Brookdale Oakwood

Based on medical record review, policy review, and staff interview, the facility failed to document a resident's behaviors and the need for administration of as needed (PRN) psychotropic medications. This affected one (#39) of the three Residents (#08, #36, and #39) reviewed for medication administration. The facility census was 52.

Findings include:

Review of the medical record for Resident #39 revealed an admission date of 12/12/26. His diagnoses included insomnia, dementia, psychotic disturbance, anxiety, essential primary hypertension, gastro-esophageal reflux disease (GERD), and atherosclerotic heart disease.

Review of the physician orders for Resident #39 dated 12/12/25, revealed the resident was ordered to receive Haloperidol (anti-psychotic medication) two milligrams (mg) at bedtime as needed (PRN) for aggression and agitation.

Review of the Medication Administration Records (MAR) for Resident #39 revealed the resident was administered PRN haloperidol on 12/15/25, 12/24/25, 12/29/25, 01/01/26, 03/04/26, 03/08/26, and 03/13/26.

Review of the nurse's progress notes for Resident #39 from 12/15/25 through 03/13/26, revealed no documentation related to the resident's behaviors and the need to have the PRN haloperidol administered on 12/15/24, 12/23/25, 12/29/25, 01/09/26, 03/04/26, 03/08/26, and 03/13/26.

Review the Assessment Summary for Resident #39 dated 01/13/26, revealed the resident was cognitively impaired and dependent on staff for medication administration and all activities of daily living (ADL).

Review of Personal Service Plans for Resident #39 dated 03/06/26, revealed the resident did not have any individual care plans related to behaviors..

During an interview on 04/01/26 at 2:00 P.M. Registered Nurse (RN) Care Manager #503 stated the facility had identified concerns related to the nursing staff providing residents with psychotropic medications and failing to properly document the need for the medication and its effectiveness. RN Care Manager #503 confirmed Resident #39 was given PRN haloperidol on 12/15/25, 12/24/25, 12/29/25, 01/01/26, 03/04/26, 03/08/26, and 03/13/26 with no documentation related to behaviors and the need for the medication.

Review of the psychiatric nurse practitioner (NP) note for Resident #39 dated 02/04/26, revealed the resident was assessed for an initial visit related to insomnia, dementia, anxiety, depression and agitation. Resident #39's symptoms were moderate and interfered with concentration and motivation. The staff reported Resident #39 had significant changes noted to his mood and behavior and the resident was difficult to redirect when confused or upset with recent reports of agitation, anger, and psychosis related to the resident thinking another resident was his wife. The resident was ordered Provera five mg daily related to inappropriate sexual behavior.

Review of the facility policy titled, Analysis of Behavior Expressions Residents Living with Dementia, dated 10/202/5 revealed residents experiencing cognitive impairments or living with a formal diagnosis of dementia may at times use behavior to communicate distress, unmet physical or emotional needs, pain or discomfort. These symptoms may be caused by something that is potentially modifiable. Care partners and associates should attempt to determine the potentially modifiable causes of behavioral expressions by utilizing the Steps for Behavioral Problem-Solving Process. When a resident exhibits behavioral expressions, associates should attempt to discover the possible contributing factors and document. If a resident was in danger to self or others the resident's primary physician and legally responsible party should be contacted. One-to-one care may be provided to assist in the prevention of harm to self or others.

Based on record reviews, staff, and physician interviews, review of the facility incident report, and policy review, the facility failed to ensure a cognitively impaired female resident was free from sexual abuse by a cognitively impaired male resident on the memory care unit (MCU). The facility also failed to implement individualized and effective interventions to ensure additional incidents of sexual abuse did not occur and failed to thoroughly investigate an incident of sexual abuse.

This resulted in Real and Present Danger and the potential for actual physical harm and/or psychosocial/emotional harm beginning on 01/31/26 at approximately 11:30 P.M. when facility staff discovered Resident #36 unclothed in Resident #39's bedroom. The facility failed to recognize an incident of sexual abuse and failed to implement effective and adequate interventions to ensure the safety and well-being of Resident #36 to prevent further sexual abuse from occurring. Resident #39 continued to display inappropriate sexual behaviors towards Resident #36 on 02/01/26, 02/17/26 and 03/29/26. This affected one (Resident #36) of 12 female residents identified with diagnoses of a cognitive decline residing in the MCU. The facility census was 52.

On 03/31/26 at 3:43 P.M. 4:01 P.M., the Executive Director (ED) was notified of Real and Present Danger began on 01/31/26 at approximately 11:30 P.M. when Resident Care Assistant (RCA) #114 discovered Resident #36 a severely cognitively impaired resident with dementia and who resided on the secured MCU lying on Resident #39's bedroom floor with her pants and incontinence brief down at her ankles. Resident #39 was in the room. Licensed Practical Nurse (LPN) #85 was called to Resident #39's room and Resident #36 told the staff members she had intercourse with Resident #39. LPN #85 called Former Health and Wellness Director (HWD) #117 to report the incident and was instructed to document it and there was nothing else that needed to be done as she didn't believe any intercourse happened. On 02/01/26 at 12:44 P.M., Resident #36 was found in Resident #39's room again. There were no details documented, no assessment of either resident and no investigation was completed. On 02/17/26 Resident #39 had Resident #36 in his room with the door shut and when LPN #87 was alerted to the room, Resident #39 was found kissing Resident #36. On 03/29/26, Residents #36's family was visiting with the resident and Resident #39 kept coming into Resident #36's room exhibiting inappropriate sexual behaviors towards Resident #36. When Resident #36's family asked the resident to exit the room, he became very agitated and increased his behaviors and made inappropriate comments and gestures about Resident #36's breasts.

The Real and Present Danger was abated on 04/09/26 when the facility implemented the following corrective actions:

On 02/01/26 at 8:45 A.M., Former HWD #117 notified Resident #36's power-of-attorney (POA) and indicated the resident would see Facility Nurse Practitioner (NP) #501 on 02/03/26.

On 02/02/26, Resident #39 started on Depakote (mood stabilizer) 125 milligrams (mg) twice daily for agitation by NP #501.

On 02/03/26 at 8:00 A.M., Residents #36 and #39 were evaluated by NP #501. Resident #39 was evaluated for behaviors and there were no new orders. Resident #36 was evaluated related to a fall follow-up and there were no new orders.

On 02/04/26, Residents #36 and #39 were evaluated by MindCare Psychiatric Services NP. Resident #36 was ordered Namenda (used to treat moderate to severe dementia associated with Alzheimer's disease by improving memory, attention, and cognitive function) and Resident #39 was ordered Provera (used for hypersexuality behaviors in men) five mg daily related to inappropriate sexual behaviors. Resident #39 continued to see psychiatric NP monthly and the most recent one being 04/07/26.

On 03/31/26 at 7:35 P.M., Resident #36 went home with her family so they could provide direct supervision. Resident #36 returned to facility on 04/01/26 and a family member sat with the resident to provide one-on-one observation. The resident left the facility on 04/03/26 and the family provided a move-out notice and never returned.

On 03/31/26 at 9:00 P.M., the facility implemented a constant one on one supervision for Resident #39. The one on one supervision continued through 04/05/26, then decreased by four hours daily until 04/10/26 at which time it would be stopped. If additional concerns arise during the reduction of the one on one supervision, the constant observation time would be re-instated and the resident's physician, mental health provider, and legal representative would be notified. Resident #39 will continue to reside in the resident's current apartment in the MCU.

On 04/01/26, the ED and Registered Nurse (RN) Care Manager #503 interviewed nine of the twelve female residents residing in the MCU for feedback on their experiences and an opportunity to provide any comments regarding their stay. All female residents stated they felt safe and happy where they were living. These female residents mentioned at times other residents, both male and female, entered their rooms; however, they felt safe at the facility. There were no inappropriate interactions or negative behaviors by Resident #39 reported from these female residents.

On 04/01/26, the ED and RN Care manager #503 were educated by the District Director of Clinical Services #505 on the following topics: Sexuality, intimacy and dementia, abuse, neglect and exploitation, Ohio Bill of Rights and associate obligations, creating a culture of behavior problem solving, reportable events and change of condition.

On 04/02/26 at 10:00 A.M., the ED and RN Care Manager #503 reviewed the incidents involving Resident #36 and #39 and the interventions taken as well as further recommendation with the district team which consisted of District Director of Operations #601, District Director of Clinical Services #505, and the Regional Director of Clinical Operations #602.

On 04/02/26, Physician #500 was made aware of the Real and Present Danger situation involving Residents #39 and #36.

On 04/02/26, RN Care Manager #503 completed skin assessments on all 12 female residents residing in the MCU. No concerns were identified.

On 04/02/26, the ED and the RN Care Manager #503 completed interviews with staff members that provided services in the MCU, including the RCAs, nurses, maintenance and housekeeping, to determine if any additional residents may have been impacted by the allegations of noncompliance. The staff were asked to provide any additional information regarding the residents, and the staff could not identify any additional residents that were impacted. The staff could not identify any additional information regarding the residents, other than to reiterate that Resident #36 entered Resident #39's apartment.

Beginning 04/02/26, the ED and/or RN Care Manager #503 will review the 24-hour report (a daily communication tool which allows the staff to notify their peers on other shifts of incidents, changes in conditions, or important happenings for residents and the report continues for 72 hours) each day for the next 90 days to help identify any resident incidents that may need additional follow-up for resident rights and safety. Any follow-up needed will be initiated by RN Care Manager #503.

On 04/02/26, the ED and RN Care Manager #503 completed retraining for all staff on the following topics: Sexuality, intimacy and dementia, abuse, neglect and exploitation, Ohio Bill of Rights and Associate Obligations, creating a culture of behavior problem solving, reportable events, and change of condition. Trainings were held in-person and via telephone. The same training topics will occur at the monthly All-Staff Meeting scheduled for 04/25/26. The staff on vacation or leave will attend the training on 04/25/26 and will not be scheduled until this training has been completed.

Beginning on 04/02/26, Divisional Dementia Care Manager #603 will identify additional opportunities for person-centered daily programming/activities for Resident #39.

Beginning 04/02/26, the ED and RN Care Manager #503 interviewed the other male residents in the MCU for feedback on their experiences and an opportunity to provide comments regarding their stay. No concerns identified at this time. Some residents reported other residents wandered into rooms, but it was not disruptive or scary.

On 04/02/26, RN Care Manager #503, ED and District Director of Clinical Services #505 reviewed the Abuse Policy. There were no changes.

Beginning 04/06/26, the ED and/or RN Care Manager #503, or designee will interview two female memory care residents and/or family members weekly for the next 60 days to verify reports of safety and comfort in their home.

On 04/09/26, Clinical Specialist #600 reviewed all Incident Reports from 01/31/26 through 04/09/26 and found no additional incidents like the ones recorded on 01/13/26 and 02/17/26.

On 04/09/26, RN Care Manager #503 reviewed all resident charts, including the 24-hour Report and no additional concerns were identified.

Beginning on 04/11/26, the facility will institute staff checks every 60 minutes for Resident #39 during waking hours with Charting Alerts for the staff. If the staff observe any inappropriate actions/behaviors by Resident #39, the staff will redirect or remove residents from the area. The RCAs will immediately notify the nurse on duty, and the nurse will notify the ED and/or RN Care Manager #503 immediately. If the 60-minute staff checks are ineffective, the facility will re-evaluate to determine more appropriate intervals/timing. The staff will redirect Resident #39 if he is attempting to enter another resident's apartment.

Beginning 04/20/26, the District Director of Clinical Services #505, and/or District Clinical Specialist #600 or their designee, will conduct a site visit monthly for the next ninety (90) days. The visit will include an audit of all incident reports from the prior ninety (30) days, interview with five staff to help identify any potential at risk residents for inappropriate actions or behaviors, and interviews with two memory care residents and/or family members to help identify any potential at risk residents. The ED and/or RN Care Manager #503 will conduct the rounds weekly during the weeks when the district team is not on-site.

Although the Real and Present Danger was removed on 04/09/26, the violation continued as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of the medical record for Resident #36 revealed an admission date of 09/22/25 and a discharge to the hospital on 11/15/25. Resident #36 was readmitted to the facility on 01/05/26 following a brief hospital and rehabilitation stay. Diagnoses included dementia, anxiety disorder, major depressive disorder, spinal stenosis, chronic kidney disease, and chronic pain syndrome.

Review of the Incident Report dated 01/31/26 at approximately 9:00 P.M. and authored by Former HWD #117 on 02/03/26 at 10:13 A.M., revealed Resident #36 was in Resident #39's room related to a sexually inappropriate incident. Resident #36 stated they had intercourse and Resident #39 denied any interaction between the two of them. Resident #36 was returned to her room, placed in bed and put on 30-minute checks. The POA and MD #500 were notified and a psychiatric provider would see the residents on 02/04/26 to see if medication would help with sexual inappropriateness.

Review of the nurse's progress note for Resident #36 dated 01/31/26 at 10:41 P.M. authored by LPN #85, revealed the resident was in Resident #39's room and stated she had intercourse with Resident #39. Resident #39 denied any interaction between the two. Resident #36 was returned to her room, placed in bed and started doing 30-minute checks. Former HWD #117 was notified, and the oncoming nurse indicated they would notify the resident's family.

Review of the Incident Log dated 01/31/26, revealed Resident #36 was listed as other and nothing else was documented.

Review of the nurse's progress note for Resident #36 dated 02/01/26 at 8:45 A.M. and authored by Former HWD #117, revealed the resident's POA was notified of an incident involving Resident #39. Both residents would see the provider on next rounds.

Review of the nurse's progress note for Resident #36 dated 02/01/26 at 12:44 P.M. and authored by Former HWD #117, revealed Resident #36 was found in Resident #39's room. The residents were separated.

Review of NP #501 progress notes for Resident #36 dated 02/03/36, revealed Resident #36 was assessed for a fall follow-up and the staff voiced no concerns with the resident. There was no documentation for the incident involving Resident #36 and #39 on 01/31/26.

Review of the psychiatric NP visit note for Resident #36 dated 02/04/26, revealed the resident was seen for an initial evaluation related to a history of dementia, major depressive disorder. anxiety, and insomnia. Information received from the staff indicated Resident #36 believed other male residents were her husband. Resident #36 was assessed to have loose associations and delusions; however, no hallucinations. Resident #36 had poor judgement, and poor impulse control related to dementia. Resident #36 had unstable symptoms and required a medication adjustment. Resident #36 was ordered Namenda five mg twice daily.

Review of the nurse's progress note for Resident #36 dated 02/17/26 at 6:02 P.M. and authored by LPN #87, revealed Physical Therapist Assistant (PTA) #125 reported Resident #36 was in Resident #39's room and PTA #125 tried to redirect Resident #39. PTA #125 stated Resident #39 told him that he needed to get rid of Resident #36. LPN #87 entered the room and observed Resident #39 kissing Resident #36, and both residents were redirected to the common area. Resident #36's POA was contacted and requested a room change for Resident #36.

Review of the Annual Functional Assessment for Resident #36, dated 03/05/26, revealed the resident had impaired cognition.

Review of the nurse's progress note for Resident #36 dated 03/29/26 at 11:25 A.M. and authored by LPN #84, revealed Resident #36's family members were visiting, and reported Resident #39 came in Resident #36's room and exhibited inappropriate behavior.

Review of the nurse's progress note for Resident #36 dated 03/31/26 at 7:73 P.M. and authored by LPN #87, revealed Resident #36 was discharged from the community to stay with family until 04/01/26.

Review of the medical Record for Resident #39 revealed an admission date 12/12/26. Diagnoses included dementia, psychotic disturbance, anxiety, essential primary hypertension, and atherosclerotic heart disease.

Review of the physician orders for Resident #39 dated 12/12/25, revealed the resident was ordered to receive Haloperidol (anti-psychotic medication) two mg at bedtime as needed (PRN) for aggression and agitation.

Review of medication administration records (MAR) for Resident #39, revealed the resident was administered Haloperidol on 01/08/26, 03/04/26, 03/08//26, 03/10/26 and 03/13/26. There was no documentation to support why the resident received the PRN doses of haloperidol.

Review of the Annual Functional Assessment for Resident #39 dated 01/13/26, revealed the resident was cognitively impaired and was dependent on staff for activities of daily living (ADL) related to cognition and memory loss.

Review of the nurse's progress note for Resident #39 dated 01/31/26, revealed no documentation related to staff finding Resident #36 unclothed in Resident #39's room.

Review of the nurse's progress note for Resident #39 dated 02/01/26 at 5:34 P.M. and authored by Former HWD #117, revealed Resident #39 continued to wander into Resident #36's room and the two residents were observed in Resident #39's room with the bedroom door closed.

Review of the nurse's progress note for Resident #39 dated 02/02/26 at 1:25 P.M. and authored by Former HWD #117, revealed Resident #39 was being sexually inappropriate with staff members. Resident #39 was scheduled to see a psychiatric NP on 02/04/026 regarding his behaviors.

Review of NP #501 progress note for Resident #39 dated 02/03/26, revealed the resident was seen for behaviors. The resident was recently started on Depakote and referred to psychiatric services. The staff reported there was some improvement since starting the Depakote. The staff voiced no concerns with the resident. There was no documentation of the incident involving Resident #39 and #36 on 01/31/26.

Review of the psychiatric NP visit note for Resident #39 dated 02/04/26, revealed the resident was seen for an initial evaluation related to a history of dementia, insomnia, anxiety, depression and agitation. Resident #39's symptoms were moderate and interfered with concentration and motivation. The staff had expressed Resident #39 had significant changes with his mood and behavior. Resident #39 was difficult to redirect when he was confused or upset and there were recent reports of the resident having agitation, anger, and psychosis related to Resident #39 believing another resident (Resident #36) was his wife. Resident #39 was disoriented to place, time and situation, memory impaired, poor insight, poor judgment, poor impulse control, and normal psychomotor activity. Provera (used for hypersexuality behaviors in men) five milligrams (mg) was ordered daily related to inappropriate sexual behaviors.

Review of the nurse's progress note for Resident #39 dated 02/17/26 at 6:10 P.M. authored by LPN #87, revealed she was notified by PTA #125 that he observed Resident #36 in Resident #39's room. PTA #125 stated when he tried to redirect Resident #39, he stated he needed to get Resident #36 of the here. LPN #87 entered the room and observed Resident #39 kissing Resident #36. Resident #39's POA was contacted and questioned what the next steps were to address Resident #39's ongoing behaviors towards Resident #36's.

Review of Service Plan for Resident #39 dated 03/06/26, revealed he was dependent on staff for ADLs; however, there was no documentation to acknowledge or address his agitation, aggressive and/or sexual behaviors towards others.

Review of the nurse's progress notes for Resident #39 dated 03/29/26 at 11:27 A.M., revealed the resident was wandering in Resident #36's room.

During an interview on 03/30/26 at 9:40 A.M., RCA #114 stated on 01/31/26 around 11:30 P.M., she observed Resident #39's bedroom closed and it was unusual. RCA #114 stated when she opened the door, she discovered Resident #36 on the floor with her pants and depends down at her ankles and Resident #39 was fully dressed and walking towards the door. RCA #114 stated she called for LPN #85 and waited for her to arrive. RCA #114 stated Resident #39 thought Resident #36 was his wife and often pushed her around the unit in her wheelchair. RCA #114 stated Resident #36 and Resident #39 had rooms directly next to each other, and the staff were constantly having to redirect Resident #39 out of Resident #36's room.

During an interview on 03/30/26 at 11:01 A.M., RCA#108 stated she had witnessed Resident #39 kiss Resident #36 on the mouth. RCA #108 stated Resident #39 thinks Resident #36 is his spouse.

During an interview on 03/30/26 at 12:19 P.M., RCA #101 stated it was normal to see Resident #39 and Resident #36 holding hands in the common area. RCA #101 stated the residents believed they were married.

During an interview on 03/30/26 at 12:26 P.M., LPN #87 stated on 02/17/26 at approximately 5:30 P.M., PTA #125 notified her that Resident #39 had Resident #36 in his bedroom with the door closed. LPN #87 stated Resident #39 had a separate room for a bedroom and when she got to Resident #39's room, she noticed the bedroom door was closed. LPN #87 stated when she opened his bedroom door, she observed Resident #39 kissing Resident #36. LPN #87 redirected the residents to the common area. LPN #87 stated she told management about this incident during the next morning's meeting; however, the ED stated Resident #39 would not be evicted. LPN #87 stated she was instructed by the ED to redirect Resident #39's behavior.

During an interview on 03/30/26 at 12:31 P.M., LPN #84 stated he was Resident #36's nurse on 03/29/26 when the resident's family reported they witnessed Resident #39 trying to kiss Resident #36 inside Resident #36's room as they visited. LPN #84 stated he did not observe this allegation reported by Resident #36's family. LPN #84 stated Resident #39 would wander through the unit and into other residents' rooms and he had observed Resident #39 in Resident #36's room with the door closed. LPN #84 stated he had observed Resident #39 pushing Resident #36 around in her wheelchair and kissing Resident #36 because he had a fondness for her; however, he never documented any of his observations and couldn't remember any dates. LPN #84 stated he did not complete any type of investigation of the alleged sexual abuse reported by Resident #36's family on 03/29/26, because he had brought up similar allegations to the attention of management and was told to just redirect their behaviors. LPN #84 sated Resident #36 had made it very clear that she did not want Resident #39 in her room and did not encourage his behaviors.

During an interview on 03/30/26 at 1:03 P.M., the ED stated she was not aware of LPN #85's charting from 01/31/26 where Resident #36 reported she had intercourse with Resident #39. The ED stated if she had known about this specific charting, she would have completed an investigation. The ED also stated she was not aware of alleged incident by Resident #39 on 03/29/26 because it just happened over the weekend and since the facility did not have a HWD in place, she wouldn't have known. The ED stated Resident #36 and #39's families were aware of their relationship status. The ED stated the residents had the right to wander around in the Memory Care Unit. The ED verified there was no individualized care plan acknowledging or addressing Resident #39's behaviors. The ED stated she did not consider the relationship between Resident #36 and #39 a behavior or Resident #39's inappropriate comments towards female staff.

During an interview on 03/30/36 at 1:34 P.M., LPN #85 stated she was the nurse assigned to the Memory Care Unit during the evening shift on 01/31/26. LPN #85 stated she was called to Resident #39's room on 01/31/26 at approximately 11:30 P.M. by RCA #114 and when she arrived, Resident #36 was seated on the floor with one pant leg on and one pant leg off and Resident #39 was fully dressed. LPN #85 stated she asked the Residents what they were doing and Resident #36 stated she knew what they were doing and was having fun. LPN #85 stated Resident #36 reported her, and Resident #39 had intercourse, but Resident #39 denied it. LPN #85 stated she contacted Former HWD #117 and relayed what she discovered and Former HWD #117 mentioned she did not think this occurred because Resident #39 was fully dressed so there was no reason to send the resident to the hospital. LPN #85 was instructed to assess Resident #36, put her into bed and do thirty-minute checks. LPN #85 stated she did not complete a full assessment on Resident #36. LPN #85 stated she assisted Resident #36 to the restroom and stated she kind of looked at Resident #36's private area but did not see any redness. LPN #85 stated she called MD #500 and there were no new orders.

During an interview on 03/30/26 at 4:16 P.M. the ED stated there was no Incident Report or an investigation completed for the 02/17/26 incident when LPN #87 entered Resident #39's room and observed Resident #39 kissing Resident #36. The Administrator verified when the POA was contacted about the 02/17/26 incident, she requested Resident #36 to be moved to a different room. The ED stated she was at the desk one day when Resident #36's POA called and she just happened to answer the phone. The ED stated the room move was discussed with the POA and the ED mentioned since the unit was small and the two residents shared a common area; Resident #36 should just stay where she was at. The ED stated there was no documentation of this conversation with the POA and verified Resident #36 was never moved to a new room per the POA's request.

During an interview on 03/30/26 at 5:32 P.M., the ED verified there was an incident on 01/31/26 involving Resident #36 and #39 and stated the facility did not need to get any staff interviews or complete an investigation because the facility knew what happened. The ED stated LPN #85 discovered the two residents and reported it. When discussing the surveyor's findings from an interview with RCA #114, the ED stated she was not aware RCA #114 was the staff member who found Resident #36 unclothed in Resident #39's room and not LPN #85.

During an interview on 03/31/26 at 1:18 P.M., Resident #36's POA stated the facility never called and informed her of the alleged sexual abuse incident on 03/29/26. The POA stated her sister (Resident #36's other daughter) was visiting the resident on 03/29/26 and when she got to the room, the door was shut. When the Resident's daughter entered the room, she found Resident #39 inside Resident #36's room attempting to kiss Resident #36. Resident #36's daughter immediately asked Resident #39 to leave the room. The POA stated during the visit, Resident #39 kept coming back in the room and Resident #39 became very agitated and started calling her a bunch of expletives. Resident #39 kept stating it was time for him to rub lotion on Resident #36's breasts. The POA stated the facility advised any family members visiting would need to take Resident #36 off the unit because Resident #39 had a right to wander through the unit and into other residents' rooms.

During an interview on 04/01/26 at 10:03 A.M., PTA #125 stated on 02/17/25 around 11:00 A.M., he observed Resident #39 in his bedroom with Resident #36 and the door was mostly closed. PTA #125 stated he knocked on the door and as he pushed the door open, he saw Residents #39 and #36 inside the bedroom room. Resident #36 stated she was talking about deep stuff to Resident #39. PTA #125 mentioned to Resident #39 it was time for his therapy session and Resident #39 wanted to push Resident #36 in her wheelchair back to her room.. Resident #39 returned to therapy; however, he appeared rushed and agitated and stated he needed to get rid of Resident #36. Resident #39 stated he was done with therapy and exited. PTA #125 stated he observed Resident #39 go back to Resident #36's room and he pushed her back to his bedroom and closed the door. PTA #125 stated LPN #87 was nearby and asked her to go into Resident #39's room. PTA #125 stated he and LPN #87 walked into Resident #39's bedroom and observed Resident #39 kissing Resident #36.

During an interview on 04/01/26 at 12:19 P.M., Memory Care Manager (MCM) #82 stated Resident #39 would make sexually inappropriate comments to her when she clipped his fingernails. MCM #82 stated one day Resident #39 started acting differently and he appeared to be aroused, so she reported it to a nurse. MCM #82 stated on the same day during lunch, Resident # 39 and Resident #36 were seated at the same table. MCM #82 stated Resident #36 was acting scared and very nervous. Resident #39 kept telling Resident #36, it was time to go to bed. MCM #82 stated she overheard Resident #36 tell Resident #39 she would not go to bed with him and she wasn't his wife. MCM #82 stated Resident #36 begged her not to leave her alone with Resident #39. MCM #82 stated one minute Resident #36 did not want Resident #39 to be around her, then the next minute she thought Resident #39 was her husband.

During an interview on 04/01/26 at 12:56 P.M., MD #500 stated she was called on the evening of 01/31/26 and notified that Resident #36 was found in Resident 39's room and one of the Resident's had their pants down. MD #500 stated she was never informed that Resident #36 stated she had intercourse with Resident #39.

During an interview on 04/01/26 at 1:18 P.M., Resident #36's POA stated she was notified that Resident #36 was found behind a closed door with Resident #39 on 01/31/26 around 11:30 P.M., however, she was never informed that Resident #36 reported they had intercourse. Resident #36's POA stated she was informed Resident #36 was found with her shirt off in Resident #39's room. Resident #36's POA stated she was very frustrated because Resident #39 would continuously walk into Resident #36's room. Resident #36's POA stated the staff advised her to visit Resident #36 off the unit because Resident #39 had the right to wander on the unit and into other resident's room. Resident #36's POA stated she requested for Resident #36 to be moved away from Resident #39 and nothing was addressed.

During an interview on 04/01/26 at 1:50 P.M., Former HWD #117 stated she was notified on 01/31/26 at approximately 11:30 P.M. when Resident #36 was found in Resident #39's bedroom. Former HWD #117 stated she was told Resident #36 did not have a shirt on and Resident #39 denied anything happening. Former HWD #117 stated it was reported to her about Resident #36 stating she had intercourse with Resident #39; however, HWD #117 did not think this occurred because Resident #39 was dressed.

During an interview on interview on 04/01/26 at 1:50 P.M., Former HWD #117 stated the progress note for Resident #36 on 02/01/26 was regarding finding Resident #36 in Resident #39's room. Former HWD #117 confirmed she found Resident #36 in the bedroom of Resident #39 with the door closed; however, was unable to recall any other details about the incident or the findings.

Review of the facility policy titled, Abuse, Neglect &Exploitation Policy, dated May 2021, revealed the facility was committed to maintaining a safe environment for each resident. Instances, or allegations of abuse, neglect or exploitation would be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation and appropriate follow-up. An investigation would be done as soon as possible, and witnesses should be interviewed and the Executive Director would maintain a written record of the investigation. A summary of interviews should be prepared by the Executive Director or designee. If suspected of sexual abuse and/or rape, the facility would develop a plan to protect the suspected victim, provide a medical examination for suspected victim as soon as possible, evidence or potential evidence would be preserved and not altered or destroyed, and the facility would provide counseling by contacting an agency or individual trained in dealing with rape or sexual abuse to provide counseling or intervention.

Based on personnel record review and staff interview, the facility failed to ensure staff that provided personal care services received first-aid training through an approved source. This had the potential to affect all of the residents residing in the facility. The facility census was 39 residents.

Findings include:

Review of the personnel file for Care Associate (CA) #83 revealed it did not include documentation of training in first aid from an approved source.

Interview on 02/19/25 at 4:43 P.M. with the Executive Director (ED) confirmed the facility had not documentation of first aid training through an approved source for CA #83.

This violation is a recite to the annual survey completed 06/02/22.

Based on observation and staff interview, the facility failed to ensure sanitation testing strips were available for testing the three-compartment sink in the kitchen. This had the potential to affect all of the residents residing in the facility. The facility census was 39.

Findings include:

Observation of main kitchen on 02/19/25 at 11:23 A.M. revealed the facility did not have sanitation testing strips available for testing of the three-compartment sink.

Interview on 02/19/25 at 11:23 A.M. with Dietary Manager (DM) #50 confirmed the facility should have test strips to test the sanitation buckets, but testing strips were not available.

This deficiency is a recite to the annual survey 06/02/22.

Based on review of fire drill records and staff interview, the facility failed to ensure receipt of fire alarm transmissions within 12 hours of coded announcements. This had the potential to affect all residents in the facility. The facility census was 39 residents.

Findings include:

Review of the night shift fire drills dated 02/20/24, 05/08/24, 08/20/24, and 11/21/24 revealed there was no documentation of verification of fire alarm transmissions within 12 hours of the coded announcements.

Interview on 02/19/25 at 2:51 P.M. with Maintenance Director (MD) #68 confirmed the fire drill records did not include documentation of the fire alarm transmissions for the night shift fire drills dated 02/20/24, 05/08/24, 08/20/24, and 11/21/24.

This violation is a recite to the annual survey completed 06/02/22.

Based on record review and staff interview, the facility failed to maintain an accurate incident and accident log that contained all resident falls. This affected three (#22, #25 and #35) out of three residents reviewed for falls. Facility census was 37.

Findings include:

1. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on 04/10/20 with diagnoses including Coronavirus (COVID-19), hyperlipidemia, hypertension, arthritis, unspecified cataract, Alzheimer's disease with late onset, restless leg syndrome, and osteoarthritis.

Review of Resident #22's service plan dated 09/23/22 revealed Resident #22 required assistance with grooming, dressing, and toileting. Resident #22 was independent with mobility and bathing.

Review of Resident #22's short portable mental status questionnaire dated 10/29/21 revealed Resident #22 had severe cognitive impairment.

Review of Resident #22's progress note dated 06/18/22 revealed Resident #22 was found on the floor next to the sitting chair across from the elevator. Resident #22 had her back leaning against the wall and was sitting on her bottom. Resident #22 could not tell the nurse if she hit her head. Resident #22 had no evidence of head injury. Range of motion was within normal limits. The physician, power of attorney (POA), Executive Director (ED), Health and Wellness Director (HWD) and hospice were notified. Resident #22 was encouraged to join in activities in the common area.

Review of Resident #22's progress note dated 06/20/22 revealed Resident #22 fell in front her apartment. Resident #22 hit her head and there was a small amount of bleeding to the upper portion of her head. The caregiver applied pressure while the nurse assessed, and the physician was called. Resident #22's head was lying in the doorway to her room and her arms were bent at the elbows holding her head. Resident #22 had a skin tear to her right elbow that was one centimeter (cm) by one and one forth cm. Resident #22 kept closing her eyes. The physician wanted hospice called and to assess Resident #22. The physician stated she would be out the next day to see the resident. Hospice and Resident #22's POA were notified, and Resident #22 was encouraged to sit in the reclining chair in the common area.

Review of Resident #22's progress note dated 07/31/22 revealed at approximately 7:36 A.M. a nurse heard clatter in the dining room. The nurse observed Resident #22 on the floor in front of the windows of the dining room. The resident's head, neck and upper half of her torso was leaning against the wall the resident's arms and legs were slightly bent in front of her. The nurse observed Resident #22 had on her helmet. Range of motion was within normal limits. The physician, hospice, POA, ED and HWD were notified.

2. Review of the Resident #25's chart revealed Resident #25 admitted to the facility on 11/15/19 with diagnoses including unspecified dementia, glaucoma, nocturia, tremor, hypertension, osteoporosis without current pathology, and COVID-19.

Review of Resident #25's service plan dated 08/14/22 revealed Resident #25 required assistance with toileting, and Resident #25 required set up assistance with showering. Resident #25 was independent with mobility.

Review of Resident #25's short portable mental status questionnaire dated 10/29/21 revealed Resident #25 had severe cognitive impairment.

Review of Resident #25's progress note dated 08/20/22 revealed at 5:20 A.M. the nurse was called by the caregiver to the unit after the caregiver reported the resident was found lying flat on her back in the bedroom during last night rounds. The nurse checked range of motion and the resident was resisting the nurse and tried to stiffen up when the nurse was trying to bend her arms and her legs. No visible injuries or open areas were noted. The resident was responsive to the nurse when the nurse rubbed her chest and the caregiver and nurse rolled the resident to get her on the hoyer lift. The resident refused to open her eyes when asked but her eyes reacted when the nurse lifted her eye lid. The physician and POA were notified.

3. Review of the Resident #35's chart revealed Resident #35 admitted to the facility on 08/03/22 with diagnoses including Alzheimer's disease, sick sinus syndrome, type two diabetes, weakness, heart failure, atrial fibrillation, and chronic kidney disease.

Review of Resident #35's service plan dated 09/03/22 revealed Resident #35 was independent with toileting, showering and mobility.

Review of Resident #35's short portable mental status questionnaire dated 10/29/21 revealed Resident #35 had mild cognitive impairment.

Review of Resident #35's progress note dated 08/15/22 revealed Resident #35 was observed on the ground in the courtyard by other residents and a visitor. Another resident came inside to let the caregiver know. Resident #35 was sitting with his back to the fence with his rollator walker collapsed under him. Resident #35's legs were straight out in front, and his arm was pinned back from the rollator. Resident #35 had bleeding to back of his left elbow. Resident #'s POA, and physician were notified. Resident #35 was sent to the hospital.

Review of Resident #35's progress note dated 10/06/22 revealed Resident #35 was observed sitting on the floor by the caregiver when the resident was yelling out for help. Resident #35 stated he had no pain and was on his way to dinner. Range of motion was within normal limits and the resident reopened old skin tears to both arms. The physician, hospice and power of attorney were notified.

Review of the facility's incident and accident log revealed the document contained no information regarding the falls for Resident #22's on 06/18/22, 06/20/22, and on 07/31/22; Resident #25 on 08/20/22; and Resident #35 on 08/15/22 and 10/06/22.

Interview with HWD #25 and Area Health District Nurse #900 on 10/07/22 at 2:07 P.M. verified Resident #22's falls on 06/18/22, 06/20/22, and on 07/31/22; Resident #25's fall on 08/20/22; and Resident #35's falls on 08/15/22 and 10/06/22 were not accurately documented on the facility's incident and accident log.

This deficiency substantiates Complaint Number OH00136218.