Jennings Assisted Living

Based on record review, interview, facility policy review, and review of Self-Reported Incident (SRI) #231151 and #231573, the facility failed to prevent the misappropriation of property from Residents #36 and #48. This affected two (Former Resident #49 and Resident #1) of two residents, reviewed for abuse, neglect, and misappropriation. The facility census was 48.

Findings include:

Review of SRI #231151, dated 01/17/23, revealed an allegation of misappropriation when on 01/10/23 Former Resident #49's family reported missing money and a credit card from their father whom was a resident in the assisted living facility and had since passed away.

Review of the medical record for Former Resident #49 revealed an admission date of 06/17/21. Diagnoses included acute delirium, anemia, cognitive impairment, frail elderly, debility, stage three kidney failure, and severe protein malnutrition. The former resident was under hospice care starting 12/09/22 and expired 01/07/23.

Review of Police Report #20230094 filed 01/10/23 at 2:56 P.M. by Former Resident #49's daughter revealed her father who died 01/07/23 had his credit card stolen with five transactions (statements amounts and business of transactions not provided) made 01/04/23. The report stated her father kept his wallet under his pillow. The family was not aware of theft until a bank statement arrived with $238.53 worth of charges including a $67.99 charge at the CVS on the same road as the facility.

Review of a 01/11/23 email to the hospice provider informing them of the family's concern over missing money and a credit card that had been used revealed Administrator #61 asked the hospice provider to collect statements from all team members who would have provided Former Resident #49 services.

Review of 15 hospice provided staff statements emailed 01/11/23 revealed hospice Registered Nurse (RN) #63 indicated when she called to offer her condolences to the family the former resident's daughter said he had some missing items, but didn't specify money. The daughter told RN #63 it was not an issue with hospice but with the facility.

Review of the facility investigation of SRI #231151 revealed statements from the facility staff which were completed up to 01/13/23 and staff education on resident rights and abuse including misappropriation. The staff statements were unremarkable. Former Administrator #61 received a visit from the local police department on 01/13/23 at approximately 1:00 P.M. The police shared a name that was attached to a CVS card with a surveillance video obtained in the community of someone using the reported missing credit card. When the officer shared the alleged perpetrator's name the facility identified that the person was Care Partner (CP) #65, employed by the facility.

CP #65 did not punch in on 01/13/23. CP #65's last day of work was 01/12/23 at 10:13 P.M.

A handwritten note by Administrator #61 indicated CP #65 was interviewed on 01/13/23 at 3:30 P.M. and did not confess to any wrong doing. SRI #231151 was substantiated for misappropriation. CP #65 was terminated.

As a result of SRI #231151 residents were made aware of the theft and asked it they had missing items, money, or credit cards.

Review of SRI #231573, dated 01/30/23 revealed an allegation of misappropriation when on 01/28/23 Resident #1's family reported missing wallet since November and that Resident #1 realized in early December that there were thousands of dollars of fraudulent charges on his credit card. Resident #1 was currently working with his bank and did not have a bank statement to share at the time.

Review of the medical record for Resident #1 revealed an admission date of 07/29/19. Diagnoses included bi-polar, major depressive disorder, anxiety disorder, and hypertension.

Review of SRI #231573 revealed Resident #1 reported during a continued investigation of SRI# 231151 that he had been missing his wallet since November but then discovered fraudulent credit card charges in the thousands of dollars to a beauty supply company and food establishments and other charges the resident could not recall. He was working with his bank to investigate and was not able to provide a statement as part of the facility investigation. The local police department was notified and a police report was filed. Further review of the facility investigation of SRI #231573 revealed statements from staff and abuse misappropriation education. There was a note from the Resident Care Coordinator/Director of Nursing dated 01/30/23 indicating a group meeting was conducted after lunch which about half the residents attended to inform the residents of a missing credit card use, and that they should let the facility know if they had any missing personal items or concerns. The residents in attendance were asked to share the information with residents not in attendance. The facility unsubstantiated the allegation of misappropriation due to inconclusive evidence as to the charges and if they were made by someone from the facility or resident.

Review of police report #20230318 filed 02/02/23 by Resident #1 for unauthorized use of a credit card indicated he noticed the credit card missing mid November and was working with his bank to have the charges reversed. He filed a report in response to another theft at the facility being investigated in case there was a connection.

Interview 02/04/23 at 5:10 P.M. with Resident #1 revealed he paid his bill at the facility with a credit card. The credit card was used exclusively once a month between the 5th and 8th of the month to pay his bill. He noticed the credit card missing in November but did not tell anyone. He indicated the bank was emailing him about suspicious charges but he did not receive the emails. The bank sent him a notice dated 12/24/22 there was unusual activity on his credit card. He called the bank 12/27/22 and they sent him an activity report. The bank found $14,624.38 in disputed charges. He said he was embarrassed of the amount of money taken and should of known sooner. He had not shared the statement with the facility or police.

Review of the letter from Resident #1's bank dated 12/24/22 and statement from the bank of disputed charges dated 01/05/23 verified the resident's statements. Review of the statement included charges at the same CVS on the road near the facility.

Review of facility policy titled Resident Abuse, Neglect, Misappropriation, and Exploitation

Based on observation, test tray, resident and staff interview, the facility failed to provide foods at palatable temperatures. This affected all 47 residents in the facility.

Findings include:

Interview with Residents #7, #8, #18, #20, #26, #27, #28 and #29 on 09/06/22 between 8:15 A.M. and 9:15 A.M. reported the food was often cold. Interview with Care Partners #101 and #102 and Licensed Practical Nurse #106 on 09/06/22 at 9:10 A.M. revealed they had heard residents complain about cold food. Interview with the Administrator on 09/06/22 at 9:26 A.M. reported culinary services had been a problem and she had conducted audits and tasted the food herself but continued to hear complaints.

Review of the Resident Advisory Meeting minutes dated 06/21/22, 07/19/22 and 08/25/22 l revealed continued concerns voiced about cold foods.

Tray line temperatures were observed on 09/06/22 at 11:54 A.M. Cook #105 took the temperatures of the foods using a probe style stem thermometer. The vegetable fish measured 172 degrees Fahrenheit (F), meatloaf 179 degrees F, peas and carrots 174 degrees F, garden rice 166 degrees F, mashed potatoes 157 degrees F, beef gravy 161 degrees F and the cheddar broccoli soup was 190 degrees F. Meals began to be delivered to the dining room at 12:00 P.M. Residents comments included not very hot, not hot, just so-so, cold, luke warm and cool.

A test tray was conducted with Care Partner #102 also tasting the foods on 09/06/22 at 12:38 P.M. The meatloaf was 92 degrees F and tasted cold, the vegetable fish was 92 degrees F and tasted cold, mashed potatoes were 120 degrees F and warm, peas and carrot were 92 degrees F and tasted ice cold and the rice was 90 degrees F and ice cold. Interview with Cook #105 on 09/06/22 at 12:42 P.M. reported she was surprised because at the beginning of service it was hot. She then noticed the dials on the steam table were moved from a 6 where she had set them to a 3. She indicated the chef might have changed the levels. The Administrator was informed of the cold foods on 09/06/22 at 12:45 P.M.

This violation substantiates Complaint Number OH00135268.

Based on observation, interview and review of meeting minutes, the facility failed to have a system of food delivery to ensure a dignified dining experience. This had the potential to affect all 47 residents.

Findings include:

Interview with Residents #7, #8, #18, #20, #26 and #27 on 09/06/22 between 8:15 A.M. and 9:15 A.M. reported the facility needed a system of serving meals so table mates could eat at the same time instead of watching them eat.

Observation of meal delivery on 09/06/22 between at 8:15 A.M. and 9:15 A.M. yielded various concerns from Residents #18, #27 and #45 regarding waiting 45 minutes to receive their breakfasts while watching residents who just arrived to the dining room getting their meal before them.

Observation of meal delivery on 09/06/22 beginning at 12:00 P.M. revealed residents not being served together at a table. For example, Resident #16 received her meal but her two table mates watched her eat. Resident #12 was watching her two table mates eat lunch and said no one had approached her yet but they were almost done eating. By 12:25 P.M. all trays had been passed in the dining room.

Interview with Chef #107 with Cooks #104 and #105 present on 09/06/22 at 12:25 P.M. reported the residents were served based on when they came down to the dining room.

Review of the Resident Advisory Meeting minutes dated 07/19/22 indicated residents voiced a disorganized delivery of meals and the minutes dated 08/25/22 indicated the Administrator was working on resolving the culinary concerns.

This violation substantiates Complaint Number OH00135268.