Health 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. Page 1 of 5 366261 366261 01/31/2024 Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 01/30/24 at 3:21 P.M. Licensed Practical Nurse (LPN) #111 verified their payroll check dated 01/19/24 was returned and had to be run through the bank again. Interview on 01/31/24 at 11:04 A.M. Administrator verified State Tested Nursing Assistant (STNA) #63, STNA #101, Housekeeper #102, Activities Assistant #103, Housekeeper #104, STNA #105, STNA #108, LPN #111, and Consultant #300 had payroll checks returned due to an error with processing of checks. The Administrator stated the money was wired to seven employees and two employees had their checks rerun through their bank. Interview on 01/31/24 at 11:22 A.M. STNA #108 verified their payroll check dated 01/19/24 was returned. STNA #108 stated the money had been wired to their account and they were to be refunded the wire transfer fee on the next payroll check on 02/02/24. Interview on 01/31/24 at 12:15 P.M. STNA #105 verified their payroll check dated 01/19/24 was returned. STNA #105 stated the money was in their account the next day. STNA #105 stated they got a full time job somewhere else and stayed on as needed at the facility due to payroll checks being returned. Interview on 01/31/24 at 11:56 P.M. Housekeeper #102 verified their payroll check dated 01/19/24 was returned. Interview on 01/31/24 at 11:58 A.M. STNA #101 verified their payroll check dated 01/19/24 was returned. b. On 01/31/24 at 9:54 A.M. with the Administrator present, an interview with American Electric Power (AEP) representative revealed the facility currently owed $3,186.19. The AEP representative stated there was not currently a past due amount. However, if the $3,186.19 was not paid by 02/01/24, a disconnect notice would be generated on 02/07/24. c. Interview on 01/31/24 at 10:19 A.M. with the Senior [NAME] President of Broad River Therapy revealed they had started providing services to Astoria Care of Barnesville in September 2023. Broad River Therapy was paid for September services in December 2023 (which correlated with the previous State agency survey). The Senior [NAME] President of Broad River Therapy verified that was the only payment received. A wire transfer was supposed to be made the week of 01/29/24 but it had not been received as of Wednesday, 01/31/24. The Senior [NAME] President of Broad River Therapy stated they had engaged their attorney to try to work out a payment plan with the facility. Senior [NAME] President of Broad River Therapy verified if a payment was not made, therapy services could be stopped. On 01/31/24 at 1:01 P.M. Administrator provided a copy of a payment summary revealing September's balance of $5,427.23 was paid to Broad River Therapy on 12/28/23. The Administrator provided invoice #108083 for the balance of $18,688.17 owed for October with a due date of 12/02/23. The Administrator verified Broad River Therapy had a past due amount. The Administrator indicated weekly calls were held with corporate to discuss vendors being paid and the Administrator stated he was not aware of Broad River Therapy not being paid. Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and 366261 Page 2 of 5 366261 01/31/2024 Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713

F 0837 Level of Harm - Minimal harm or potential for actual harm operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator and to the compliance and ethics officer by scheduling executive board sessions with the compliance and ethics officer that allows for a free flow of information without potential for conflict. The governing body consisted of Chief Financial Officer #600, Chief Executive, Officer #601, and Chief Nursing Residents Affected - Many Officer/Compliance Officer #602. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. Review of the administrator job description revealed they would operate the facility in accordance with the established policies and procedures of the facility. The job description indicated the administrator would supervise the recruitment, employment and discharge of staff. And work closely with the DON to assure there were adequate numbers of staff to meet the needs of each resident and to comply with the state of Ohio licensure law. The administrator would act as a liaison with the facility owners and the medical, nursing, and other supervisory staff through regular meetings. This deficiency represents non-compliance investigated under Complaint Number OH00150510. 366261 Page 3 of 5 366261 01/31/2024 Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 30. Residents Affected - Many Findings include: Review of the provided QAPI documentation, beginning 10/01/23, revealed an identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with the Administrator and Business Office Manager were to be completed weekly. The QAPI did not identify any type of ongoing systemic monitoring and mechanisms to ensure there was no disruption of employee payroll responsibilities and to ensure all staff were paid on the agreed payroll date. a. During the onsite investigation, the facility provided a list of nine employees who had paychecks returned from payroll on 01/19/24. Interview on 01/31/24 at 11:04 A.M. with the Administrator verified State Tested Nursing Assistant (STNA) #63, STNA #101, Housekeeper #102, Activities Assistant #103, Housekeeper #104, STNA #105, STNA #108, LPN #111, and Consultant #300 had payroll checks returned due to an error with processing of checks. The Administrator stated the money was wired to seven employees and two employees had their checks rerun through their bank. The Administrator verified payroll was not listed as one of the concerns listed as discussed at the weekly or monthly QAPI meetings. Interview on 01/30/24 at 10:33 A.M. Corporate Financial Officer (CFO) #600 revealed there had been a positive pay upload error that caused nine employee checks to be returned. CFO #600 stated once the error was identified, it was corrected. CFO #600 stated corporate was looking at ways to ensure the upload error did not occur again. CFO #600 verified payroll was not listed as one of the concerns discussed in the weekly QAPI calls. b. On 01/31/24 at 9:54 A.M. with the Administrator present, an interview with American Electric Power (AEP) representative revealed the facility owed $3,186.19. The AEP representative stated there was not currently a past due amount. However, if the $3,186.19 was not paid by 02/01/24, a disconnect notice would be generated on 02/07/24. c. Interview on 01/31/24 at 10:19 A.M. with the Senior [NAME] President of Broad River Therapy revealed they had started providing services to Astoria Care of Barnesville in September 2023. Broad River Therapy was paid for September services in December 2023 (which correlated with the previous State agency survey). The Senior [NAME] President of Broad River Therapy verified that was the only payment received. A wire transfer was supposed to be made the week of 01/29/24 but it had not been received as of Wednesday, 01/31/24. The Senior [NAME] President of Broad River Therapy stated they had engaged their attorney to try to work out a payment plan. The Senior [NAME] President of Broad River Therapy verified if a payment was not made, therapy services could be stopped. On 01/31/24 at 1:01 P.M. Administrator provided a copy of a payment summary revealing September's balance of $5,427.23 was paid to Broad River Therapy on 12/28/23. The Administrator provided invoice 366261 Page 4 of 5 366261 01/31/2024 Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many #108083 for the balance of $18,688.17 owed for October with a due date of 12/02/23. Administrator verified Broad River Therapy had a past due amount. The Administrator also verified weekly calls were held with corporate to discuss vendors being paid and stated the Administrator was not aware of Broad River Therapy not being paid. Review of the facility policy dared February 2020 titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. This deficiency represents non-compliance investigated under Complaint Number OH00150510. 366261 Page 5 of 5