**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 02/16/24 when the lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization, displacement due to potential interruption in staffing and/or outside service providers. This had the potential to affect all 32 residents residing in the facility. On 03/05/24 at 5:24 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/16/24 when the onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying staff in a timely manner and having outstanding balances with vendors and providers. This included, but was not limited to, insufficient funds to meet staff payroll on 02/16/24 and 03/01/24, delinquent balances owed to nutrition services which resulted in dietitian services being terminated from 03/01/24 through 03/04/24, delinquent property taxes, therapy services, medical director services, refuse/recycling, and pest control services. The Immediate Jeopardy remains ongoing, as the facility failed to implement corrective measures to remove the Immediate Jeopardy situation. Findings include: Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. 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 12/04/23 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, during a complaint survey completed on 01/31/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and their Quality Assurance and Performance Improvement Program had continued evaluations to ensure ongoing compliance with all financial obligations for the delivery of care including therapy services, payment of the electricity bill and staff payroll. Interview with the Administrator on 03/04/24 at 8:39 A.M. revealed employees were being paid every other week and were receiving paper checks on payday. However, as of this date there were employee's checks that were being returned for insufficient funds (from the most recent pay date of 03/01/24). The Administrator revealed Epic Healthcare Solutions (the corporate management company) would then wire the funds to the affected employee's bank account after being notified the employee's check was not clearing at the bank. Interview during the survey with an anonymous staff member revealed she was very concerned with her payroll checks bouncing and being returned for sufficient funds. She stated she had both 02/16/24 and 03/01/24 paydays affected by this and would more than likely be terminating her employment and looking for another job. Interview on 03/04/24 at 9:00 A.M. with Registered Nurse (RN) #205 revealed her payroll check on 02/16/24 was returned due to insufficient funds. She stated she updated the DON on 02/19/24 who then updated corporate. RN #205 stated she received a wire transfer for her payroll check but not until 02/20/24. Interview on 03/04/24 at 9:21 A.M. with the Business Office Manager (BOM) #207 verified there were payroll checks that did not clear employee banks on 02/16/24 due to insufficient funds. She provided a list that revealed 41 out of 62 staff members did not get paid on the 02/16/24 payday as their checks bounced. BOM #207 revealed staff had been made aware by their bank their payroll checks were returned for insufficient funds for the 02/16/24 payday. The staff had reported this to the DON who then updated BOM #207. She stated she sent a list to the corporate management company who then wired the money directly into the employees' personal accounts. She stated employees who experienced wire fees or bounced check fees from the 02/16/24 pay issue, were also to be reimbursed these fees on the 03/01/24 payday. During the interview, BOM #207 also shared most of the facility bills were being sent directly from the vendors to the facility corporate office. Any bills or invoices received at the facility were scanned and emailed directly to Stampli (the company that processed and paid invoices). Review of the 02/16/24 list of employees who had their payroll checks returned for insufficient funds included the current Administrator, BOM #207, Maintenance #340, RN #205, RN #302, RN #303, RN #304, RN #339, Licensed Practical Nurse (LPN) #306, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, State Tested Nurse Aide (STNA) #203, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #320, STNA #321, STNA #324, STNA #325, STNA #326, STNA #327, Dietary #328, Dietary #330, Dietary #331, Dietary #332, Dietary #333, Dietary #335, Dietary #336, Housekeeping (HK) #341, HK #342, HK #343, HK #345, HK #346, HK #348 and Hospitality Aide #347. Interview on 03/04/24 at 9:57 A.M. with the Chief Financial Officer (CFO) #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated this was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from their human resource file to the bank and those were then paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. Additional interview on 03/05/24 at 10:36 A.M. With CFO #600 verified he had been updated that payroll checks were returned as having insufficient funds for the payroll date of 03/01/24. He stated he was unsure of what had occurred. He stated payroll accounts were separate then those accounts used to pay facility vendors and suppliers. He also stated they had separate accounts at the same bank (Bank of Oklahoma Financial) for all the facilities owned by the corporation. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. Interview on 03/04/24 at 11:29 A.M. with the Ombudsman revealed a resident had stated to her during a visit that she was worried the facility would be closing and she would have to find another place to live. The resident stated to the Ombudsman that she had overhead staff talking about not being paid correctly and their payroll checks being returned for insufficient funds. The Ombudsman stated she had updated Administrator #351 (the previous facility Administrator) about the concern. Interview on 03/04/24 at 12:15 P.M. with an anonymous staff member revealed she was concerned every payday about her payroll checks not clearing her bank. Review of emails from the DON dated 03/05/24 at 11:31 A.M. through 03/11/24 at 9:33 A.M. revealed 45 out of 62 staff members received returned paychecks due to insufficient funds (from the 03/01/24 pay day). These staff included the Administrator, Previous Administrator #351, BOM #207, Social Services Designee (SSD) #337, RN #204, RN #205, RN #300, RN #301, RN #303, RN #304, RN #339, Maintenance #340, LPN #307, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, STNA #203, STNA #206, STNA #312, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #319, STNA #320, STNA #321, STNA #322, STNA #323, STNA #324, STNA #325, STNA #326, STNA #327, Dietary Director #208, Dietary #328, Dietary #333, Dietary #336, HK #341, HK #342, HK #343, HK #348 and Hospitality Aide #347. An interview on 03/07/24 at 8:40 A.M. with Activities Director #352 revealed she had been taking her check to a local grocery store to cash as she had been afraid to take it to her bank and be returned for insufficient funds. She stated she had been taking her payroll checks to the grocery store, cashing them (for which the grocery store charged a fee based on the amount of the check) and then would take the cash and deposit it into her bank account. She stated she was aware there were employee checks that had been cashed at the grocery store that had not cleared the grocery store's bank and been returned to them for insufficient funds. An attempt to reach the grocery store manager/owner on 03/07/24 at 10:56 A.M. was unsuccessful. A message was left for the owner/manager to return the call to the surveyor, but no return call was provided. On 03/07/24 at 11:21 A.M. a phone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met due to the identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation had been provided. On 03/11/24 at 9:05 A.M. an interview with the DON verified the last wire transfer to staff to pay from the 02/16/24 pay day was not made until 02/29/24 (almost two weeks after the pay date). The DON stated the (unidentified) staff member notified her on 02/28/24 that their check bounced, and the corporation then wired the funds directly to the staff member's account. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: a. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24. Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services. b. Review of the invoice from [NAME] Recycling dated 02/13/24 revealed a total balance due of $1,531.10. This showed services due for 02/01/24 for $765.55 and 01/01/24 for $765.55. This had been received by the facility and scanned to the corporate office on 02/20/24. An interview on 03/04/24 at 11:05 A.M. with the recycling company's Accounts Receivable Clerk (AR) #213 revealed the facility was behind 60 days on their billing. c. Review of the invoice from Buckeye Pest Management dated 02/20/24 revealed a total balance due of $723.95. This showed services due for 10/05/23, 11/06/23, 12/07/23, 01/04/24 and 02/01/24. The statement was received and scanned to the corporate office on 02/28/24. Interview on 03/04/24 at 10:50 A.M. with the pest management's Accounts Receivable Clerk (AR) #133 revealed she had been in contact with the facility related to their balance of $723.95. She stated they had not received any payments from the facility since prior to October 2023. d. Interview on 03/05/24 at 11:45 A.M. with Medical Director (MD) #351 revealed he was unaware of how much the facility owed him for medical director fees. During the interview, he contacted his office and spoke to one of the staff and discovered the facility owed MD #351 for September 2023, November 2023, December 2023, January 2024 and February 2024. This totaled $15,000.00. It was noted the corporation had made payment arrangements and had kept those arrangements until January 2024. There was no payment received in the month of February 2024. e. Review of the invoice from Broad River Therapy dated 03/06/24 revealed a total balance due of $103,531.89. This was due for services from 11/02/23 to 12/02/23 for $27,251.19; 12/01/23 to 12/31/23 for $28,291.58; 01/02/24 to 02/01/24 for $22,527.73; and 02/02/24 to 03/03/24 for $25,461.39. Interview on 03/04/24 at 11:57 A.M. with Therapy Office Manager #128 revealed the facility had not paid for services since September 2023. However, she stated CFO #600 stated the corporation would be sending checks the week of 03/04/24. f. Interview on 03/05/24 at 10:16 A.M. with Clerk #350 at the [NAME] Country Treasurer's Office revealed the facility had set-up a payment plan for the balance due which included a delinquent balance, late fees and interest. She stated the facility owed a total of $101,283.27 for property taxes and had made a payment arrangement to pay $5,000 a month and made a payment on 01/12/24. However, Clerk #350 stated the facility (corporation) had failed to make a payment in February 2024. On 03/10/24 the Ombudsman conducted an onsite visit at the facility. The Ombudsman reported staff were worried about getting paid on Friday (03/15/24). This date is the next scheduled date for staff to be paid in the facility. Review of the Nursing Facility admission Agreement, undated, provided to all residents, revealed the facility was responsible for basic services including room and board, routine nursing care and supplies for residents and such other personal services as may be necessary for the resident's health, well-being and grooming. The facility would also provide meals, linens, housekeeping, social services and activities and other regular services required by law. Review of the Employee Handbook, dated 2020, revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the facility policy titled, Abuse Prevention, Identification and Reporting, revised 08/15/22, revealed the facility defined resident abuse to include neglect which was the failure of the facility, its employees or service providers, to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Facility assessment dated [DATE] revealed the facility provided all care and services as required 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, psychiatrist services and pharmacist. This deficiency represents non-compliance investigated under Master Complaint Number OH00151629, Complaint Number OH00151626 and Complaint Number OH00151535.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review including review of facility payroll records, review of facility billing/financial information, review of the [NAME] County Auditor website, review of the facility assessment, review of the employee handbook, review of the facility admission agreement, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility and failed to have adequate and effective systems in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 10/13/23 when the identified lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization, displacement due to potential interruption in staffing regarding non-payment of payroll benefits and continued 10/16/23 due to non-payment of essential bills. This had the potential to affect all 31 residents residing in the facility. On 11/20/23 at 5:08 P.M., the Director of Nursing (DON) and the Assistant Administrator were notified Immediate Jeopardy began on 10/13/23 when an onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying vendors and staff in a timely manner. This included insufficient funds to meet staff payroll on 10/13/23, delinquent balances owed to the facility food vendor resulting in delayed food delivery and the facility utilizing emergency food supplies, a city water disconnect notice due to non-payment and/or returned checks due to insufficient funds, outstanding balances with the electric company with potential shut off notices if payments were not received, delinquent property taxes since 02/21, non-payment for therapy services resulting in a change of therapy providers and a hold placed on the oxygen and respiratory supply account by the vendor due to non-payment of the outstanding balance causing potential interruption of services and the inability to meet the total care needs of the residents admitted to and/or retained in the facility. The Immediate Jeopardy was removed on 11/28/23 when the facility implemented the following corrective actions: • On 11/20/23 at 6:00 P.M. the Assistant Administrator and the DON verified the residents had the needed supplies (food, oxygen, medication, medical supplies) to meet the needs of the residents and there were no negative outcomes resulting from negative practice. • Beginning on 11/20/23 and concluding on 11/21/23, the Administrator and/or designee re-educated, through in-person and phone communication, all facility staff on the abuse policy. This education included the requirement to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. • Beginning on 11/20/23 and concluding on 11/21/23 the DON and Assistant Director of Nursing (ADON) completed education with all clinical staff (nine Registered Nurses (RN), nine Licensed Practical Nurses (LPN), 17 State Tested Nursing Assistants (STNA) & four Hospitality Aides) on communicating if there are any supply, vendor and/or food supply concerns to immediately notify the DON and the Administrator. • On 11/21/23, the DON, ADON and RN Supervisor #47 completed a review of all 31 residents to verify that there were no resident condition changes related to the facility's lack of payment to vendors. • Beginning on 11/21/23, the Administrator and/or designee monitors and ensures essential resident care services are provided by daily communication in the stand-up meeting with the facility leadership team by asking if there are any essential vendor concerns. • Beginning on 11/21/23, the Administrator and or designee communicates needs to the management company (Compliance Officer #602, Chief Executive Officer (CEO) #601, and/or Chief Financial Officer (CFO) #600) as they arise via email communication. • The Business Office Manager (BOM) was re-educated by the Administrator on 11/21/23 regarding the Stampli process. BOM and/or designee scan bills into Stampli, the online portal for the Management Company's approval and payment. • On 11/21/23, Corporate Compliance Officer #602 re-educated the Administrator, the Assistant Administrator and the DON on the abuse policy. This education included the requirement to meet Financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. • On 11/27/2023, the Administrator verified with the Management Company (CEO, CFO, Corporate Compliance Officer) that the following vendors bills were made current; AEP (Electric), [NAME] (Trash), [NAME] Gas (Natural Gas), Respiratory Care Partners (Oxygen), and City of Cambridge (Water/Sewer). The Administrator also verified with the Management Company (CEO, CFO, Corporate Compliance Officer) that the following vendors were placed on a payment plan: [NAME] County Treasurer (Property Taxes), MedOne (Medical Director), Medline (Medical Supplies), and Broad River (Therapy). • The facility provided a payment plan dated 11/27/23 for delinquent taxes with a balance of $79,428.51. The contract started on 11/27/23 with a down payment of $10,000 (no date) and a payment of $5,000 on 12/22/23. A payment of $4,964.28 would be made the twenty-second of each month through 02/22/25 and a final payment of $4,964.31 would be made on 04/22/25. • Beginning on 11/28/23, the DON or designee will interview five clinical employees weekly for four weeks and randomly thereafter to verify that staff have adequate supplies, food and staffing to meet the needs of the residents. • On 11/28/23 Administrator provided a copy of check #1008 dated 11/28/23 to RCP in the amount of $1,897.19. • On 11/28/23 the Administrator provided a copy of check #1005 dated 11/15/23 for $765.55 was submitted to [NAME] Refuse for payment in full. • On 11/28/23 the Administrator provided a copy of check #1006 dated 11/17/23 to the City of Cambridge for $11,786.96, for the water bill to be paid in full. • Interviews on 11/29/23 at 9:03 A.M. with BOM #46, at 10:05 A.M. with DD #48, at 10:24 A.M. with LPN #5, at 10:34 A.M. with STNA #30, at 10:40 A.M. with Housekeeper #58, at 10:42 A.M. with LPN #10, and 10:45 A.M. with Laundry/Housekeeping Supervisor #55 revealed they had received education on abuse and reporting any calls regarding outstanding bills, and any concerns with supplies not being delivered. • Beginning on 11/29/23, weekly conference calls will be held on Wednesdays at 11:00 A.M. with the Administrator and/or designee with management company (Corporate Compliance Officer, CEO, or CFO) to communicate any concerns with essential resident care services weekly for 12 weeks. • Beginning on 11/29/23, the Administrator and/or designee and CFO #600 of the management company and/or designee, will complete weekly audits for four weeks and then randomly thereafter of financial obligations to essential resident care services (food, pharmacy, oxygen, medical supplies, therapy, staff) by ensuring that invoices are being paid and that no disconnect/cut off/end of service notifications were delivered within the week. • Beginning on 11/29/23 Social Services #45 and/or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. • Beginning on 11/29/23 Social Services #45 and or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. • Beginning on 12/19/23 (the next scheduled meeting date) results of all audits and interventions will be brought to the Quality Assurance Performance Improvement (QAPI) meeting monthly for three months and as needed for review and recommendations. Although the Immediate Jeopardy was removed on 11/28/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings Include: On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. Interview on 11/16/23 at 8:36 A.M. with State Tested Nursing Assistant (STNA) #32 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. At 8:38 A.M. interview with Housekeeper #56 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. At 8:40 A.M. interview with Housekeeper #58 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. STNA #32, Housekeeper #56 and Housekeeper #58 stated corporate wired money to their accounts the same day the checks were returned and covered any penalties/fees that occurred due to the facility's insufficient funds to make payroll. Interview on 11/16/23 at 8:53 A.M. with Dietary Director (DD) #48 revealed some of the emergency supply of food had to be used due to food not being delivered by the food vendor ([NAME]) on 10/16/23. DD #48 stated a delivery truck arrived on 10/16/23 but did not unload any food (due to non-payment of the food bill) and left the facility. Review of the menus and substitutions revealed on 10/16/23 the dinner meal did not have cabbage available due to no truck delivery. On 10/17/23 and 10/18/23 the lunch and dinner meals were substituted with other food items due to no truck delivery on 10/16/23. DD #48 revealed a food delivery was made on 10/18/23 and 10/23/23 with the 10/23/23 delivery duplicating the items from the 10/18/23 order. Review of an invoice dated 10/18/23 and invoice dated 10/23/23 verified the duplicate orders. Review of meal substitutions revealed substitutions were made for dinner on 10/27/23, lunch and dinner on 10/28/23, and lunch and dinner on 10/29/23. DD #48 clarified the menu was followed from 10/19/23 until 10/27/23 but since there was a duplicate delivery on 10/23/23, substitutions were made on 10/27/23, 10/28/23, and 10/29/23 so residents were not served the same meals two weeks in a row. Some of the emergency food supply was used to prevent duplicate meals and some of the food on hand was used to make different meals. The facility started using [NAME] Food Service on 10/27/23 and stopped using [NAME]'s services for food delivery. Review of the invoice dated 10/31/23 revealed [NAME] Food Service delivered food on 10/31/23. Interview on 11/16/23 at 12:37 P.M. interview with Business Office Manager (BOM) #46 revealed most bills were sent directly from vendors to Epic Healthcare Solutions. All bills and invoices received at the facility were scanned and emailed directly to Stampli (company that processes and pays invoices) every Wednesday. If there were any disconnect notices or notice that services would be stopped, those bills would be emailed to the Administrator, Epic Healthcare Solutions, and Stampli immediately. On 11/16/23 at 12:42 P.M. an interview with the Administrator regarding the facility finances and billing/payment process revealed BOM #46 would forward invoices and bills received at the facility to Stampli via email. The facility did not pay any of the vendors directly for services rendered at the facility, the payments were being made by an accounts payable department based in Florida. The Administrator stated there had been a few disconnect notices, but no utilities had ever been disconnected. An additional interview on 11/16/23 at 2:28 P.M. with the Administrator revealed any disconnect notices were forwarded to Epic Healthcare Solutions. The Administrator stated he received an email (sender not identified by the Administrator) dated 09/08/23 that Arbor Rehabilitation and Healthcare Services (the previous therapy provider) would be ending their services. Another therapy department (Broad River Rehabilitation) would start providing services. The Administrator stated there was no disruption in therapy services for the residents. The Administrator also shared BOM #46 sent payroll information to corporate on a Monday and paper checks were sent overnight to the facility for payday (every other Friday). The Administrator stated paper checks had been used for several months but he was unsure why this was changed from direct deposit. Further interview revealed the Administrator called corporate on 10/13/23 when his check and 20 additional employees were returned on 10/13/23 due to insufficient funds. The Administrator identified himself; RN #6, RN #66, and RN #509; Maintenance Director #20, Hospitality Aide (HA) #24, #56, #57, #58 and #59; STNA #36, STNA #41, Social Services Designee #45, BOM #46, Dietary Staff (DS) #49, #52; Marketing #61, Beautician #62, the Assistant Administrator, Activity Aide #64 and #65 that had payroll checks returned due to insufficient funds. Corporate had wired money to employees in the amount of their pay and any fees that had occurred when they were notified a check was returned for insufficient funds. The 21 staff (the Administrator, RN #6, RN #66, and RN #509; Maintenance Director #20, Hospitality Aide (HA) #24, #56, #57, #58 and #59; STNA #36, STNA #41, Social Services Designee #45, BOM #46, Dietary Staff (DS) #49, #52; Marketing #61, Beautician #62, the Assistant Administrator, Activity Aide #64 and #65) identified were verified with facility payroll records to have payroll checks dispersed and dated 10/13/23. On 11/20/23 at 9:12 A.M. Dietician #508 revealed food suppliers had been changed in October of 2023 from [NAME] to [NAME]. Dietician #508 stated she was unaware some of the emergency supply of food had been used but was aware there were several substitutions made in October and it was protocol to make substitutions if a food item was not available. Further interview verified DD #48 followed the procedure of making substitutions and identifying the reason why it was necessary. An additional interview on 11/27/23 at 11:28 A.M. with Dietician #508 revealed she was aware substitutions had been made due to delivery truck not delivering food on the correct day and then sending the same food items two weeks in a row. Dietician #508 stated she approved of the substitutions that were made. On 11/20/23 at 9:39 A.M. an additional interview with DD #48 revealed she contacted [NAME] on 10/16/23 when the food delivery was not made. An employee of [NAME] stated orders could not be placed until a payment had been made to [NAME] food distribution. The emergency food supply had to be used during this time. On 11/20/23 at 10:59 A.M. interview with RN #509 revealed she had worked at the facility for 12 years but had recently quit due to insufficient funds on 10/13/23 and then her bank held her next pay dated 10/27/23 until 11/07/23 since the facility had a previous issue with insufficient funds. The RN stated she resigned due to instability of the paycheck system and needing to be paid on time. RN #509 stated there had been times the trash dumpster was overflowing at the facility because the bill had not been paid and food was not delivered due to nonpayment to the supplier. Lastly, the facility had purchased t-shirts for the staff for nurse's week and the vendor was calling the facility asking for payment. On 11/20/23 at 11:07 A.M. RN #6 verified they had a paycheck return for insufficient funds. RN #6 stated a food delivery truck had arrived at the facility but left without unloading any food due to nonpayment. The trash dumpster had overflowed because the refuse company was owed money. A lot of vendors call the facility all hours of the day and night asking for payment. The staff would tell the vendors to call back when someone was in the office. Sometimes the staff left a note at the front desk about a vendor calling and wanting payment. On 11/20/23 at 1:31 P.M. CFO #600 revealed Epic Healthcare Solutions was in the process of transferring financial accounts to a different bank (from Regency Bank to the Bank of Oklahoma). There had been an issue with funds being moved from one account to another account. This had caused problems with payroll being covered. A conscious decision as an organization was made to use paper checks to help with timing and cash flow and there had been a change in banks due to Regency Bank not moving money from one account to another quick enough to meet the facility's financial needs. CFO #600 stated communication and payments were handled at the corporate office so the facility staff could focus on the residents. CFO #600 stated no services had been disconnected and stated he would have to check to see if any disconnection notices had been received. CFO #600 stated they would investigate trash service not being provided in September. When asked about the disconnect notice from the City of Cambridge, CFO #600 revealed the corporation made sure everyone got paid and residents and staff had everything they needed. CFO #600 verified there had been multiple checks that were returned for insufficient funds to the City of Cambridge and banks were being changed due to returned checks. CFO #600 stated they had made an agreement last week with the [NAME] County Auditor's Office for the delinquent property taxes and had made a payment for the first two months of a 12-month agreement. CFO #600 verified money was still owed to the two previous food vendors. A payment had been made to Avalon (a previous food vendor) not too long ago and there was communication daily with [NAME] (a previous food vendor). When asked why bills were not being paid on time, CFO #600 stated there was communication with vendors to make sure they received payments. CFO #600 stated most of the payment agreements were verbal and there were no written agreements. CFO #600 stated the therapy providers changed due to corporate wanted to try a different provider and he was unable to recall how much was owed to Arbor Rehabilitation. CFO #600 verified corporate did not always pay for services quickly but made sure the facility had the essential supplies. Payments were based off cash flow and corporate worked with vendors daily, but the CFO could not provide a reason the bills were not paid on time when he was asked. Interview on 11/24/23 at 10:04 A.M. interview with the Administrator revealed any final notices and/or disconnect notices were also sent to Epic Healthcare Solutions. The Administrator stated the only disconnect notice he could recall was from the city for water and sewage and he was aware food was not delivered one time but was not aware it was due to nonpayment. Dietary Director #48 was given money from petty cash to purchase anything that was needed for the residents. Additionally, the Administrator verified the facility did not receive a bill for the medical director and was not aware the medical director was not being paid. On 11/24/23 at 10:41 A.M. an interview with BOM #46 revealed any calls received at the facility about bills being owed were emailed to accounts payable at Epic Healthcare Solutions. BOM #46 stated the email to accounts payable included multiple people and not one specific person (the multiple people were not identified by the BOM). The following vendor/suppliers were reviewed as part of the State agency investigation: a. Review of bill from the City of Cambridge Utilities Department dated 11/02/23 revealed $11,786.96 was owed and this was a final shut off notice. If payment was not received by 11/15/23, service will be turned off on 11/16/23 without further notice. On 11/16/23 at 2:22 P.M. interview with City of Cambridge Office Manager #500 revealed the facility was sent a final shut-off notice dated 11/02/23 due to nonpayment for water and sewage in the amount of $11,786.96. If payment was not received by 11/15/23, service would be turned off without further notice on 11/16/23 and a delinquency charge would be made. City of Cambridge Office Manager #500 shared a check from Epic Healthcare Solutions had been received on 11/14/23 but Epic Healthcare Solutions had checks returned for insufficient funds in July, twice in August, and in September. An additional interview on 11/28/23 at 8:49 A.M. with City of Cambridge Office Manager #500 revealed the previous check received on 11/14/23 had been returned for insufficient funds after speaking with surveyor on 11/16/23. The City of Cambridge Office Manager #500 stated another check was received and deposited and had not been returned at the time of the interview. b. On 11/16/23 at 4:33 P.M. interview with Sales/Service #501 for [NAME] Innovative Management Partners verified Epic Healthcare Solutions owed $132,100.42. Sales/Service #500 stated there was a tentative schedule for weekly payments, but the vendor did not share what the agreed upon amount was with the facility. If Epic Healthcare Solutions was unable to adhere to the schedule, then there would be a meeting to brainstorm about payments. Review of statement from [NAME] Innovative Management Partners dated 11/18/23 revealed invoice amounts from 06/15/23 through 10/28/23 a total balance of $132,100.42 was owed. c. Review of statement from Avalon Foodservice dated 10/31/23 revealed there were outstanding charges from 12/06/22 through 10/31/23 totaling $31,106.05. On 11/20/23 at 8:31 A.M. an interview with Credit Manager #505 at Avalon Foodservice revealed the facility elected to stop services on 01/24/23. The facility still had an outstanding balance of $29,106.05 owed to Avalon Foodservice. d. Review of monthly statements from American Electric Power (AEP) revealed a payment in the amount of $8890.42 was made on 07/03/23. The check was returned on 07/07/23. A statement dated 07/13/23 revealed there was a balance of $12,614.68 including a previous balance of $8890.42. A payment of $8950.20 was made on 07/20/23 and was returned on 07/28/23. The monthly bill dated 08/11/23 revealed an outstanding balance of $16,645.91. A payment of $12672.88 was made on 08/28/23 and returned on 09/05/23. The monthly bill dated 09/12/23 revealed an outstanding balance of $20,908.49. The monthly bill dated 10/11/23 revealed a balance of $7,858.82. The monthly bill dated 11/09/23 revealed a balance of $13,260.14 with an outstanding balance of $7,907.19 and a current balance of $5,352.95. On 11/20/23 at 10:07 A.M. an interview with a representative of AEP revealed there was an outstanding balance of $5,401.32. If payment was not received by 12/14/23 the facility would be at risk for disconnection of service e. On 11/20/23 at 10:46 A.M. Chief Executive Officer (CEO) #503 for Arbor Rehabilitation and Healthcare Inc. revealed therapy services were ended due to a lack of payment. The representative supplied documentation dated 11/15/23 showing an outstanding balance of $247,604.28. CEO #503 stated Epic would not commit to a payment plan as it was too binding, and they wanted flexibility, so he was not receiving money monthly and had not received payment for a while. CEO #503 verified he speaks with the company frequently, but they are not easy to work with since they won't set a payment amount and don't send routine payments, He also stated he had to take out a line of credit due to the facility's failure to make payments on their owed debt. f. On 11/20/23 at 11:14 A.M. Representative #504 at Broad River Rehab revealed services were started on 09/18/23. The first invoice #106862 was sent on 10/03/23 for $8,897.76 and was due on 11/02/23. g. On 11/20/23 at 11:22 A.M. a representative at [NAME] Refuse company revealed the facility currently had service of trash pickup six days a week. There was an outstanding bill for $760.55 and the present bill was $766.55. Review of an invoice dated 08/01/23 revealed a balance due of $1,538.05 including a past due amount of $772.50. An invoice dated 09/01/23 revealed a balance due of $2,303.60 including a past due amount of $1,538.05. An invoice dated 11/01/23 revealed a current balance due of $760.55 and no past due amounts. h. On 11/20/23 at 12:15 P.M., an interview with Medical Director #506 revealed he was not aware of vendors not being paid. Medical Director #506 stated he had not been paid since June 2023 and payments prior to that had been sporadic. Medical Director #506 was aware there had been a change in therapy services but did not know it was due to the previous company not being paid. There was no bill or statement provided for review. i. Review of the property taxes owed at https://auditor.guernseycounty.gov revealed unpaid taxes with a total of $432.44 with $260.42 delinquent for parcel number 04-0000094.000. There were also unpaid taxes with a total of $79,428.51 with $47,626.26 delinquent for parcel number 04-0000038.000. On 11/20/23 at 12:49 P.M. interview with Representative #507 of [NAME] County Treasurers Office #507 verified the facility owed a total of property taxes in the amount of $79,860.95. The last tax payment was received on 02/18/21. j. On 11/20/23 at 4:41 P.M., an interview with Accounts Receivable Specialist #510 at Respiratory Care Partners (RCP) revealed there was an outstanding balance of $1,897.19. A hold had been put on delivery of services until a payment was received. An additional interview on 11/27/23 at 11:05 A.M. with Accounts Receivable Specialist #510 revealed a payment had been promised and the owner of RCP had lifted the hold on deliveries. However, no confirmation of the promised payment amount or payment arrangements had been shared. k. Attempts were made to contact Medline, the facility's medical supply company regarding payments and outstanding balances. Medline did not return calls and the facility did not provide billing statements from the medical supply company as requested. Review of the Nursing Facility admission Agreement provided to all residents revealed the facility would provide routine nursing care and supplies, meals, housekeeping, social services, activities, and medical supplies. Review of the Facility assessment dated [DATE] revealed the facility's residents were at a clinically complex and special high categories who oftentimes have one or more chronic or comorbid conditions including their acuity. Residents of the facility were at risk for falls, pressure ulcers, infections, incontinence, increased disability, weight loss, depression, and other potential areas of decline. Review of Employee Handbook revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposit. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the facility's policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy revised 08/15/22 revealed, Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00148291.