The Loft at Cambridge

Based on observation and staff interview, the facility failed to ensure food items were stored appropriately by dating opened food items to protect against spoilage. This had the potential to affect all 26 residents within the facility.

Findings include:

Observations of the facility kitchen on 10/01/25 at 10:35 A.M. revealed the following items in the walk in cooler without any label of when opened: pan on sliced onions, pan of sliced tomatoes, serving pitcher halfull of chicken noodle soup and a serving container halfull of brown gravy.

On 10/01/25 at 10:35 A.M. interview with Cook #33 verified the observation.

Based on observation, staff interview, facility record review,and facility policy review the facility failed to ensure meals were prepared and served as per the planned menu. This affected all 25 residents residing in the facility.

Findings include:

1. Review of the meal spreadsheet, dated Fall/Winter 2024-2025 revealed the lunch menu for Monday included polish sausage and crushed pineapple.

Review of the meal tickets, dated 12/02/24 revealed polish sausage and crushed pineapple was offered as part of the lunch meal. Eighteen tickets indicated the residents selected the meal for lunch.

Review of a menu substitution form, dated 12/02/24 revealed polish sausage was not available and was substituted with quiche.

Review of a concern/follow up log dated 08/29/24 revealed residents were asked during a resident council meeting if they were getting what they requested on the menu and a resident stated no one ever asks them and they don't ever know what they are having. An inservice dated 08/30/24 provided staff with education to make sure they are asking residents their meal preference prior to the meal. Eight staff members signed the inservice.

On 12/02/24 at 11:26 A.M. observation of the lunch meal revealed no evidence of polish sausage or crushed pineapple being prepared and/or available. At the time of observation, interview with Cook #52 revealed polish sausage was forgotten about when the previous food supply was ordered. Cook #52 stated they didn't think the residents would want or like the crushed pineapple. Cook #52 stated they believed quiche was a proper substitution to polish sausage. Cook #52 confirmed crushed pineapple was not prepared for the meal and pudding and jello cups were being served instead. When asked if the dietician was consulted regarding the substitutions, the cook stated they did not confer with the dietician.

The facility identified all 25 residents received a meal tray from the kitchen.

The facility was unable to provide a policy for food service or substitutions.

2. Review of the meal spreadsheet, dated Fall/Winter 2024-2025 revealed the dinner menu for Monday included tuna salad on a bun for regular diets and tuna salad on white bread for mechanical soft diets.

Review of the meal tickets dated 12/02/24 revealed tuna salad on a bun was offered as part of the dinner meal. Fifteen tickets indicated the residents selected the meal for dinner.

Review of the facility's menu substitution form revealed no documentation of a substitution for the dinner meal on 12/02/24.

On 12/02/24 at 4:15 P.M. an observation of the dinner meal revealed tuna salad was being served on two slices of white bread instead of a bun. At the time of observation, interview with Dietary Manager (DM) # 54 revealed the facility served a lot of meals requiring buns in the previous week and not enough buns were ordered. DM #54 stated it was hard to tell how much supply the facility would need from one week to the next. DM #54 revealed the substitution of white bread in place of a bun wasn't added to the substitution log because both items were pretty much the same thing.

The facility was unable to provide a policy for food service or substitutions.

Based on facility record review, staff interview, and policy review, the facility failed to conduct a fire drill on each shift at least every three months. The facility also failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the facility during at least two fire drills per shift per year as required. This had the potential to affect all 25 residents that resided at the facility.

Findings Include:

1. Review of fire drills dated 11/30/23 to 10/25/24 revealed fire drills were not conducted once per shift every three months as required. There were no fire drills completed on first shift between 08/2024-11/2024. There were no fire drills completed on second shift between 03/2024-07/2024. There were no fire drills completed on third shift from 02/2024-05/2024.

Interview with Executive Director (ED) #62 at the time of review confirmed the findings. ED #62 stated the facility was working on correcting fire drill procedures since being cited on a previous survey for the Nursing Home earlier in the year.

The facility was unable to provide a policy for Fire Drills.

2. Review of fire drills dated 11/30/23 to 10/25/24 revealed no evidence of residents who were capable of self-evacuation were evacuated to a safe area or to the exterior of the facility during at least two fire drills per shift per year.

Interview with Executive Director (ED) #62 at the time of review confirmed the findings. ED #62 stated the facility was working on correcting fire drill procedures since being cited on a previous survey for the Nursing Home earlier in the year.

The facility was unable to provide a policy for Fire Drills

Based on observation, facility record review, and staff interview, the facility failed to conduct complete monthly fire safety inspections. This had the potential to affect all 25 residents residing in the facility.

Findings Include:

An observation of the resident dining area on 12/02/24 at 8:22 A.M. revealed the fire extinguisher in the area was last signed off as checked on 09/25/24. At the time of observation, interview with Certified Nursing Assistant (CNA) #56 confirmed the findings.

An observation of the fire extinguisher located next to the nurses station on 12/02/24 at 8:36 A.M. revealed the fire extinguisher was last signed off as checked on 09/25/24. At the time of observation, interview with Licensed Practical Nurse (LPN) #58 confirmed the findings.

An observation of the fire extinguisher located near the resident lounge on 12/02/24 at 8:39 A.M. revealed the fire extinguisher was last signed off as checked on 09/25/24. At the time of observation, LPN #58 confirmed the findings.

Review of the Fire Safety Self Inspection Form dated 09/19/24 revealed Maintenance Director (MD) #60 signed off the fire extinguishers monthly inspection tag was signed and dated.

Review of the Fire Safety Self Inspection Form dated 10/24/24 revealed MD #60 signed off the fire extinguishers monthly inspection tag was signed and dated.

Review of the Fire Safety Self Inspection Form dated 11/14/24 revealed MD #60 signed off the fire extinguishers monthly inspection tag was signed and dated.

Based on observation, record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Real and Present Danger beginning on 02/16/24 when the lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization, displacement due to potential interruption in staffing and/or outside service providers. This had the potential to affect all 30 residents residing in the facility.

On 03/05/24 at 5:24 P.M., the Administrator and Director of Nursing (DON) were notified Real and Present Danger began on 02/16/24 when the onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying staff in a timely manner and having outstanding balances with vendors and providers. This included, but was not limited to, insufficient funds to meet staff payroll on 02/16/24 and 03/01/24, delinquent balances owed to nutrition services which resulted in dietitian services being terminated from 03/01/24 through 03/04/24, delinquent property taxes, therapy services, medical director services, refuse/recycling, and pest control services.

The Real and Present Danger remains ongoing, as the facility failed to implement corrective measures to remove the Real and Present Danger situation.

Findings include:

During the onsite survey, completed on 03/11/24 observations revealed the facility residential care (RCF) was physically located within the same building as Astoria Place of Cambridge, a skilled nursing facility (SNF). The facility was noted to use the same staff in both the RCF and SNF. In addition, the same vendors and service providers provided services in both the RCF and SNF.

Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances, non-payment and shut off notices being issued to the facility. Following the 12/04/23 survey, the facility provided evidence of payments being made to various different supplies/vendors removing the likelihood of situations of neglect and the resolution of shut off notices for the facility. However, during a complaint survey completed on 01/31/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and their Quality Assurance and Performance Improvement Program had continued evaluations to ensure ongoing compliance with all financial obligations for the delivery of care including therapy services, payment of the electricity bill and staff payroll.

Interview with the Administrator on 03/04/24 at 8:39 A.M. revealed employees were being paid every other week and were receiving paper checks on payday. However, as of this date there were employee's checks that were being returned for insufficient funds (from the most recent pay date of 03/01/24). The Administrator revealed Epic Healthcare Solutions (the corporate management company) would then wire the funds to the affected employee's bank account after being notified the employee's check was not clearing at the bank.

Interview during the survey with an anonymous staff member revealed she was very concerned with her payroll checks bouncing and being returned for sufficient funds. She stated she had both 02/16/24 and 03/01/24 paydays affected by this and would more than likely be terminating her employment and looking for another job.

Interview on 03/04/24 at 9:00 A.M. with Registered Nurse (RN) #205 revealed her payroll check on 02/16/24 was returned due to insufficient funds. She stated she updated the DON on 02/19/24 who then updated corporate. RN #205 stated she received a wire transfer for her payroll check but not until 02/20/24.

Interview on 03/04/24 at 9:21 A.M. with the Business Office Manager (BOM) #207 verified there were payroll checks that did not clear employee banks on 02/16/24 due to insufficient funds. She provided a list that revealed 41 out of 62 staff members did not get paid on the 02/16/24 payday as their checks bounced. BOM #207 revealed staff had been made aware by their bank their payroll checks were returned for insufficient funds for the 02/16/24 payday. The staff had reported this to the DON who then updated BOM #207. She stated she sent a list to the corporate management company who then wired the money directly into the employees' personal accounts. She stated employees who experienced wire fees or bounced check fees from the 02/16/24 pay issue, were also to be reimbursed these fees on the 03/01/24 payday. During the interview, BOM #207 also shared most of the facility bills were being sent directly from the vendors to the facility corporate office. Any bills or invoices received at the facility were scanned and emailed directly to Stampli (the company that processed and paid invoices).

Review of the 02/16/24 list of employees who had their payroll checks returned for insufficient funds included the current Administrator, BOM #207, Maintenance #340, RN #205, RN #302, RN #303, RN #304, RN #339, Licensed Practical Nurse (LPN) #306, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, State Tested Nurse Aide (STNA) #203, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #320, STNA #321, STNA #324, STNA #325, STNA #326, STNA #327, Dietary #328, Dietary #330, Dietary #331, Dietary #332, Dietary #333, Dietary #335, Dietary #336, Housekeeping (HK) #341, HK #342, HK #343, HK #345, HK #346, HK #348 and Hospitality Aide #347.

Interview on 03/04/24 at 9:57 A.M. with the Chief Financial Officer (CFO) #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated this was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from their human resource file to the bank and those were then paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. Additional interview on 03/05/24 at 10:36 A.M. With CFO #600 verified he had been updated that payroll checks were returned as having insufficient funds for the payroll date of 03/01/24. He stated he was unsure of what had occurred. He stated payroll accounts were separate then those accounts used to pay facility vendors and suppliers. He also stated they had separate accounts at the same bank (Bank of Oklahoma Financial) for all the facilities owned by the corporation. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed.

Interview on 03/04/24 at 11:29 A.M. with the Ombudsman revealed a resident of the SNF had stated to her during a visit that she was worried the facility would be closing and she would have to find another place to live. The resident stated to the Ombudsman that she had overhead staff talking about not being paid correctly and their payroll checks being returned for insufficient funds. The Ombudsman stated she had updated Administrator #351 (the previous facility Administrator) about the concern.

Interview on 03/04/24 at 12:15 P.M. with an anonymous staff member revealed she was concerned every payday about her payroll checks not clearing her bank.

Review of emails from the DON dated 03/05/24 at 11:31 A.M. through 03/11/24 at 9:33 A.M. revealed 45 out of 62 staff members received returned paychecks due to insufficient funds (from the 03/01/24 pay day). These staff included the Administrator, Previous Administrator #351, BOM #207, Social Services Designee (SSD) #337, RN #204, RN #205, RN #300, RN #301, RN #303, RN #304, RN #339, Maintenance #340, LPN #307, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, STNA #203, STNA #206, STNA #312, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #319, STNA #320, STNA #321, STNA #322, STNA #323, STNA #324, STNA #325, STNA #326, STNA #327, Dietary Director #208, Dietary #328, Dietary #333, Dietary #336, HK #341, HK #342, HK #343, HK #348 and Hospitality Aide #347.

An interview on 03/07/24 at 8:40 A.M. with Activities Director #352 revealed she had been taking her check to a local grocery store to cash as she had been afraid to take it to her bank and be returned for insufficient funds. She stated she had been taking her payroll checks to the grocery store, cashing them (for which the grocery store charged a fee based on the amount of the check) and then would take the cash and deposit it into her bank account. She stated she was aware there were employee checks that had been cashed at the grocery store that had not cleared the grocery store's bank and been returned to them for insufficient funds.

An attempt to reach the grocery store manager/owner on 03/07/24 at 10:56 A.M. was unsuccessful. A message was left for the owner/manager to return the call to the surveyor, but no return call was provided.

On 03/07/24 at 11:21 A.M. a phone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met due to the identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation had been provided.

On 03/11/24 at 9:05 A.M. an interview with the DON verified the last wire transfer to staff to pay from the 02/16/24 pay day was not made until 02/29/24 (almost two weeks after the pay date). The DON stated the (unidentified) staff member notified her on 02/28/24 that their check bounced, and the corporation then wired the funds directly to the staff member's account.

In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified:

a. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24.

Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services.

b. Review of the invoice from Kimble Recycling dated 02/13/24 revealed a total balance due of $1,531.10. This showed services due for 02/01/24 for $765.55 and 01/01/24 for $765.55. This had been received by the facility and scanned to the corporate office on 02/20/24.

An interview on 03/04/24 at 11:05 A.M. with the recycling company's Accounts Receivable Clerk (AR) #213 revealed the facility was behind 60 days on their billing.

c. Review of the invoice from Buckeye Pest Management dated 02/20/24 revealed a total balance due of $723.95. This showed services due for 10/05/23, 11/06/23, 12/07/23, 01/04/24 and 02/01/24. The statement was received and scanned to the corporate office on 02/28/24.

Interview on 03/04/24 at 10:50 A.M. with the pest management's Accounts Receivable Clerk (AR) #133 revealed she had been in contact with the facility related to their balance of $723.95. She stated they had not received any payments from the facility since prior to October 2023. .

. Interview on 03/05/24 at 11:45 A.M. with Medical Director (MD) #351 revealed he was unaware of how much the facility owed him for medical director fees. During the interview, he contacted his office and spoke to one of the staff and discovered the facility owed MD #351 for September 2023, November 2023, December 2023, January 2024 and February 2024. This totaled $15,000.00. It was noted the corporation had made payment arrangements and had kept those arrangements until January 2024. There was no payment received in the month of February 2024.

e. Review of the invoice from Broad River Therapy dated 03/06/24 revealed a total balance due of $103,531.89. This was due for services from 11/02/23 to 12/02/23 for $27,251.19; 12/01/23 to 12/31/23 for $28,291.58; 01/02/24 to 02/01/24 for $22,527.73; and 02/02/24 to 03/03/24 for $25,461.39.

Interview on 03/04/24 at 11:57 A.M. with Therapy Office Manager #128 revealed the facility had not paid for services since September 2023. However, she stated CFO #600 stated the corporation would be sending checks the week of 03/04/24.

f. Interview on 03/05/24 at 10:16 A.M. with Clerk #350 at the Guernsey Country Treasurer's Office revealed the facility had set-up a payment plan for the balance due which included a delinquent balance, late fees and interest. She stated the facility owed a total of $101,283.27 for property taxes and had made a payment arrangement to pay $5,000 a month and made a payment on 01/12/24. However, Clerk #350 stated the facility (corporation) had failed to make a payment in February 2024.

On 03/10/24 the Ombudsman conducted an onsite visit at the facility. The Ombudsman reported staff were worried about getting paid on Friday (03/15/24). This date is the next scheduled date for staff to be paid in the facility.

Review of the Employee Handbook, dated 2020, revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card.

Review of the facility policy titled, Abuse Prevention, Identification and Reporting

Based on record review, facility policy review, and interviews, the facility failed to ensure an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care.

This affected all 29 residents residing in the facility.

Findings include:

Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances, non-payment and shut off notices being issued to the facility. Following the 12/04/23 survey, the facility provided evidence of payments being made to various different supplies/vendors removing the likelihood of situations of neglect and the resolution of shut off notices for the facility. However, at the time of this complaint survey, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility, which included ongoing compliance with all financial obligations for the delivery of care as detailed below:

a. Interview on 01/29/24 at 8:39 A.M. with the Director of Nursing (DON) verified there were some employee payroll checks that did not clear on 01/19/24. The DON stated corporate had wired money to cover the checks that did not clear. The staff could work in the residential care facility or the long term care facility.

The facility provided a list of 14 employees that had paychecks returned from payroll on 01/19/24. Interview on 01/29/24 at 10:31 A.M. Administrator revealed himself, the Assistant Administrator, STNA #54, STNA #55, LPN #59, RN #62, STNA #63, STNA #66, STNA #69, STNA #72, STNA #75, LPN #89, Social Service #90, and Hairdresser #110 all had payroll checks returned due to an error with processing of the checks. Corporate either wired money to employees in the amount of their pay or had the bank rerun the checks through.

Interview on 01/29/24 at 8:49 A.M. with State Tested Nursing Assistant (STNA) #54 verified their payroll check did not clear.

Interview on 01/29/24 at 8:50 A.M. with STNA #55 verified their payroll check did not clear.

Interview on 01/29/24 at 8:54 A.M. with Licensed Practical Nurse (LPN) #59 verified payroll check did not clear.

Interview on 01/29/24 at 10:26 A.M. with STNA #63 verified their payroll check did not clear.

STNA #54, STNA #55, LPN #59, and STNA #63 verified corporate did provide the money through wire transfer or having the checks rerun. If the money was wired to an employee's account, the employee would be reimbursed on the payroll check for 02/02/24.

Interview on 01/30/24 at 10:33 A.M. with Corporate Financial Officer (CFO) #600 revealed there had been a positive pay upload error. CFO #600 explained each check was matched for payment to be made. If the check number or amount was incorrect or not listed, then the check would be returned. CFO #600 stated this was done to decrease the risk of check fraud. CFO #600 stated once the error was discovered the file was corrected and the check numbers were added so the checks could be rerun by the banks. If the employee did not want the check rerun, the money was wired to their bank. CFO #600 stated they had already identified the error that occurred when some of the check numbers were left off the file and would be working on a process to ensure that did not happen again.

b. On 01/29/24 at 4:06 P.M., with the Administrator present, a telephone interview with the electric company (AEP) Representative #100 revealed the facility had a balance of $13,010.70 due on 02/06/24 with a past due balance of $661.83, due immediately. She stated the past due balance was from 12/11/23. The electric company had received multiple payments on 01/24/24 but the past due amount remained. Lastly, AEP Representative #100 confirmed there were no pending shut off notices for the facility.

On 01/29/24 at 4:10 P.M. .interview with the Administrator verified he was unaware of the outstanding balance owed to the electric company despite the weekly calls regarding bill payment.

c. On 01/31/24 at 11:02 A.M. interview with Broad River Therapy Vice President (VP) #200 revealed the corporation had not paid the balance for October, November or December therapy services at this time. She was unsure of the amount owed offhand but there were concerns arranging payment with the facility.

Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator and to the compliance and ethics officer by scheduling executive board sessions with the compliance and ethics officer that allows for a free flow of information without potential for conflict. The governing body consisted of Chief Financial Officer #600, Chief Executive, Officer #601, and Chief Nursing

Officer/Compliance Officer #602.

Review of the administrator job description revealed they would operate the facility in accordance with the established policies and procedures of the facility. The job description indicated the administrator would supervise the recruitment, employment and discharge of staff. And work closely with the DON to assure there were adequate numbers of staff to meet the needs of each resident and to comply with the state of Ohio licensure law. The administrator would act as a liaison with the facility owners and the medical, nursing, and other supervisory staff through regular meetings.

This violation represents non-compliance investigated under Complaint Number OH00150407.

Based on record review and interviews, the facility failed to respond promptly to requests for Resident #24. This affected one (Resident #24) out of three residents reviewed. Facility census was 29.

Findings include:

Review of the medical record revealed Resident #24 was admitted on 11/04/21, readmitted on 01/28/22 and discharged on 11/18/23. Resident #24 diagnoses included heart disease, anxiety disorder and major depressive disorder.

The medical record revealed Resident #24 had a guardian of person.

Review of billing statement dated 11/06/23 revealed Resident #24 owed the facility $192.14.

Interview on 01/29/24 at 9:47 A.M. Guardian for Resident #24 revealed Resident #24 was discharged to live at home independently. Guardian of Resident #24 stated they started the process and went to the office to get a copy of Resident #24's billing. Resident #24 had a negative balance of $192.14. Resident #24 had not resided the whole month of November 2023 and should have been refunded some of the money that was paid for November 2023. When the guardian asked about the refund, Business Office Manager (BOM) #93 stated they had to check with corporate about issuing a refund. Guardian of Resident #24 revealed they had not received any additional information about what was owed to the facility or what was to be refunded to Resident #24.

Interview on 01/29/24 at 9:58 A.M. BOM #93 revealed they were unable to issue a refund to Resident #24 until the negative balance of $192.14 was taken care of. BOM #93 stated Resident #24's guardian needed to sign a paper stating the $192.14 could be deducted from the amount owed before a check could be issued. BOM #93 verified Resident #24's guardian had not signed any papers and the facility had not been billed for the #192.14 since November 2023.

Interview on 01/30/24 7:48 A.M. BOM #93 verified corporate had issued a reimbursement with check 1052 on 01/29/24 in the amount of $1,191.26 to Resident #24.

This violation represents non-compliance investigated under Complaint Number OH00150505.