Inspection·November 8, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, staff interview, review of a self reported incident (SRI) and subsequent investigation, review of a transcribed interview, policy review, and review of corrective action documentation, the facility failed to ensure residents were free from misappropriation. This affected two (#1 and #2) of three residents reviewed for misappropriation. The facility census was 83. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of one person for completing her activities of daily living (ADLs). Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, congestive heart failure, and malnutrition. Review of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact and required extensive assistance of one person for completing her ADLs. Review of an SRI and investigation documentation revealed on 10/24/24 at approximately 3:00 P.M. Resident #1 reported money missing from her cellular telephone (cell phone)/wallet. Resident #1 stated the money was removed at some point after 10:00 A.M. on 10/23/24. Resident #1 verbalized she was in possession of $85.00. Resident #1 stated when she went to check on the money at 2:30 P.M. on 10/24/24 it was gone. An investigation into the missing personal funds began immediately which included identifying all staff that worked around the time of the incident, interviewing staff, interviewing other residents, and a in-depth interview with Resident #1 and Resident #1's son. A camera was authorized and placed in Resident #1's private room on 10/24/24 and $25.00 was placed in Resident #1's cell phone/wallet. While staff were placing the camera in Resident #1's room, Resident #2 reported to the facility's receptionist he was also missing money. Resident #2 stated he was out of his room from approximately 1:15 P.M. to 3:10 P.M. on 10/24/24, and when he returned and checked his wallet all but $2.00 were missing. Resident #2 stated he got money from a bank the previous day and sold a cell phone to a friend for $100.00. Resident #2 stated he had a total of $200.00 in his possession. A second camera was ordered after the information was obtained from Resident #2. On Monday 10/28/24, the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365508 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 365508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welcome Nursing Home 417 South Main Street Oberlin, OH 44074 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)