Health inspection·January 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, resident representative interview, staff interviews, review of the grievance log, review of a missing items concern form, and facility policy review, the facility failed to protect Resident #74's belongings from being lost. This affected one resident (#74) of three reviewed for missing items. The facility census was 72. Findings Include: Review of the former Resident #74's closed medical record revealed an admission date on 11/21/23 and a discharge date on 12/14/23. Medical diagnoses included anxiety disorder, unsteadiness on feet, chronic kidney disease Stage 3, dementia with behavioral disturbance, and metabolic encephalopathy. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had impaired cognition and scored nine out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required set-up or clean-up assistance with self-care activities of daily living (ADL), except bathing required partial to moderate assistance from staff. Resident #74 required supervision or touch assistance from staff for mobility, including bed mobility and transfers. Resident #74 was ambulatory without the use of any assistive devices. Review of the progress notes revealed on 11/21/23 at 7:34 P.M., Resident #74 arrived by stretcher with two Emergency Medical Services (EMS) staff. The resident was alert and oriented to self only. A head-to-toe assessment was completed. Medications were verified with the on-call physician/Certified Nurse Practitioner (CNP). There was no documented evidence Resident #74's inventory of the resident's belongings was completed. Review of the care plan dated 11/21/23 revealed Resident #74 had impaired cognitive process related to decision making. Resident #74 wandered in and out of rooms and removed others bedding and items. Interventions included encourage resident to make routine daily decisions, administer medications as ordered, communicate with staff, family, physician/CNP regarding resident's needs, and obtain input from family, friends regarding the resident's likes and dislikes. Review of the grievance log dated from September 2023 through January 2024 revealed Resident #74's sister filed a grievance on behalf of Resident #74 for missing items on 12/08/23. The log noted follow up was completed on 12/09/23 and final communication was made on 12/26/23. Review of the Missing Item Form dated 12/08/23 and completed by Social Worker (SW) #101 for Resident #74 revealed Sister #175 reported a bag from the hospital was missing that contained shirts, Page 1 of 3 365980 365980 01/08/2024 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

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 365980 Page 2 of 3 365980 01/08/2024 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

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. 365980 Page 3 of 3