Summit Point

Based on medical record review, staff interview, and review of facility policy, the facility failed to administer pain medications as ordered for one resident (#669) of four residents reviewed for hospice and pain management. The facility census was 64.

Findings include:

Review of Resident #669's medical record revealed an admission date of 03/31/23. Medical diagnoses included arthritis, cardio vascular accident (CVA), depression, adjustment disorder, anxiety, hypertension, spinal stenosis, and chronic pain.

Review of Resident #669's physician's orders dated 07/01/24 revealed the resident was to receive morphine 5mg/0.25 ml, by mouth/sub lingual every four hours scheduled and every one hour as needed.

Review of Resident #669's medication administration record (MAR) for July 2024 revealed the resident did not receive the scheduled every four hour dose after the initial dose at 8:45 P.M. on 07/01/24 until 8:00 A.M. on 07/03/24.

Interview on 08/08/24 at 12:45 P.M. with the Executive Director revealed that he was aware of Resident #669 not receiving her pain medication on 07/02/24. Resident #669's daughter informed him of the error that next morning. An investigation was started immediately, the nurse in question was suspended pending the investigation and shortly after being suspended, she resigned without notice.

Review of a facility policy titled Employee Partner Procedures for Medication Assistance

Based on review of the medical record, review of the facility self-reported incident (SRI), interviews with residents and staff, and facility policy review the facility failed to protect Residents #13, #19 and #21 from misappropriation of property by an agency staff member contracted with the facility. This affected three residents (#13, #19 and #21) of five residents reviewed for misappropriation. The facility census was 60.

Findings include:

1. Review of the medical record revealed Resident #19 was admitted to the facility on 11/30/23. Diagnoses included kidney failure, atrial flutter, hypertension, osteoarthritis, polyneuropathy, and vitamin D deficiency.

Review of the Nursing Daily Assignment Sheet dated 05/13/24 revealed Agency State Tested Nurse Aide (STNA) #300 was scheduled on the 3100, 3200 and 3400 units from 11:00 P.M. to 7:30 A.M.

Review of the banking statement for Resident #19 revealed on 05/14/24 there was a $205.20 charge at an unnamed Cleveland business, a $34.64 charge at Paul's Service Rite in Cleveland, and a $61.75 charge at the Dollar General in Cleveland for a total of $301.59 with all three charges being disputed by the bank.

Review of the facility grievance log report dated 05/16/24 revealed Family Member #200 reported two of her mother's (Resident #19) bank cards were missing with one showing four charges for $301.99 and the other not showing any charges at this time. The police have been notified and report was filed.

Review of the signed statement from Sales Director #202 dated 05/16/24 at 5:05 P.M. revealed the daughter of Resident #19 reported her mother called her crying indication her bank cards were missing and there were multiple charges on her PNC bank account to places she would never shop. Resident #19 called the bank and reported the fraudulent charges. The resident also stated her Citi bank card was missing as well and she was calling the bank to report the same.

Review of the police report dated 05/16/24 revealed on 5/16/24 at 5:57 P.M. a police officer was dispatched to the facility for a report of theft. Per dispatch, two residents believed they had items stolen. Operations Manager #403 stated she believed this incident was related to another incident which happened a few days ago, report # 2400330. Two residents on the third floor had items missing and she believed a temporary worker, Agency STNA #300, may be responsible. Operations Manager #403 stated Resident #19 was checking her online banking when she noticed suspicious activity, which led her to check her wallet to discover her Citi Bank credit card and PNC debit card were missing. Resident #19 stated she kept her wallet in her purse in her closet. Operations Manager #403 advised the closet can be accessed from a Jack and Jill door in the kitchen, which is near the front door. Resident #19 was able to provide her banking statement, which showed that the unauthorized transactions began on 5/14/24, totaling $382.49. Resident #19 stated her bank had flagged her account for fraudulent activity, she was going to change her passwords and continue to check her bank accounts. The police officer also met with Resident #21 who stated she believed someone stole a twenty-dollar bill from her closet. Resident #21 stated she remembered folding her money and putting it in her closet on 5/13/24 and when she went to retrieve it after 5/14/24, it was gone. She did not believe anything else was missing at this time. Operations Manager #403 stated Agency STNA #300 was the only aide who was working on the third floor on 5/14/24. She stated he was a temporary employee with a staffing company. She said on 5/14/24, he was assigned to the memory care unit but was then sent to work in the assisted living portion, where Residents #19 and #21 reside. Agency STNA #300 would have had access to all the units. Operations Manager #403 stated they were beginning their own investigation and they advised Agency STNA #300 he was no longer allowed to work at the facility.

Review of the email from Regional Clinical Manager #204 dated 05/17/24 at 10:19 A.M. revealed Operations Manager #403 completed an investigation at the facility and spoke with Resident #19 regarding her missing bank cards. Her cards were kept in her wallet in her purse which was in her double closet. On 05/14/24 Resident #19 was reviewing one of the bank accounts online and discovered several charges she had not made. She then went to her purse and discovered her cards were missing. Resident#19 called her daughter and informed her that her cards were missing and told her about the information she found online. Her daughter called Sales Director #202 and reported the incident to Regional Director of Operations #204. Resident #19 shared her banking statement, and there were charges totaling $301.59. The police were called. As Sale Director #202 was heading back to the Executive Directors office she was handed a note stating that Resident #21 had called the front desk asking why nobody had come to speak to her about her missing $20.00 she had reported on 05/14/24. Resident #21 stated she had folded up the $20.00 bill and tucked in under some items in her closet on 05/13/24, she went to get it on 05/14/24, and it was gone. She stated she searched the closet and could not find it, so she called the front desk to speak to someone about the missing money. The police were called to interview both residents and while interviewing Resident #21, she was asked to check her wallet for the money and discovered her bank card was also missing. Upon review of the scheduled it was discovered Agency STNA #300 was on duty. He was the same individual who the family reported had entered the room of Resident #56 on 05/13/24, and the daughter reported her wallet had been taken and charges filed on 05/14/24.

On 06/14/24 at 11:00 A.M. an interview with the Executive Director indicated they had not been able to contact Agency STNA #300 to interview him, and the staffing company had not provided them with much information other than they were doing their own investigations. He stated they believe it was him because on 05/13/24 Family Member #400 was staying with her mother and a male aide came in the room in the middle of the night stating he was emptying the trash. Family Member #400 stated her purse was on the table in the kitchen and when she went to get it the next morning it was gone. He stated Family Member #400 called the police and filed a report and within the next few days other residents had items missing and they all were within a few rooms of each other. This was the only time Agency STNA #300 had worked at the facility.

On 06/14/24 at 12:45 P.M. an interview with Resident #19 revealed a month ago she went to get her bank card and noticed it was missing. She stated she got online and noticed several charges she had not made, and she called her daughter. She then realized there were two bank cards missing and she called both banks to report them stolen. She stated the bank reimbursed her. She stated she had not heard anything else about it since she spoke to the police officer.

On 06/14/24 at 2:00 P.M. an interview with Sales Director #202 revealed she found out about the incident by accident because Resident #19's daughter called her about something else and asked her if they knew about her mom's credit cards and that was when she told her the story of her mom's bank cards being missing.

Review of the undated facility policy titled, Prevention of Abuse, Neglect and Misappropriation revealed the company would not tolerate any abuse, neglect or exploitation that would include misappropriation of resident property. Any employee who engaged in any of these actions would be subjected to discipline up to and including dismissal from employment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

2. Review of the medical record revealed Resident#13 was admitted to the facility on 03/27/23. Diagnoses included respiratory failure, atherosclerotic heart disease, chronic obstructive pulmonary disease, hypertension, cataracts, and atrial fibrillation.

Review of the Nursing Daily Assignment Sheet dated 05/13/24 revealed Agency STNA #300 was scheduled on the 3100, 3200 and 3400 units from 11:00 P.M. to 7:30 A.M.

Review of the witness statement for Resident #13 dated 05/17/24 revealed during audits, Resident #13 stated she noticed her debit card was missing on 05/15/24 and she called the bank to report it and make sure there were no fraudulent charges on her account. She stated there were not any charges. They looked for her debit card in her room and could not find it.

On 06/14/24 at 12:30 P.M. an interview with Resident #13 revealed a month ago she was in the dining room and Resident #19 told her she had her bank card missing. She stated he went back to her room and checked her purse and hers was missing also. She stated the night before that someone had gone into her room around 4:00 A.M. because her door slammed. She stated she thought it was the nurse bringing her 6:00 A.M. medication so when she heard the door slam, she looked at the clock and it was 4:00 A.M. She stated she always hung her purse on her bedroom door. She stated she reported to the facility, and she canceled the card. She stated no purchases were made.

On 06/14/24 at 11:00 A.M. an interview with the Executive Director indicated they have not been able to contact Agency STNA #300 to interview him, and the staffing company had not provided them with much information other than they were doing their own investigations. He stated they believe it was him because on 05/13/24 Family Member #400 was staying with her mother and a male aide came in the room in the middle of the night stating he was emptying the trash. Family Member #400 stated her purse was on the table in the kitchen and when she went to get it the next morning it was gone. He stated Family Member #400 called the police and filed a report then within the next few days other residents (Residents #13 and #21) had items missing, and they all were within a few rooms of each other. He stated this was the only time Agency STNA #300 had worked at the facility.

Review of the undated facility policy titled, Prevention of Abuse, Neglect and Misappropriation revealed the company would not tolerate any abuse, neglect or exploitation that would include misappropriation of resident property. Any employee who engaged in any of these actions would be subjected to discipline up to and including dismissal from employment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

3. Review of the medical record revealed Resident #21 was admitted to the facility on 05/03/24. Diagnoses included arthritis, hypertension, atrial fibrillation, osteoarthritis, and hyperlipidemia.

Review of the police report dated 05/16/24 revealed on 5/16/24 at 5:57 P.M. a police officer was dispatched to the facility for a report of theft. Per dispatch, two residents believed they had items stolen. Operations Manager #403 stated she believed this incident was related to another incident which happed a few days ago, report #2400330. Two residents on the third floor had items missing and she believed a temporary worker, Agency STNA #300, may be responsible. Operations Manager #403 stated Resident #19 was checking her online banking when she noticed suspicious activity, which led her to check her wallet to discover her Citi Bank credit card and PNC debit card were missing. Resident #19 stated she kept her wallet in her purse in her closet. Operations Manager #403 advised the closet can be accessed from a Jack and Jill door in the kitchen, which is near the front door. Resident #19 was able to provide her banking statement, which showed that the unauthorized transactions began on 5/14/24, totaling $382.49. Resident #19 stated her bank had flagged her account for fraudulent activity, she was going to change her passwords and continue to check her bank accounts. The police officer also met with Resident #21 who stated she believed someone stole a twenty-dollar bill from her closet. Resident #21 stated she remembered folding her money and putting it in her closet on 5/13/24 and when she went to retrieve it after 5/14/24, it was gone. She did not believe anything else was missing at that time. Operations Manager #403 stated Agency STNA #300 was the only aide who was working on the third floor on 5/14/24. She stated he was a temporary employee with a staffing company. She said on 5/14/24, he was assigned to the memory care unit but was then sent to work in the assisted living portion, where Residents #19 and #21 reside. Agency STNA #300 would have had access to all the units. Operations Manager #403 stated they were beginning their own investigation and they advised Agency STNA #300 he was no longer allowed to work at the facility.

Review of the email from Regional Clinical Manager #204 dated 05/17/24 at 10:19 A.M. revealed Operation Manager #403 completed an investigation at the facility and spoke with Resident #19 regarding her missing bank cards. Her cards were kept in her wallet in her purse which was in her double closet. On 05/14/24, Resident #19 was reviewing one of the bank accounts online and discovered several charges she had not made. She then went to her purse and discovered her cards were missing. Resident#19 called her daughter and informed her that her cards were missing and told her about the information she found online. Her daughter called Sales Director #202 and reported the incident to Regional Director of Operations #204. Resident #19 shared her banking statement and there were charges totaling $301.59. The police were called. As Sale Director #202 was heading back to the Executive Directors office she was handed a note stating that Resident #21 had called the front desk asking why nobody has come to speak to her about her missing $20.00 she had reported on 05/14/24. Resident #21 stated she had folded up the $20.00 bill and tucked in under some items in her closet on 05/13/24, she went to get it on 05/14/24, and it was gone. She stated she searched the closet and could not find it, so she called the front desk to speak to someone about the missing money. The police were called to interview both residents and while interviewing Resident #21 she was asked to check her wallet for the money, and it was discovered her bank card was also missing. Upon review of the schedule, it was discovered Agency STNA #300 was on duty. He was the same individual who the family reported had entered the room of Resident #56 on 05/13/24 and the daughter reported her wallet had been taken, and charges filed on 05/14/24.

On 06/14/24 at 11:00 A.M. an interview with the Executive Director indicated they have not been able to contact Agency STNA #300 to interview him, and the staffing company had not provided them with much information other than they were doing their own investigations. He stated they believed it was him because on 05/13/24 Family Member #400 was staying with her mother and a male aide came in the room in the middle of the night stating he was emptying the trash. Family Member #400 stated her purse was on the table in the kitchen and when she went to get it the next morning it was gone. He stated Family Member #400 called the police and filed a report and within the next few days other residents (Residents #13 and #21) had items missing, and they all were within a few rooms of each other. He stated this was the only time Agency STNA #300 had worked at the facility.

Review of the undated facility policy titled, Prevention of Abuse, Neglect and Misappropriation revealed the company would not tolerate any abuse, neglect or exploitation that would include misappropriation of resident property. Any employee who engaged in any of these actions would be subjected to discipline up to and including dismissal from employment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

This violation represents non-compliance investigated under Self-Reported Incident, Control Number OH00154194.

Based on interviews and record reviews, the facility failed to ensure tuberculosis testing and screening was completed to prevent the potential spread of infection. This had the potential to affect all 57 residents.

Findings include:

Review of personnel records for Two-Step Tuberculosis testing for employees revealed two employees, Certified Nursing Assistant (CNA # 567) and Licensed Practical Nurse (LPN #511), were not completed upon hire.

Review of Personnel Records for Annual Tuberculosis Risk Assessment for employees revealed two employees, CNA #535 (none since initial TB test 2021) and LPN #549 (last assessment done in 2022), were not completed.

An interview on 03/26/24 at 8:10 A.M. with the Executive Director confirmed CNA #567 and LPN #511 did not have Two-Step Tuberculosis (TB) Mantoux Testing completed. Also, CNA #535 and LPN #549 did not have an Annual Tuberculosis Risk Assessment Questionnaire.

This violation demonstrates non-compliance investigated under Complaint Number OH00151126.

Based on interview and record review the facility failed to ensure Fire Safety Self Inspections were completed monthly. This had the potential to affect all 57 residents. The facility census was 57.

Findings include:

Review of the Facility Fire Safety Inspection Forms revealed for the months of October 2023, November 2023, December 2023, and January 2024, the inspections were not completed or signed.

An interview with the Executive Director on 03/25/24 at 12:22 P.M. confirmed Fire Safety Self Inspection forms were not completed for October 2023, November 2023, December 2023, and January 2024.