Inspection·December 24, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of a self-reported incident (SRI), and policy review, the facility failed to timely investigate and report allegations of misappropriation to the State Survey Agency. This affected one (#5) of three residents reviewed for misappropriation. The facility census was 47. Findings included: Review of the medical record for Resident #5 revealed an admission date of 08/18/24. Diagnoses included congestive heart failure, alcoholic cirrhosis of liver with ascites, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of an SRI submitted to the State Survey Agency on 12/19/24 at 12:21:15 P.M. revealed an allegation of a staff member taking $40.00 from Resident #5. The SRI revealed Resident #5 alleged he gave Housekeeper #200 $40.00 on 12/10/24 to purchase vape (an electronic device that heats a liquid into an aerosol that is inhaled through a mouthpiece) supplies. Resident #5 reported to Activity Director (AD) #206 on 12/12/24 that Housekeeper #200 took his money and did not return the money or vaping supplies. Further review of the SRI revealed the facility indicated in the report the allegation occurred on 12/12/24 and the date of discovery was 12/16/24. Review of an attached document titled, Self-Reported Incident Initial Form, included with the SRI submitted to the State Survey Agency on 12/19/24, revealed an allegation category of misappropriation of property/exploitation was reported to AD #206 on 12/12/24 at approximately 2:15 P.M. and the Administrator was notified of the allegation on 12/12/24 at approximately 2:30 P.M. Further review of the document revealed a notation that the report was submitted on 12/13/24 at approximately 4:00 P.M. Interview on 12/24/24 at 8:56 A.M. with the Administrator confirmed he did not report Resident #5's allegation of misappropriation to the State Survey Agency within the required timeframe when it was reported to him on 12/12/24. Interview on 12/24/24 at 9:20 A.M. with Regional Director of Clinical Operations (RDCO) #300 confirmed the SRI for Resident #5's allegation of misappropriation was not timely reported to the State Survey Agency as it was not submitted until 12/19/24. Review of facility abuse policy, dated 10/06/22, revealed reporting for misappropriation of (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 2 Event ID: 365731 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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)