Health inspection·January 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm pants, underwear, socks, a coat, and a blanket. The concern was relayed to the Administrator and Director of Nursing (DON) on 12/08/23 via email. The Administrator spoke to Sister #175 via phone on 12/26/23 regarding the missing items and the facility's reimbursement policy. The facility would replace items that were not found once family provided proof of purchase/receipts. The final form was signed and dated by the Administrator and SW #101. Residents Affected - Few Review of the Resident Inventory list, received on 12/11/23, listed the following items for Resident #74: four nightgowns, two pairs of flannel pajamas, one pair of shoes (found), ten pairs of underwear, four bras, four pairs of slacks, one winter down jacket, ten pairs of socks, 12 tops, two wool sweaters, one purse (found), one black and white blanket, and one pair of bifocal glasses. Interview via phone on 01/08/24 at 10:39 A.M. with Sister #175 revealed she visited Resident #74 at the facility from 12/08/23 to 12/13/23. Sister #175 stated Resident #74 was discharged from the hospital to the facility with personal belongings including clothes, shoes, and blankets. Sister #175 stated she noticed several of those items were missing when she visited Resident #74 at the facility and reported the concern to the facility staff. Sister #175 stated the DON found the staff had not completed an inventory of Resident #74's belongings upon admission and would educate the staff on taking an inventory of any resident's personal belongings. Sister #175 stated she last spoke with facility staff on 12/26/23 and Resident #74's shoes and purse had been found but the remaining items that had been reported missing had still not been found and the facility had not reimbursed the resident for the missing items. Interview on 01/08/24 at 1:44 P.M. with Licensed Practical Nurse (LPN) #95 revealed she had completed Resident #74's admission on [DATE]. LPN #95 stated Resident #74 arrived at the facility with a couple of bags of belongings. LPN #95 stated she did not complete an inventory of Resident #74's belongings because the resident was admitted close to the end of her shift. LPN #95 did not think she had told the oncoming nurse that an inventory needed to be completed in her report to the oncoming nurse. LPN #95 stated the nurses typically did complete an inventory of any personal belongings upon admission. Interview on 01/08/24 at 1:59 P.M. with LPN #93 revealed when a resident was admitted to the facility with any personal belongings an inventory of the items was supposed to be taken of the items. Then the belongings were taken to the front desk to be labeled and then returned to the resident. Interview on 01/08/24 at 2:13 P.M. with State Tested Nurse Aide (STNA) #91 revealed Sister #175 reported some of Resident #74's personal belongings were missing. STNA #91 did search the resident's room and went to the laundry room to search for items but was not able to find any of the items and notified the DON. Interview on 01/08/24 at 3:02 P.M. with the DON confirmed an inventory of Resident #74's personal belongings was not completed upon admission. The DON stated there appeared to be miscommunication among staff as to who was responsible for completing the inventory because Resident #74 was admitted at the end of day shift/start of night shift. The DON completed education with the nursing staff and front desk staff related to the admissions process, completing an inventory of personal items, and labeling personal belongings. The DON stated an inventory log was initiated due to the incident. The DON stated prior to the grievance surrounding Resident #74's items missing, the facility did not have a specific procedure for admitting residents with personal belongings. Interview on 01/08/24 at 3:37 P.M. with the Administrator revealed Sister #175 reported the concern (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365980 If continuation sheet Page 2 of 3 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 365980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of missing items for Resident #74 on 12/08/23. The Administrator stated the initial list of items that were missing provided by Sister #175 did not include specific descriptions, colors, sizes, or brands. The Administrator followed up with Sister #175 approximately one week later and reviewed the list of items again with Sister #175 in order to obtain some additional information about the items. The Administrator offered to reimburse Resident #74 for the missing items once proof of purchase or receipts were provided for the items. The Administrator followed up again with Sister #175 on 12/26/23 about the missing items. At the time of the interview, no receipts or proof of purchase had been received. Review of the facility policy, Resident admission Procedure, revised 08/2018, revealed the policy stated, document whether or not the resident had retained any valuables in his or her possession. Complete the admission packet, assessments, education, consents, personal inventory, and documentation per facility policies and procedures. The deficiency represents non-compliance investigated under Complaint Number OH00149291. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365980 If continuation sheet Page 3 of 3