Inspection·January 31, 2024

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, facility assessment review, and interviews, the facility failed to establish 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 had the potential to affect all 30 residents in the facility. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. 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 12/18/23 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. On 01/30/24 at 10:33 A.M. interview with Corporate Financial Officer (CFO) #600 revealed there had been a positive pay upload error involving employee payroll on 01/19/24. 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 identified the error that occurred when some of the check numbers were left off the file and stated they would be working on a process to ensure this did not happen again. The facility provided a list of nine employees, State Tested Nursing Assistant (STNA) #63, STNA #101, Housekeeper #102, Activities Assistant #103, Housekeeper #104, STNA #105, STNA #108, Licensed Practical Nurse (LPN) #111, and Consultant #300 who had paychecks returned from payroll on 01/19/24. (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 5 Event ID: 366261 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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)