National Church Residences at Hopeton Village

Based on medical record review, review of a police report, detective interview, staff interview and review of facility policy, the facility failed to ensure investigations for allegations of abuse were initiated and thoroughly investigated. This affected one (#8) of three residents reviewed for abuse. The facility census was 39.

Findings include:

Review of the medical record for Resident #8 revealed an admission date of 09/29/23. Diagnoses included type two diabetes, Post Traumatic Stress Disorder, shortness of breath, and mild intellectual abilities.

Review of the annual assessment dated 03/05/24 revealed Resident #8 was independent with most mobility tasks. Further review of the cognitive assessment dated 03/01/24 revealed the resident had no suspected dementia.

Review of a progress note dated 05/15/24 revealed staff received a complaint that Resident #8 approached a female resident and placed his hands on her back and called her beautiful. The reporting resident stated she was uncomfortable with the encounter. Further review of a progress note dated 05/16/24 revealed the previous Wellness Director spoke with the resident about the allegation on 05/15/24. The note provided no additional information. Lastly, review of a progress note dated 05/19/24 revealed a resident made a complaint to staff of Resident #8 rubbing her shoulders. She stated it made her feel uncomfortable.

Review of the facility's investigations revealed Resident #8 was involved in two investigations:

Investigation dated 05/07/24 revealed Resident #30 was invited to watch a baseball game. During this visit, Resident #30 came to staff and informed them Resident #8 made a sexual advance and asked do you want me to do it. Resident #30 stated he was not that kind of guy. There was no information to indicate what Resident #8 meant when he asked do you want me to do it. The investigation included a statement from Nursing Aide (NA) #58 and Licensed Practical Nurse (LPN) #55. The investigation included an interview with Resident #8 but included no statement or interview with Resident #30. Five additional residents were interviewed with no concerns identified with Resident #8. The investigation included no evidence of staff education related to the facility's abuse policy.

Investigation dated 05/15/24 revealed Resident #6 reported Resident #8 touched her shoulders and called her beautiful. She informed staff it made her feel uncomfortable. Staff spoke with Resident #6 and #8 about the incident but no statements were obtained or documented. No staff statements were taken, no other residents were interviewed and no education was provided to staff.

Interview on 06/17/24 at 10:31 A.M. with Executive Director (ED) revealed several months ago the police conducted an investigation related to Resident #8 talking with children on-line. The allegation came from a vigilante child predator group from another state. The ED stated no charges had been filed.

Interview on 06/17/24 at 4:17 P.M. with the Executive Director (ED) and Corporate Nurse (CN) #70 confirmed residents had reported feeling uncomfortable at times with Resident #8, according to progress notes, but those notes did not correspond to investigations. The ED verified the facility did not initiate or complete thorough investigations, including statements from all parties, interviews with residents, resident assessments or staff education on the abuse policy and procedures. The ED confirmed staff should complete a concern form when an incident occurred and not just document in the progress notes, to ensure management was aware and to conduct a thorough investigation.

Interview on 06/18/24 at 9:19 A.M. with Police Detective (PD) #100 revealed in March 2024 he had forwarded a criminal investigation to the county prosecutors office on Resident #8, after an allegation was made by a vigilante child predator group in another state. PD #100 did not provide any specific information related to those allegations. While that investigation was open, he was informed of a new allegation involving Resident #8. Resident #40 alleged Resident #8 fondled her breasts without her consent and called her his girlfriend. While his investigations had been turned over to the prosecutors office, no charges had been filed at this time against Resident #8.

Review of a police report dated 03/12/24 revealed Resident #40 alleged Resident #8 fondled her breasts and referred to her as his girlfriend. The report indicated the resident provided conflicting information on when this occurred and filed the report after receiving information Resident #8 was the focus of a child predator group from another state. PD #100 interviewed Resident #8, who denied the allegation. The report indicated there was no known video of the alleged incident, no witnesses and no physical evidence.

Interview on 06/18/24 at 4:10 P.M. with the ED and CN #74 confirmed allegations of unwanted touching were considered sexual abuse and an investigation should have been completed when Resident #40, who transferred to a skilled nursing facility and no longer resided at the facility, made the allegation of Resident #8 fondling her breasts. The ED and CN #74 verified they were unable to locate any investigations related to allegations made in March 2024 by the child predator group (no specific information related to the allegations) or the allegation involving Resident #8 and Resident #40. The ED and CN #74 also verified the facility did not conduct an investigation for the incident on 05/19/24 involving Resident #8 rubbing another resident's shoulders.

Review of facility policy titled Abuse Neglect and Misappropriation

Based on observation, resident interview and staff interview, the facility failed to ensure resident concerns were responded to timely. This affected one (#13) of three residents reviewed for concerns. The facility census was 39.

Findings include

Review of the medical record for Resident #13 revealed an admission date of 03/31/23. Diagnoses included atrial fibrillation, heart disease, mood disorder and muscle weakness.

Review of a progress note dated 05/20/24 revealed Resident #13 made a complaint to management related to his bathroom and vents smelling like cigarette smoke. Further review of another progress note dated 05/20/24 revealed the Wellness Director spoke with the resident and stated they would look into it.

Observation on 06/18/24 at 2:45 P.M. of Resident #13's room revealed the bathroom had a faint smell of cigarette smoke.

Interview on 06/18/24 at 3:36 P.M. with Resident #13 revealed he informed the facility approximately one month ago of a cigarette smell in his bathroom, stating he had spoken with a nurse about his concern. Resident #13 denied the odor had stopped or improved since he reported it. Resident #13 stated smoking was not allowed in the building and he believed someone was smoking in their bathroom and the smoke traveled through the vent system.

Interview on 06/18/24 at 4:10 P.M. with the Executive Director (ED) and Corporate Nurse (CN) #74 confirmed the facility had no record of the complaint being on file or any documentation of a resolution or plan to address the concern.

This violation represents non-compliance investigated under Complaint Number OH00154282.