Inspection Report

Meadowbrook Manor: Sexual Assault Investigation - OH

May 22, 2026

Fowler, OH

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The August 13 incident at Meadowbrook Manor exposed a facility with no investigation policies and staff who couldn't account for when they had last checked on either resident involved.

Licensed Practical Nurse #200 discovered Resident #16 in Resident #49's room at approximately 9:00 P.M. The female resident was sitting on the edge of her bed with her incontinence brief opened and pulled down. The male resident was touching her private area inappropriately.

The nurse immediately separated the residents and placed the male resident on one-to-one supervision. She performed a full body assessment on the female resident with the Director of Nursing and found no injuries. Both residents' physicians and families were notified.

But when federal inspectors arrived two weeks later, they discovered the facility had conducted virtually no investigation into how long the assault lasted.

"Witness statements obtained in the investigation revealed no evidence when Resident #16 was last seen or checked on by staff prior to the incident to determine how long the Resident #16 was in Resident #49's room," inspectors wrote.

The Director of Nursing told investigators he received a call from the licensed nurse on August 13 informing him that Resident #16 was sitting on Resident #49's bed, touching her private area while her incontinence brief was down. He said the nurse immediately separated the residents and assessed the female resident with no negative findings discovered.

The male resident was transferred to a psychiatric inpatient facility. The female resident was seen by her psychiatric care team the following day with no changes in mental status noted.

Social Service Designee #208 acknowledged the investigation "could have been more thorough and included more specific information regarding when Resident #16 had last been seen to determine how long Resident #16 was in Resident #49's room."

She told inspectors she knew the male resident had a history of wandering but was generally redirectable. She could not verify when either resident had last been checked on prior to the incident. The male resident was not on any type of increased supervision or checks at the time.

The Director of Nursing denied having any knowledge that Resident #16 had a history of sexually inappropriate behaviors.

When inspectors interviewed the licensed nurse who discovered the assault, she could not recall crucial details about the incident. She could not remember if she asked the male resident what he was doing or what the female resident's reaction was to the situation. She could not verify what time she had seen either resident prior to the incident.

The facility lacked any policy related to investigation of serious reportable incidents.

Federal inspectors cited Meadowbrook Manor for failing to ensure residents were free from abuse and neglect. The violation was classified as minimal harm or potential for actual harm affecting few residents.

The inspection was conducted in response to a complaint filed against the 120-bed facility located on Five Points Hartford Road.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Manor from 2025-08-28 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026 · Our methodology

Quick Answer

MEADOWBROOK MANOR in FOWLER, OH was cited for violations during a health inspection on August 28, 2025.

Licensed Practical Nurse #200 discovered Resident #16 in Resident #49's room at approximately 9:00 P.M.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at MEADOWBROOK MANOR?

Licensed Practical Nurse #200 discovered Resident #16 in Resident #49's room at approximately 9:00 P.M.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in FOWLER, OH, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MEADOWBROOK MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 365902.

Has this facility had violations before?

To check MEADOWBROOK MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.