Arden Courts (Bath)

Based on medical record review, observation, staff interview, review of facility self-reported incident (SRI) with investigative documents, and facility policy review, the facility failed to protect Resident #13's right to be free from sexual abuse by Resident #9.

This resulted in Actual Harm, on 06/05/26 when Resident #13, a severely cognitively impaired resident, was sexually abused by Resident #9, who had a history of sexually aggressive behaviors. Resident #13 and Resident #9 were found in a resident room with Resident #13's pants down and Resident #9's finger penetrating Resident #13's anus. Although Resident #13's cognitive impairment limited her ability to express the impact of the event, a reasonable person subjected to such conduct would likely experience humiliation, degradation, emotional distress and/or a profound invasion of personal dignity. This affected one resident (#13) of four residents reviewed for abuse. The facility census was 48.

Findings include:

Review of Resident #13's medical record revealed an admission date of 03/25/26 and diagnoses including Alzheimer's disease, insomnia, Crohn's disease, and age-related osteoporosis.

Review of Resident #13's Health and Service Evaluation Results dated 05/20/26 revealed the resident had severe impairment of orientation. Resident #13 was frequently disorientated, unable to remember or use information, had history of wandering, impaired safety awareness, and could not make appropriate decisions for self. Resident #13 required supervision for cognitive and psychosocial needs. Resident #13 was independent for ambulation and mobility. Resident #13 required full staff assistance for dressing.

Review of Resident #13's Service Plan dated 05/20/26 revealed the resident required supervision for psychosocial needs. Resident #13 was independent for mobility and ambulation. Resident #13 required full staff assistance for dressing. Resident #13 required spot checks for safety and risk every two hours.

Review of Resident #9's medical record revealed an admission date of 05/26/26 and diagnoses including vascular dementia with moderate anxiety, prediabetes, conductive hearing loss, and essential hypertension.

Review of Fax Report dated 05/22/26 revealed Resident #9 required emergency discharge from his prior assisted living facility. Resident #9 had behaviors including anxiety, physical violence, disorientation, delusions, agitation, hostility, wandering, and confusion. Resident #9 was noted to have inappropriate sexual behaviors. Resident #9 had previously taken Premarin (estrogen medication, which when introduced to the male body, reduces testosterone production and can decrease libido) and Cimetidine (histamine receptor antagonist, can be used off label to suppress sexual behaviors) for management of sexual behaviors.

Review of Resident #9's Service Plan dated 05/26/26 revealed the resident required supervision for psychosocial needs. Resident #9 required prompts and cues for ambulation and mobility. Resident #9 required spot checks for safety and risk every two hours. There was no service plan for Resident #9 to address a history of inappropriate sexual behaviors.

Review of a progress note dated 05/31/26 at 9:15 A.M. revealed Resident #9 was attempting to lure female residents. The NP was notified and an order was received to increase his Provera dose to 10 mg daily. The note indicated the DON educated staff to increase monitoring and provide redirection as needed.

Review of a progress note dated 06/03/26 at 3:30 P.M. revealed Resident #9 was observed repeatedly making attempts to push a (unspecified) female resident in her wheelchair to his room and indicated he wants her. Resident #9 required redirection multiple times. While staff were away, Resident #9 was able to bring the female resident into his room. Staff found Resident #9 attempting to remove the female resident's shirt, and she was trying to push Resident #9 away. Staff intervened and separated the two residents. There were no new interventions implemented at this time to prevent unwanted sexual behaviors.

Review of a progress note dated 06/05/26 revealed at 9:15 A.M., Resident #13 was observed in another resident's room with her pants pulled down exposing her buttocks. Resident #13 was lying on the bed while Resident #9 was standing over her with his finger penetrating Resident #13's anus. Staff separated Resident #9 and Resident #13. Resident #13 was placed on 15-minute checks and was assessed for injury. The nurse practitioner (NP), Director of Nursing (DON), family, and police department were notified of the incident. The NP gave an order to monitor Resident #13 for physical and mental wellbeing for three days.

Review of the facility Self-Reported Incident (SRI) Form dated 06/08/26 revealed the facility filed a report of sexual abuse involving Resident #9 and Resident #13. The report listed Resident #9 as the alleged perpetrator and stated on 06/05/26 at 9:15 P.M., Resident #13 was found lying on her side in bed facing the wall with her pants pulled down exposing her buttocks. Resident #9 was standing next to the bed with his pants pulled down to expose his groin and appeared to be touching Resident #13. Staff witnesses report Resident #9 had his finger penetrating Resident #13's anus. Resident #9 and Resident #13 were separated by staff. The SRI report indicated there were no apparent negative impacts to Resident #13. The facility placed Resident #9 on one-on-one monitoring until 06/08/26 (the resident's family was responsible for providing additional one-on-one monitoring after this date). Resident #9 was to be evaluated by the facility psychiatrist on 06/08/26. It was noted Resident #9 continued to express inappropriate sexual desires following the incident. Both residents' families were notified and the police were notified. The facility substantiated sexual abuse occurred.

Review of a witness statement for Caregiver #845 dated 06/05/26 revealed she was assisting Caregiver #820 to find Resident #9 and Resident #13. Caregiver #845 indicated Residents #9 and #13 were found in another resident's room. Resident #13 was witnessed lying on her side facing the wall with her pants halfway down. Resident #9 had his pants down and was trying to pull Resident #13's pants down further. Caregiver #845 and #820 separated the two residents. Caregiver #845 took Resident #13 back to her room and sat with her for a while.

Review of police incident report dated 06/05/26 revealed the police were dispatched to the facility at 10:19 P.M. Police were notified of inappropriate behavior between two memory care residents at the facility.

Review of witness statement for Licensed Practical Nurse (LPN) #812 dated 06/06/26 revealed LPN #812 was notified by a caregiver on 06/05/26 at 9:15 P.M. that Resident #9 was witnessed with his pants pulled down exposing himself and was standing over Resident #13 who was lying on her left side on the bed. Resident #9 had his finger penetrating Resident #13's anus. LPN #812 indicated she knew they had not been together long as LPN #812 stated she had passed Resident #9 walking in the hallway minutes before.

Review of witness statement for Caregiver #820 dated 06/10/26 revealed on 06/05/26 at approximately 9:15 P.M., Caregiver #820 was doing rounds and checking residents. Caregiver #820 reported when she opened a door to another resident's room, she found Resident #9 and Resident #13. Resident #13 was lying on the bed facing the wall with her pants pulled down. Resident #9 was sitting on the edge of bed with his pants pulled down and had a finger penetrating Resident #13's anus. Caregiver #820 stated she closed the door in shock but with the assistance of Caregiver #845, returned to the room and separated the two residents. Caregiver #820 stated she took Resident #9 to his room, washed his hands, and dressed him for bed.

Interview on 06/10/26 at 1:29 P.M. with the Executive Director (ED) revealed on 06/05/26 at around 9:30 P.M., she was notified of inappropriate sexual behaviors between Resident #9 and #13. The ED indicated wandering and napping in other resident rooms was a common behavior for Resident #13. The ED indicated the facility was aware of Resident #9's heightened sexual behaviors at his previous facility (prior to his admission). The ED indicated when Resident #9 moved in they did an education with staff on managing sexual behaviors, placed Resident #9 on a primarily male unit, and started him on Provera to limit sexual behaviors. The ED reported Resident #9 had attempted to lure female staff and residents into his room prior to the incident with Resident #13 on 06/05/26. The ED stated she believed residents like this were able to be managed at the facility in the past and they were monitoring the situation on a week-by-week basis to determine if Resident #9 could stay. The ED indicated following the incident on 06/05/26 both families were notified of the situation, and no criminal charges were requested.

Interview on 06/10/26 1:59 P.M. with Caregiver #829 revealed Resident #9 had attempted to invite her to his room with implied sexual behavior. Caregiver #829 indicated Resident #9 would approach any female, not just specific residents.

Interview on 06/10/26 at 2:55 P.M. with Caregiver #820 revealed she was looking for Resident #9 to provide him with assistance for bedtime care on 06/05/26. Caregiver #820 stated she was initially unable to find him, so she began going to each hallway then room to room. Caregiver #820 reported she found Resident #9 in another resident's room on his unit. Caregiver #820 reported Resident #9 was in the room with Resident #13. Resident #13 was laying on the bed on her side facing the wall with her pants and brief down to her knees. Resident #9 was sitting on the edge of the bed with his pants and brief down to his ankles. Caregiver #820 confirmed she observed Resident #9's finger penetrating Resident #13's anus. Caregiver #820 indicated it appeared he may have also had a finger in her vagina but was unable to confirm. Caregiver #820 indicated with the assistance of Caregiver #845 she was able to separate the two residents. Caregiver #820 indicated she had worked with Resident #9 at another facility and he had displayed similar sexually inappropriate behaviors. Caregiver #820 indicated Resident #9 had decreased behaviors since being monitored one-on-one; however, she indicated Resident #9 would likely have continued behaviors once someone was not monitoring him any longer.

Interview on 06/10/26 at 3:15 P.M. with Caregiver #845 revealed on 06/05/26 she was assisting another resident to the bathroom and Caregiver #820 asked her if she had seen Resident #9. Caregiver #845 indicated she had finished up toileting the other resident and started assisting Caregiver #820 in looking for Resident #9. Caregiver #845 indicated they found Resident #9 and Resident #13 engaged in sexual activity. Caregiver #845 stated she did not see the behavior but did find the residents partially undressed and Resident #9 touching Resident #13. Caregiver #845 indicated she and Caregiver #820 separated the residents.

Interview on 06/10/26 at 3:24 P.M. with LPN #812 revealed she was notified by caregivers that Resident #9 and Resident #13 were found engaged in sexual behaviors. LPN #812 stated when she arrived at the room, Resident #13 was still lying on the bed with her pants down and Resident #9 was standing with staff with his pants pulled up. LPN #812 stated she was in the lobby signing in medications when she was notified. LPN #812 stated she had seen both Resident #9 and Resident #13 wandering the hallways prior to going to the lobby. LPN #812 stated both residents were assessed for injury without any findings. LPN #812 stated she notified the NP, DON, and ED then tried to call both families, but could not immediately reach Resident #13's family. LPN #812 stated the police arrived to take statements.

Observations on 06/11/26 between 8:06 A.M. and 9:13 A.M. revealed Resident #9 was seen sitting in the dining room/common area of his unit. Resident #9 was being monitored by a sitter. Resident #13 was noted to wander on her unit and throughout the building. Resident #9 and Resident #13 were unable to be interviewed due to cognitive impairments.

Interview on 06/11/26 at 12:00 P.M. with Senior ED #851 verified there was no new interventions implemented to address Resident #9's behavior after the incident with a female resident on 06/03/26.

Interview on 06/11/26 at 12:26 P.M. with LPN #850 revealed she had picked up several shifts at the building but had not been a regular employee of the facility. LPN #850 stated on 06/03/26, the caregiver notified her Resident #9 was found with a female resident in his room and he was attempting to undress her. LPN #850 stated the residents were separated, the DON was notified, and the female resident was brought to the nursing station to keep close eye on her. LPN #850 stated she did not know anything about Resident #9 having sexual behaviors at the start of her shift.

Interview on 06/11/26 at 1:29 P.M. with Caregiver #821 revealed on 06/03/26, Resident #9 had been trying to push a female resident to his room in her wheelchair and had been making inappropriate comments. Caregiver #821 stated she had kept both residents in eyesight and had reported the behaviors to the nurse on duty and to the ED. Caregiver #821 stated she had to use the restroom and left both residents in the common area sleeping. Caregiver #821 stated when she returned neither resident was in the common area. Caregiver #821 stated she found Resident #9 trying to undress the female resident in his room. Caregiver #821 stated she was unaware of Resident #9's sexual behaviors prior to her shift on 06/03/26.

Review of the facility policy Resident Protection dated May 2025 revealed if the resident has a personal history of or was at risk for developing abusive actions or behaviors towards others, the community was to review the status to determine if move in is appropriate and if the facility can meet the resident's needs. The policy stated residents have the right to be free from abuse, neglect, misappropriation, and exploitation.

This violation represents non-compliance investigated under Complaint Number OH00170887.

Based on observation, policy review, coaching form review, and interview, the facility failed to complete hand hygiene during medication administration. This affected two of two residents (#41 and #38) observed for medication administration. The census was 44.

Findings include:

Observation on 05/04/26 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #50 was standing at the medication cart passing medication on the Country Lane unit. LPN #50 began dispensing Resident #41's medication from bubble medication packets; LPN #50 did not complete hand hygiene prior to dispensing medications. LPN #50 pressed the isosorbide mononitrate tablet medication through the foil backing into her bare right hand and dropped the medication into a plastic medication cup. LPN #50 continued to press a Metamucil capsule, omeprazole capsule and risperidone tablet into her bare right hand and dropped the medication into the same plastic medication cup. LPN #50 then removed the two capsule medications with her bare right hand. LPN #50 emptied the tablet medications into a plastic disposable medication pouch and crushed the mediations using a manual medication crush device. LPN #50 opened and emptied the two-capsules medications into the plastic disposable medication pouch to combine with the crushed medications. LPN #50 mixed the medications with chocolate pudding in the plastic medication cup. LPN #50 took the plastic medication cup and the Lantus insulin pen into Resident #41's room. Resident #41 was lying in bed, sleeping and LPN #41 awoke the resident for his medication. LPN #50 used a plastic spoon to administer Resident #41's medications within the chocolate pudding from the plastic medication cup into his mouth. LPN #50 then used an alcohol pad to wipe Resident #41's stomach prior to injecting Resident #41 with the Lantus insulin pen. At 8:05 A.M., LPN #50 walked back to the mediation cart and picked up the walkie-talkie with her bare right hand; LPN #50 did not complete hand hygiene. LPN #50 then began dispensing Resident #38's medication of aripiprazole into her right bare hand, dropped into a plastic medication cup, then dispensed sertraline medication into her bare right hand and dropped into the same plastic medication cup. LPN #50 walked to Resident #38's room and handed her the plastic medication cup. Resident #38 put the plastic medication cup to her mouth to take the medication.

Interview on 05/04/26 at 8:10 A.M. with LPN #50 verified she did not complete hand hygiene prior to dispensing Resident #41's and Resident #38's medications into her bare right hand.

Interview on 05/04/26 at 11:25 A.M. with the Executive Director (ED) and Resident Services Coordinator (RSC) #52 verified hand hygiene should be completed between administering medications to different residents.

Review of the coaching form dated 05/04/26 revealed LPN #50 administered insulin without gloves, touched medication with her hand and didn't wash hands/sanitize between residents. LPN #50 and the Residents Services Coordinator (RSC) #52 signed the form.

Review of the facility Medication Administration: Medication Pass policy and procedure dated May 2025 revealed staff were to perform hand hygiene and not touch medications or inside of the medication cup.

Based on record review and interview the facility did not ensure fire drills were conducted as required. This had the potential to affect all 33 residents in the facility. The census was 33.

Findings include:

Review of the facility fire drill records dated 03/04/24 through 02/06/25 revealed no fire drills were conducted during May 2024, July 2024 and December 2024. In addition, no fire drills were conducted on second shift for the second quarter of 2024 and no fire drills were conducted on third shift for the third quarter of 2024.

An interview was conducted on 02/26/25 at 10:11 A.M. with the Maintenance Director who verified the above findings.