Health inspection·June 16, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on observation, interview, record review, review of facility self-reported incidents (SRI) and facility policy review, the facility failed to ensure Resident #4 was free from misappropriation. This affected one resident (#4) of three residents reviewed for abuse, neglect and misappropriation of property. The facility census was 44. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, recurrent urinary tract infection (UTI), chronic kidney disease, atrial fibrillation and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively impaired and required extensive assistance with activities of daily living. Review of a facility self-reported incident (SRI) control number 260103 dated 05/06/25 revealed Resident #4's daughter had called the facility and notified them that a check had been written from Resident #4's account in the amount of $3,225.00 dollars. The check was written to a former employee who had attempted to deposit the check. Resident #4's daughter had been notified by the bank of the attempted deposit. The SRI referenced that the police were involved and were investigating. The facility substantiated that misappropriation occurred. Review of the facility's SRI investigation dated 05/06/23 revealed on 05/06/25 the Resident #4's daughter was notified by the bank that check #4413 was attempted to be deposited on 05/02/25 by mobile deposit and was pending. On 05/06/25 at 3:30 P.M. Resident #4's daughter notified the facility of the incident. The facility filed a SRI and notified the local police department. The check was dated 05/02/25 and was made out to former Certified Nursing Assistant (CNA) #100 with a signature of Resident #4. The back of the check was signed by STNA #100 and there was a handwritten statement that the check was for mobile deposit only. Review of the CNA #100's employee status revealed she was hired on 02/09/24 and terminated on 01/19/25 for unrelated attendance concerns. Review of the local police report dated 05/06/25 revealed the police arrived at the facility at 4:53 P.M. and filed a report of theft with a note stating Resident #4 had a check stolen from her room. Interview on 06/12/25 at 11:10 A.M. with Resident #4's daughter stated a former CNA had taken one Page 1 of 3 366266 366266 06/16/2025 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident #4's checks and had attempted to deposit funds in the CNA's personal account. Resident #4's daughter reported she was notified, and the blank flagged the check. The check did not clear and there had been no transfer of funds. Interview with the Administrator on 06/12/25 at 11:45 A.M. revealed CNA #100 was hired on 02/09/24 and was terminated on 01/19/25. CNA #100 worked the 7:00 P.M. to 7:00 A.M. shift. The Administrator stated they were not aware of Resident #4's check being missing until they received a call from Resident #4's daughter on 05/06/25. Interview with the Director of Nursing (DON) on 06/12/25 at 12:30 P.M. revealed the facility reached out several times to former CNA #100, however she never responded. The DON stated she compared the writing on the check, and it appeared to be CNA #100's handwriting. The DON reported CNA #100 signed the letter A in a unique manner that appeared the same on the check and other documents she had signed. Observation and interview on 06/12/25 at 3:49 P.M. of Resident #4's checkbook revealed the check numbers remaining in the checkbook started at 4414. There was no handwritten ledger. Interview with the Administrator at this time revealed there was only one check missing, check number 4413. Resident #4's daughter was the only one who has access to monthly statements. The Administrator stated the facility was unable to identify when the check went missing. CNA #100 could have taken the check when Resident #4 was sleeping. She stated Resident #4's daughter lived out of town and was adamant that Resident #4 had her checkbook. Since the incident, the facility had secured the checkbook in the office but ensured Resident #4 could have access to her checkbook whenever needed. The Administrator stated the SRI was substantiated due to the CNA #100 taking the check while she was employed at the facility. Review of the facility policy titled Abuse, Neglect, Misappropriation Policy, revised November 2010 revealed the facility defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The police state the facility will not tolerate verbal, sexual, physical or mental abuse, involuntary seclusion or neglect of its resident or misappropriation of resident's funds or property by anyone. This violation represents non-compliance investigated under Complaint Number OH00165844. The deficient practice was corrected on 05/30/25 when the facility implemented the following corrective actions: - On 05/06/25, the police were notified of the potential theft and misappropriation of Resident #4's checkbook. The investigation remains ongoing. - On 05/07/25 the DON and the Assistant Administrator interviewed all in-house residents for misappropriation with no negative finding. - On 05/12/25, the DON and Assistant Administrator conducted night shift observations of staff. Night shift observations will continue twice monthly by the Administrator or designee and will be ongoing. - On 05/13/25, the facility's abuse, neglect, and misappropriation policy was briefly discussed 366266 Page 2 of 3 366266 06/16/2025 Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during their monthly staff meeting. Ongoing re-education of the facility's abuse, neglect, and misappropriation policy will continue at the monthly staff meeting for a duration of six months. - On 05/22/25, all staff were re-educated on the facility's abuse, neglect, and misappropriation policy. - On 05/30/25, the DON and Assistant Administrator reviewed resident council meeting minutes for any concerns related to misappropriation or missing items. There were no concerns identified. This will continue monthly on an ongoing basis. - The DON and Assistant Administrator will conduct weekly audits of residents for abuse, neglect, and misappropriation. These weekly audits will conclude on 07/03/25. The results of the audits will be reported to the Administrator. 366266 Page 3 of 3