed Resident #138 was scheduled to have showers on Tuesdays and Fridays.

Review of Resident #138's shower sheet for May 2024 revealed she received a shower on 05/03/24, 05/07/24, 05/21/24, and 05/27/24. No showers were recorded for 05/10/24, 05/14/24, 05/17/24 and 05/28/24 as scheduled.

3. Review of the medical record for Resident #151 revealed an admission date of 10/18/23. Diagnoses included but were not limited to dementia, epistaxis, atrial fibrillation, and hypothyroidism.

Review of the 10/11/23 preadmission assessment for Resident #151 revealed Resident #151 had severe cognitive impairment and was dependent upon staff for dressing, bathing, toileting. Resident #151 also required assistance with feeding and mobility.

Review of facility shower schedule revealed Resident #151 was scheduled to have showers on Mondays and Thursdays.

Review of Resident #151's shower sheet for May 2024 revealed showers were given on 05/07/24, 05/10/24, 05/13/24, 05/16/24, 05/20/24, and 05/27/24. No showers were documented for 05/02/24, 05/23/24 or 05/27/24.

4. Review of the medical record for Resident #160 revealed an admission date of 05/10/21. Diagnoses included but were not limited to chronic atrial fibrillation, Parkinson's disease, traumatic subdural hemorrhage, osteoporosis, and cognitive deficits following cerebral infarction.

Review of the 05/08/24 personal service assessment for Resident #160 revealed Resident #160 had moderate cognitive impairment and required feeding assistance. Resident #160 was dependent on staff for dressing, toileting, showering and mobility.

Review of the facility shower schedule revealed Resident #160 was scheduled for showers on Sundays and Wednesdays.

Review of the facility shower sheet for May 2024 for Resident #160 revealed showers were given on 05/05/24, 05/12/24, 05/19/24 and 05/26/24. No evidence of showers was available to review for 05/01/24, 05/08/24, 05/15/24, and 05/22/24.

Interview on 05/28/24 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #129 had an order for daily weights but was unable to provide proof of completed daily weight records.

Interview on 05/29/24 at 8:18 A.M. with the DON confirmed the above shower findings for Residents #131, #151 and #160 and stated residents were supposed to get two showers per week from the facility.

Review of the undated facility policy How to Obtain Resident's weight revealed weights could be ordered more frequently per physician order or as recommended the weight loss or weight gain clinical guideline. Staff were to obtain the resident's weight accurately and monitor for significant weight gain or loss that could signal a change in health status.

Review of the undated facility policy How to shower or bath revealed associates were to assist with a shower or bath as needed by the resident.

This violation is a recite to the complaint survey completed 01/24/24.

Based on facility record review and interview, the facility failed to develop and follow a tuberculosis control plan based on the facility assessment. This had the potential to affect all 67 residents residing at the facility.

Findings include:

Review of the facility's policies and procedures revealed no evidence of a tuberculosis control plan based on the facility's assessment of the facility.

Interview on 05/29/24 at 12:57 P.M. with the Director of Nursing confirmed the facility did not have a completed tuberculosis risk assessment for review.

Based on medical record review and interview the facility failed to ensure a registered dietitian completed nutrition assessments and monitoring. This affected two (Resident #129 and #138) of three residents reviewed for weights and two (Resident #100 and #129) of three residents reviewed for therapeutic diets. The facility identified 17 residents (#100, #104, #108, #113, #125, #126, #129, #131, #136, #140, #144, #146, #148, #154, #158, #161, and #164) receiving a therapeutic diet.

Findings include:

1. Review of the medical record for Resident #100 revealed an admission date of 02/15/22. Diagnoses included but were not limited to end stage renal disease, dependence upon renal dialysis and chronic obstructive pulmonary disease.

Review of Resident #100's cognitive psychosocial assessment dated 02/21/24 revealed she was cognitively intact. Review of activities of daily living (ADLs) for Resident #100 revealed Resident #100 was independent in ADLs although required assistance with monitoring and adjusting oxygen and laundry.

Review of Resident #100's physician orders revealed an order dated 08/19/22 for a renal diet.

Review of Resident #100's service assessment revealed a renal diet order.

Review of the electronic medical record and paper chart for Resident #100 did not reveal any nutrition progress notes or assessments.

Interview on 05/29/24 at 10:15 A.M. with Resident #100 revealed she alerted the facility as to what menu items she wanted for her meals and stated she did not recall speaking to a dietitian at the facility related to her renal diet or nutritional status.

2. Review of the medical record for Resident #129 revealed an admission date of 06/05/23. Diagnoses included but were not limited to heart failure, atrial fibrillation, stroke with residual aphasia and vision change.

Review of Resident #129's assisted living service plan dated 06/01/23 revealed Resident #129 had mild cognitive impairment. Resident #129 was on a two-gram sodium diet related to increased edema.

Review of physician orders for Resident #129 dated 09/20/23 revealed an order for daily weights in the morning related to diagnosis of congestive heart failure.

Review of the May 2024 Medication Administration Record (MAR) for Resident #129 revealed daily weights were checked as being completed but no weights were recorded.

Review of the electronic medical record and paper chart for Resident #129 did not reveal any nutrition progress notes or assessments.

3. Review of the medical record for Resident #138 revealed an admission date of 01/22/24. Diagnoses included but were not limited to hyperlipidemia, hypertension, and Alzheimer's dementia.

Review of the 01/22/24 service plan for Resident #138 revealed Resident #138 had moderate cognitive impairment. Resident #138 was independent for eating.

Review of Resident #138's May 2024 Medication Administration Record revealed the last weekly weight was completed on 05/07/24. No additional weights were recorded 05/14/24, 05/21/24 or 05/28/24.

Review of the electronic medical record and paper chart for Resident #138 did not reveal any nutrition progress notes or assessments.

Review of the facility diet type report revealed seventeen residents (#100, #104, #108, #113, #125, #126, #129, #131, #136, #140, #144, #146, #148, #154, #158, #161, and #164) with physician orders for therapeutic diets.

Interview on 05/28/24 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #129 had an order for daily weights and Resident #138 had an order for weekly weights but was unable to provide proof of completed weight records and also confirmed she was unable to locate any nutrition monitoring documentation in the electronic medical record or the paper chart for Residents #100, #129 and #138.

Phone interview on 05/29/24 at 10:55 A.M. with Registered Dietitian (RD) #11 revealed she made her first visit to the facility on 05/14/24 and was scheduled to come to the facility quarterly. RD #11 stated she visited the list of residents the facility gave her but was not aware of all the resident diets or nutritional needs since it was her first visit. RD #11 confirmed she was unable to review all of the therapeutic diets while at the facility and was unsure of how often or where the previous dietitian charted since it was her first visit.

Interview on 05/29/24 at 3:23 P.M. with Business Office Manger #10 revealed she was unable to find a job description or policy for the duties of the Registered Dietitian.

Based on record review and interview the facility failed to ensure two disaster drills were conducted per year as required. This had the potential to affect all 67 residents residing in the facility.

Findings include:

Review of the disaster drill records on 05/28/24 at 12:00 P.M. with Maintenance Director #9 revealed the facility conducted a tornado drill on 03/19/24 but did not conduct a second disaster preparedness drill in the past 12 months. Maintenance Director #9 verified a second disaster drill was not conducted.

This violation is a recite to the annual survey completed 03/25/22.

Based on medical record review and interview the facility failed to ensure residents were provided with fire safety training. This affected five of five residents (#100, #129, #138, #151 and #160) reviewed for fire safety. This had the potential to affect all 67 residents residing in the facility.

Findings include:

Review of the medical records for Residents #100, #129, #138, #151 and #160 revealed no evidence of fire safety training.

Interview on 05/29/24 at 12:57 P.M. with the Director of Nursing confirmed she was unable to provide evidence of fire safety training for the above-listed residents.

Based on record review and interview, the facility failed to ensure Resident #67 was provided a wheelchair in a timely manner as indicated in the physician's orders. This affected one (Resident #67) of three residents reviewed for accidents and hazards. The facility census was 66.

Findings include:

Review of Resident #67's Record of Inquiry form dated 03/21/23 revealed the resident was arriving from a skilled nursing facility (SNF), required one person staff assist with grooming, bathing, toileting, and transfers; was mentally alert; incontinent; feeds self; ambulatory and walked with assistance.

Review of Resident #67's closed medical record revealed the resident was admitted on 03/22/23 with diagnoses including a urinary tract infection, essential hypertension, muscle weakness, anxiety, and depression.

Review of Resident #67's physician orders revealed an order dated 03/22/23 for a walker and wheelchair with no specific directions specified for the order.

Review of Resident #67's facility service plan dated 03/22/23 revealed the resident required a wheelchair and walker daily; required staff assistance every two hours for incontinence; required staff to administer medications; required one staff assist for bathing/personal hygiene; one staff assist for dressing; independent with eating; one staff assist with toileting and was incontinent; one staff assist with ambulation and one staff assist with transferring in and out of the bed or chair.

Review of Resident #67's Nurse Practitioner (NP) Progress note dated 01/26/24 revealed indicated the resident would like to work with therapy again as she would like to have some ability to get around on her own and was too weak to do so and needed a wheelchair.

Review of Resident #67's Written Order form dated 01/26/24 revealed an order for a manual wheelchair, hospital bed (semi-electric), physical therapy (PT)/occupational therapy (OT)/speech therapy (ST) evaluations for gait, strength, balance and swallowing.

Review of Resident #67's Home Health Care Referral form dated 02/02/24 revealed the resident was ordered PT, OT, ST, a manual wheelchair, and a hospital bed (semi electric).

Review of Resident #67's therapy notes revealed the PT evaluation was completed on 02/05/24 and the OT evaluation was completed on 02/06/24.

Review of Resident #67's Nurse Practitioner progress note dated 02/23/24 revealed a follow-up visit for chronic medication conditions was completed. She had ongoing issues with general weakness and fear of falls. Therapy was ordered on the last visit but has not been completed yet. The therapy was reordered. She needed a wheelchair and currently only had a transport chair and was unable to propel it. The wheelchair was also ordered on the last visit.

Review of Resident #67's Verbal Order form dated 02/23/24 revealed an order for PT/OT evaluation and treatment for gait/balance/transfers as well as a follow-up on a wheelchair and hospital bed.

Review of Resident #67's progress note dated 02/23/24 at 9:57 P.M. authored by Licensed Practical Nurse (LPN) #807 indicated the son was in to visit and was concerned the resident was not getting out of her chair and assisted with activities of daily living (ADLs). The son requested the resident go to the emergency room (ER) for evaluation.

Telephone interview on 05/01/24 at 1:51 P.M. with Therapy #811 indicated the physician order dated 01/26/24 for a semi-electric bed and wheelchair were ordered and they were waiting on the insurance company to approve them. Therapy #811 also confirmed the OT, PT and ST evaluations were completed for Resident #67 and then the resident was transferred to the hospital on 02/23/24 and subsequently went to a different assisted living.

Interview on 05/01/24 at 1:55 P.M. with the Executive Director stated she had observed Resident #67 with a manual walker and a rollator was in her room. She could not state why the resident did not have a wheelchair as ordered because she was not working here at the time.

This violation represents non-compliance investigated under Complaint Number OH00152176.

Based on observation, record review and interviews, the facility failed to provide adequate staffing levels to meet the residents' needs. This affected four (Residents #9, #15, #58 and #70) of four residents reviewed for staffing but had the potential to affect all residents. The facility census was 71. Findings include: Review of the medical records for Residents #9, #15, #58, #70, revealed they did not receive showers as scheduled and per their preference. Review of the facility staff schedule for January 2024 revealed at times there were only two staff members scheduled in the building to care for 71 residents. Observation on 01/23/24 at 5:40 A.M. revealed there was one nurse and one Patient Care Assistant (PCA) in the building to care for 71 residents. Interview on 01/23/24 at 6:10 A.M. with Licensed Practical Nurse (LPN) #519 verified showers were not getting completed. She stated there was a PCA on the memory care caring for 16 residents and she was the only staff member in the general portion of the facility to care for the remaining 55 residents. She stated no residents were able to receive their showers on her shift due to insufficient staffing. LPN #519 stated showers do not get completed on the resident shower days due to the acuity of the residents and the amount of staffing that was being scheduled on the shifts. Interview on 01/23/24 at 6:30 A.M. with PCA #515 verified the showers scheduled are not completed due to insufficient staffing. Interview on 1/23/24 at 10:15 A.M. with LPN #528 confirmed the showers scheduled are not completed due to lack of staffing. Interview on 01/23/24 at 10:25 A.M. with PCA #547 verified showers on her shift today were not going to be completed. She stated she had four residents who had showers scheduled and she had only completed two. She stated due to the staffing for the day she would not be able to perform the remaining two showers. Interview on 01/24/24 at 10:39 A.M. with Resident #35 revealed he was not getting showers as scheduled. He stated he may wait two weeks before getting a shower due to insufficient staffing. Review of the facility policy titled, Shower or BathBased on observation, record review and interviews, the facility failed to provide adequate staffing levels to meet the residents' needs. This affected four (Residents #9, #15, #58 and #70) of four residents reviewed for staffing but had the potential to affect all residents. The facility census was 71.

Findings include:

Review of the medical records for Residents #9, #15, #58, #70, revealed they did not receive showers as scheduled and per their preference.

Review of the facility staff schedule for January 2024 revealed at times there were only two staff members scheduled in the building to care for 71 residents.

Observation on 01/23/24 at 5:40 A.M. revealed there was one nurse and one Patient Care Assistant (PCA) in the building to care for 71 residents.

Interview on 01/23/24 at 6:10 A.M. with Licensed Practical Nurse (LPN) #519 verified showers were not getting completed. She stated there was a PCA on the memory care caring for 16 residents and she was the only staff member in the general portion of the facility to care for the remaining 55 residents. She stated no residents were able to receive their showers on her shift due to insufficient staffing. LPN #519 stated showers do not get completed on the resident shower days due to the acuity of the residents and the amount of staffing that was being scheduled on the shifts.

Interview on 01/23/24 at 6:30 A.M. with PCA #515 verified the showers scheduled are not completed due to insufficient staffing.

Interview on 1/23/24 at 10:15 A.M. with LPN #528 confirmed the showers scheduled are not completed due to lack of staffing.

Interview on 01/23/24 at 10:25 A.M. with PCA #547 verified showers on her shift today were not going to be completed. She stated she had four residents who had showers scheduled and she had only completed two. She stated due to the staffing for the day she would not be able to perform the remaining two showers.

Interview on 01/24/24 at 10:39 A.M. with Resident #35 revealed he was not getting showers as scheduled. He stated he may wait two weeks before getting a shower due to insufficient staffing.

Review of the facility policy titled, Shower or Bath

Based on record review, observation and interviews the facility failed to ensure residents were provided showers as scheduled and per their preference. This affected four (Residents #9, #15, #58 and #70) of four residents reviewed for showers. The facility also did not ensure call lights were answered timely. This affected one (Resident #9) of one resident observed for call light response but had the potential to affect all residents. The facility census was 71.

Findings include:

1. Review of the medical record for Resident #9 revealed an admission date of 04/24/22 with diagnosis including chronic kidney disease and hypertension.

Review of the service plan dated 04/21/23 revealed Resident #9 needed assist of one for bathing and hygiene.

Review of the shower schedule revealed Resident #9 was to have showers on Mondays and Wednesdays on dayshift.

Review of the Resident Skin Care Assessment form (facility shower sheets) dated December 2023 and January 2024, revealed Resident #9 only had showers on 12/21/23, 12/25/23, 12/27/23, 01/01/24, 01/19/24 and 01/22/24.

Observation on 01/23/24 of call light functioning revealed Resident #9's call light was activated at 11:01 A.M. After 12 minutes, at 11:13 A.M., this surveyor searched for staff and Patient Care Assistant (PCA) #518 was noted to be in the opposite hallway. PCA #518 was made aware of the call light being activated for Resident #9 at 11:01 A.M. PCA #518 reached for her pager in her pocket and confirmed that Resident #9's call light was on and she did not answer the page as she had the pager on vibrate and did not hear the alarm sound.

An interview on 01/23/24 at 6:30 A.M. with PCA #515 verified the showers scheduled are not completed as scheduled.

An interview on 1/23/24 at 10:15 A.M. with Licensed Practical Nurse (LPN) #528 confirmed the showers scheduled are not completed.

Review of the facility policy titled, Shower or Bath

Based on interview and record review the facility failed to ensure resident records were stored in a manner that protects and ensures confidentiality and allows for immediate access to the records in an emergency. This had the potential to affect all 59 residents living in the facility.

Findings include:

Interview on 12/15/23 at 9:39 A.M. with Representative #608 from a storage unit verified the facility had a storage unit containing medical records. Representative #608 reported the facility had stopped paying the bill in July of 2023 and phone calls and letters were sent to obtain payment. Representative #608 from the storage unit reported the lock had been taken off the unit and replaced with their own lock and the facility no longer had access to the storage unit.

Interview on 12/15/23 at 9:50 A.M. with Administrator revealed Receptionist #600 had told her medical records were held in the facility and in a storage unit and the facility had not been paying the bill on the storage unit. The Administrator reported she contacted the past Regional Director #607 but he would not give her any information on the storage unit.

Interview on 12/15/23 at 9:59 A.M. with Receptionist #600 verified medical records were stored in the facility and stored in a storage unit. The storage unit had called multiple times and reported the facilities' bill for the medical records storage unit was not being paid. Receptionist #600 reported the phone calls went to the former Executive Director #609.

Record review on 12/15/23 at 1:30 P.M. revealed a lease from the storage unit to the facility dated 06/17/11 for the purpose to store files and small furniture.

Review of call logs from the storage unit to the facility revealed calls were made on 08/07/23, 08/21/23, 10/03/23, 10/12/23 and 10/17/23 to secure payment.

Review of invoice on 08/26/23 to the facility revealed an overdue balance of $501.76 and an invoice on 10/27/23 revealed an overdue balance of $1039.00.

Review of Notice of Unpaid Storage Rent and Pending Sale of Your Stored Property dated 10/27/23 revealed if payment was not made in full in ten days the stored property would be advertised for sale and sold for auction.

Review of a picture of the storage unit revealed file boxes stacked in a storage unit.

Record review of undated facility policy labeled Record Retention revealed records would be retained as necessary for six years.

This violation represents non-compliance investigated under Complaint Number OH00148055.