Serene Suites

Based on medical record review, staff interview, review of video footage, review of personnel files, review of facility policy, review of facility Self-Reported Incidents (SRI), review of the police report, the facility failed to prevent staff to resident physical abuse when State Tested Nursing Assistant (STNA) #350 was observed on video to be rough with the resident during incontinence care, then STNA #350 was observed to forcefully push the residents leg followed by slapping the residents in the face on two different occasions. This affected one of three residents reviewed for abuse. The facility census was 29.

Record review for Resident #01 revealed an admission date of 02/02/23 with Diagnosis of dementia with behavioral disturbances. Resident #01 was cognitively impaired and required assistance of one staff for all activities of daily living (ADLs).

Review of the video footage dated 05/21/23 at 11:22 P.M. with Memory Care Operations Director (MCOD) #500 revealed STNA #350 entered Resident #01's room and started providing incontinence care. STNA #350 appeared to be very rough as he provided the incontinence care. The resident raised her left leg and STNA #350 used his right elbow to forcefully push the resident's leg away. The resident raised her left leg again and STNA #350 used his right hand to forcefully push the resident's leg away and immediately afterwards, STNA #350 leaned over the resident and slapped her face.

Review of video footage dated 05/22/23 at 5:11 A.M. with MCOD #500 revealed STNA #350 entered Resident #01's room and started incontinence care. STNA #350 appeared to be very rough as he provided the incontinence care. The resident raised her left leg and STNA #350 used his right elbow to forcefully push the resident's leg away. The resident raised her left leg again and STNA #350 used his right hand to forcefully push the resident's leg away and immediately afterwards, STNA #350 leaned over the resident and slapped her face.

Review of Police Incident Number 202300000777, dated 05/25/23, revealed the facility contacted the police and reported a case of resident abuse. The police initiated an investigation, including watching the videos provided by Resident #01's family. Report indicated STNA #350 was captured on video slapping Resident #01 twice. The first was on 05/21/23 at 11:20 P.M. and the second was on 05/22/23 at 5:09 A.M. Police did not interview Resident #01 due to her cognitive decline. The case was pending and referred the investigative unit. The follow-up to the report indicated CEO #900 explained to STNA #350 that he was terminated due to violation of company policy. STNA #50 made no admissions to the offense and acted as if he was unaware of why he was being terminated. Report also revealed the police signed two charges for assault (felony) against STNA #350.

Review of the Self-Reported Incident (SRI) created 05/26/23 at 1:03 P.M. revealed the facility was notified by Resident #01's hospice team that an act of abuse had occurred between one of the facility employees (STNA #350) and one of the residents (Resident #01). A video was made available from a family member and the video was reviewed by facility staff. In the video on 5/21/23 (11:20 P.M.) and 5/22/23 (5:09 A.M.) it clearly showed facility staff member hitting our resident twice and was rough with her while providing personal care. The staff member violated our abuse policy. The facility substantiated abuse was verified by evidence.

Interview on 06/20/23 at 1:42 P.M. Resident #01's spouse stated Resident #01 had an uncharacteristic angry outburst, which he stated surprised him. Resident #01's spouse stated out of an abundance of caution, he placed a camera in Resident #01's room two weeks prior to the recorded abuse and without telling the facility. He stated that he reviewed the footage every two to three days and was only aware of this one shift, 05/21/23 night shift into 05/22/23 day shift, that STNA #350 did anything to Resident #01.

Interview with Chief Executive Officer (CEO) #900 and MCOD #500 on 06/20/23 at 2:30 PM revealed the Resident #01's family requested that Resident #01 only have female care givers. The Resident's family denied other concerns at that time. That care plan was immediately updated. The facility indicated Hospice Chaplain #600 and the Chaplain's Supervisor, Registered Nurse (RN) #601 came into the facility and notified MCOD #500 of the abuse allegations on 05/25/23. On 05/25/23 at 12:30 P.M. Resident #01's family arrived at the facility and provided their video footage. MCOD #500, CEO #900 and Residents #01's family watched the video and witnessed the resident abuse. Immediately afterwards, the CEO#900 called the police to report the resident abuse. CEO #900 attempted to contact STNA #350 to get him to come in earlier for his shift, however STNA #350 refused. STNA #350 arrived for work between 5:00 P.M. and 6:00 P.M. Once the STNA #350 arrived, CEO #900 met him at the front door and escorted STNA #350 to the office. STNA #350 was informed he violated the abuse policy and was immediately terminated.

Attempted to contact STNA #350 on 06/21/23 which was unsuccessful.

Review of personnel file for STNA #350 was hired on 06/04/21. There were no disciplinary or coachable moments in the file and STNA #350 was terminated on 05/25/23 for violating the facility's abuse policy.

Review of the STNA registry for STNA #350 revealed the STNA had an active STNA license with no restrictions.

This violation represents non-compliance investigated under Complaint Number OH00143222.

Based on review of staffing schedules, observations, and staff interview, the facility failed to ensure a staff person was physically present in the facility at all times. This had the potential to affect all residents residing in the facility. Facility census was nine.

Findings include:

Review of the staffing schedule for 01/23/23 revealed Care Partner (CP) #300 was the only staff person scheduled from 01/22/22 at 7:00 P.M. to 01/23/23 at 7:00 A.M.

Observation on 01/23/23 at 6:22 A.M. revealed CP #300 was seated in a vehicle parked in front of the facility with the door of the facility shut. When surveyor approached the entrance to the facility CP #300 exited the vehicle, greeted surveyor, and unlocked the front door with a badge.

Interview on 01/23/23 at 6:34 A.M. with CP #300 confirmed he had gone outside to his personal vehicle for his break which was 30 minutes long.

Interview on 01/23/23 at 9:15 A.M. with the Executive Director (ED) confirmed the expectation is a staff person should be physically present in the facility at all times. ED further confirmed CP #300 was the only staff person assigned to work in the facility from 01/22/23 at 7:00 P.M. to 01/23/23 at 7:00 A.M. ED confirmed a staff person inside his/her personal vehicle parked outside the facility did not fulfill the requirement to have a staff person physically present in the facility. ED confirmed the facility did not have a written policy regarding staffing.

Based on review of employee personnel files and staff interview, the facility failed to ensure new employees were examined by a physician or other appropriate health professional prior to commencing work with the facility. This had the potential to affect all residents residing in the facility. Facility census was nine.

Findings include:

Review of the personnel file for the Executive Director (ED) revealed a hire date of 01/04/23. The personnel file did not include a pre-employment physical examination for the ED.

Review of the personnel file for Care Partner (CP) #425 revealed a hire date of 10/17/22. The personnel file did not include a pre-employment physical examination for CP #425.

Interview on 01/23/23 with the ED confirmed the facility had not completed a pre-employment physical examination for the ED or for CP #425.

Based on record review and staff interview, the facility failed to ensure there were complete initial health assessments conducted for residents upon admission to the facility. This affected four (#60, #170, #220 and #235) of five resident records reviewed. The facility census was nine.

Findings include:

1. Review of the medical record for Resident #60 revealed an admission date of 05/04/22 with diagnoses including dementia, and hypertension (HTN.)

Review of the record for Resident #60 revealed the facility had not completed an initial health assessment for resident upon admission to the facility.

2. Review of the medical record for Resident #170 revealed an admission date of 12/23/21 with diagnoses including dementia, hypertension (HTN), depression, and urinary retention.

Review of the record for Resident #170 revealed the facility had not completed an initial health assessment for resident upon admission to the facility.

3. Review of the medical record for Resident #220 revealed an admission date of 12/22/21 with diagnoses including peptic ulcer, hyperglycemia, malaise and fatigue.

Review of the record for Resident #220 revealed the facility had not completed an initial health assessment for resident upon admission to the facility

4. Review of the medical record for Resident #235 revealed an admission date of 08/05/22 with a diagnosis of Lewy body dementia.

Review of the record for Resident #235 revealed the facility health assessment dated 08/05/22 did not include a functional assessment regarding the how the resident performed activities of daily living (ADL's.)

Interview on 01/23/23 at 5:00 P.M. with the Executive Director (ED) confirmed the facility had not completed an initial health assessment for Residents #60, #170, and #220. ED confirmed Resident #235's initial assessment did not include an assessment regarding resident's ability to perform ADL's. The facility did not have a policy regarding completion of initial health assessments.

Based on record review, staff interview, and review of the facility policy, the facility to assess residents for change in condition. This affected one (#235) of three residents reviewed for change in condition. Facility census was nine.

Findings include:

Review of the medical record for Resident #235 revealed an admission date of 08/05/22 with a diagnosis of Lewy body dementia.

Review of the initial health assessment for Resident #235 dated 08/05/22 revealed resident was cognitively impaired. The assessment did not include an activities of daily living (ADL) assessment.

Review of the telephone orders for Resident #235 revealed an order dated 08/09/22 for resident to receive hospice services for a terminal diagnosis of Lewy body dementia.

Review of the August 2022 Medication Administration Record (MAR) for Resident #235 revealed resident was offered medications but refused to take medications on most days. Resident #234 did receive as needed doses of Roxanol for pain and shortness of breath on 08/11/22 and 08/13/22.

Review of the medical record for Resident #235 revealed it did not include a note regarding resident's admission to the facility nor was did it include a clinical assessment of the resident's condition leading up to his death in the facility on 08/15/22.

Interview on 01/23/23 at 5:00 P.M. with the Executive Director (ED) confirmed the facility had not assessed the Resident #235 regarding his change in condition prior to his death in the facility on 08/15/22. ED confirmed Resident #235 was a Do Not Resuscitate Comfort Care (DNRCC) code status and was receiving hospice services for a terminal diagnosis of Lewy body dementia.

Review of the facility policy titled Change in Resident Health Status undated revealed when a resident exhibits a change in condition, action will be taken to coordinate appropriate care. The resident's physician, resident's representative, and hospice provider (if applicable) should be notified of the change in condition. Documentation of the resident's change in condition and interventions implemented should be noted in the resident's medical record.

This violation represents non-compliance investigated under Complaint Number OH00138877.

Based on review of employee personnel files, review of facility infection control documents, staff interview, and review of the facility policy, the facility failed to ensure new employees had a two-step tuberculosis (TB) test upon hire. Additionally, the facility also failed to complete an annual TB risk assessment. This had the potential to affect all nine residents residing in the facility. Facility census was nine.

Findings include:

Review of the personnel file for the Executive Director (ED) revealed a hire date of 01/04/23. The personnel file did not include a TB test upon hire for the ED.

Review of the personnel file for Care Partner (CP) #425 revealed a hire date of 10/17/22. The personnel file did not include a TB test upon hire for CP #425.

Review of the facility ' s infection control documents for 2022 and 2023 revealed the facility did not complete a TB risk assessment during this timeframe.

Interview on 01/23/23 with the ED confirmed the facility had not completed TB tests upon hire for the ED or for CP #425. ED further confirmed the facility had not completed a TB risk assessment in 2022 or 2023.

Review of the facility policy titled Tuberculosis Control Plan undated revealed the facility would provide screening for TB to employees (paid and unpaid) and residents as part of a comprehensive TB exposure control program; and would comply with established federal, state, and local requirements and be in accordance with the recommendation of the Centers for Disease Control (CDC). All employees would have a two-step TB test upon hire. Further review of the policy revealed the facility would complete an annual TB risk assessment in the month of April.

Based on review of fire drill records, staff interviews and policy review, the facility failed to ensure fire drills were completed as required. This had the potential to affect all nine residents residing in the facility. Facility census was nine.

Findings include:

Review of the facility's fire drill log revealed there was no evidence a fire drill was conducted for the month of February 2022.

Review of the fire drill log revealed a fire drill was conducted in January 2022 on 01/26/22 at 11:32 A.M. and in March 2022 on 03/30/22 at 10:50 A.M.

Interview on 01/23/23 at 11:01 A.M. with Maintenance Director (MD) #450 confirmed the facility did not have record of a fire drill for February 2022. MD #450 further confirmed the fire drills for January and March 2022 were both conducted on the day shift. MD #450 confirmed the monthly drills should be conducted on First, Second, and Third shift as described in the facility policy.

Review of the facility policy titled Fire Drill Schedule undated revealed fire drills are to be scheduled once per shift per quarter and they should be within 30 days of each other. The shift times for fire drills were are as follows: First Shift 7:00 A.M. to 3:00 P.M., Second Shift 3:00 P.M. to 11:00 P.M., Third Shift 11:00 P.M. to 7:00 A.M.