Meadowbrook Manor: Sexual Assault by Wandering Resident - OH
The August 13th incident at Meadowbrook Manor occurred when LPN #200 entered Resident #49's room to give medications and discovered Resident #16 sitting on her bed. The female resident's incontinence brief was open.
The nurse could not recall what either resident's reaction was to the situation or when she had last checked on them before the assault.
Neither resident was on 15-minute checks or any other supervision at the time, despite Resident #16's documented history of wandering into other residents' bedrooms and bathrooms. Staff immediately separated the residents and placed Resident #16 on one-to-one supervision while arranging his transfer to a psychiatric facility.
The facility had implemented 15-minute room checks for Resident #16 after finding him sitting naked on his bed on June 21st. But those safety measures were discontinued on July 2nd when a psychiatric nurse practitioner saw him and started medications, according to Corporate Risk Manager #207.
The timing proved catastrophic. Resident #49's sister noticed Resident #16 had been "wandering more frequently prior to the incident, in and out of people's rooms and sitting on their beds" during her visits to the facility.
LPN #203 confirmed the male resident "typically wandered into other people's bedrooms and bathrooms" and that staff "did the best they could in redirecting and monitoring him." But she had no knowledge of increased supervision before the sexual assault occurred.
The facility's own policy required the interdisciplinary team to "evaluate behavioral symptoms to determine the degree of severity, distress and potential safety risk to the resident" and implement "safety strategies to protect the resident and others from harm."
No such evaluation occurred after the psychiatric visit in July, even though the nurse practitioner's note specifically referenced Resident #16 being "sexually inappropriate."
Director of Nursing staff denied knowing about any history of sexually inappropriate behaviors, despite the documented June incident and July psychiatric consultation. Social Service Designee #208 could not verify when Resident #16 had last been checked before the assault and confirmed no discussion occurred about increased supervision after his psychiatric visit.
The breakdown in communication proved dangerous. CNA #204 acknowledged the male resident's wandering was "difficult at times" and that staff "attempted to redirect him as much as possible." But she confirmed there was "no increased level of supervision immediately prior to the incident" and "no tracking in place to verify when Resident #16 had last been checked on."
Federal inspectors found the facility failed to protect residents from harm despite clear warning signs. The male resident had exhibited sexually inappropriate behavior just seven weeks before the assault, prompting temporary safety measures that were quietly discontinued without proper assessment.
Resident #49 showed no signs of distress when her sister visited the morning after the incident. The sister spoke with the former administrator, who confirmed Resident #16 was being transferred for psychiatric care but might return to the facility upon discharge.
That possibility prompted Resident #49's family to make a difficult decision. After discussing the assault with relatives, her sister "felt it was in Resident #49's best interest to have her moved to a different facility."
The psychiatric nurse practitioner who had seen Resident #16 in July and recommended discontinuing his room checks was not available for interview during the inspection.
Staff members consistently described Resident #16 as "generally redirectable" despite his persistent wandering behavior. This characterization appears to have influenced the decision to eliminate safety monitoring, even after documented inappropriate sexual conduct.
The facility policy explicitly required ongoing behavioral assessment and intervention adjustments "based on the impact of the behavior." Inspectors found no evidence such assessments occurred between the July psychiatric visit and the August sexual assault.
Resident #49's psychiatric care team evaluated her the day after the incident and found no changes in her mental status. But the trauma of sexual assault by a fellow resident while under facility care prompted her family's decision to seek placement elsewhere.
The male resident remained on one-to-one supervision until his transfer to an inpatient psychiatric facility. Whether he will return to Meadowbrook Manor depends on his psychiatric treatment outcomes.
Federal investigators cited the facility for failing to ensure residents were free from abuse and neglect, documenting how discontinued safety measures directly contributed to the sexual assault of a vulnerable female resident.
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
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
MEADOWBROOK MANOR in FOWLER, OH was cited for violations during a health inspection on August 28, 2025.
The female resident's incontinence brief was open.
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.