Riverside Nursing: Sexual Abuse Investigation Failure - OH
A male resident was standing in front of her at the end of the bed, fully clothed.
The nurse walked the man to the common area, had the woman assessed for injuries, helped her get dressed, and brought her to the common area too. Then the facility waited three days to write anything down about what had happened, never completed a formal abuse investigation, and never reported the incident to the Ohio Department of Health.
The woman, identified in inspection records as Resident #160, has lived at Riverside Nursing and Rehabilitation Center since June 2022. She has dementia, major depressive disorder, chronic obstructive pulmonary disease, and anxiety disorder. A cognitive assessment documented in her medical record gave her a score of four on the Brief Interview for Mental Status, a 15-point scale. A score of four indicates severe cognitive impairment. She required supervision to use the toilet and needed help with dressing.
The man, Resident #49, has lived at the facility since March 2023. His diagnoses include dementia, mood disorder, post-traumatic stress disorder, and major depressive disorder. His cognitive assessment placed him at a seven on the same 15-point scale, also in the severe impairment range. He required supervision for toileting, dressing, and transfers. When staff asked him why he had been in her room, he could not recall.
Neither resident had been care planned for sexually inappropriate behaviors.
Three days after the incident, on May 1, the Social Services Director wrote nearly identical progress notes for each resident, three minutes apart. The notes described both residents as "allegedly attempting to solicit" the other "to physically engage." The notes said the guardian had been notified, that the facility recognized residents' rights to consensual contact, and that interventions had been put in place due to cognition concerns. Social services would "continue to follow up as needed."
That was the documentation. There was no incident report. There was no formal Sexual Abuse/Resident-to-Resident Abuse investigation, known internally as an SRI. There was no report to state regulators.
When a federal inspector interviewed the Director of Nursing on August 6, more than three months after the incident, the director confirmed what the records showed. Resident #160 had been found on her bed with no pants or depends on. Resident #49 had been standing at the end of the bed. He could not explain why he was there. The director said the facility had completed an investigation but acknowledged it was never provided to the surveyor.
Then the director offered the reason the facility had not reported the incident to the Ohio Department of Health: the daughter of Resident #160 had reviewed the camera footage and told staff she didn't see anything on it.
A family member's review of a hallway or room camera became the facility's substitute for a mandatory abuse investigation and a mandatory state report.
The Unit Manager, a licensed practical nurse identified as LPN #406, gave inspectors more detail when interviewed on August 14. She confirmed that LPN #491 had found Resident #49 in the room, that Resident #160 had been found with no pants or depends on, and that both residents had progressive dementia and appeared not to know each other. Then she said something that explained why none of the required steps had been taken.
The administrator at the time of the incident, she told inspectors, did not feel it was necessary to complete an SRI for the incident.
The Unit Manager also confirmed that no incident report had been completed at all.
The facility's own care plan records made the oversight harder to explain away. Resident #160's care plan contained no notation about sexually inappropriate behaviors, despite the incident having occurred in April. Resident #49's care plan, reviewed by inspectors and dated July 17, 2025, still contained no care plan entry for inappropriate sexual behaviors, nearly three months after a nurse had walked into a room and found him standing over a bottomless woman who could not remember what had happened to her.
What the Social Services Director wrote in those May 1 notes framed the incident as mutual, describing both residents as attempting to solicit the other. The inspection record does not support that framing with any evidence. What the nurse documented on April 28 was a woman on her bed with her clothing on the floor and a man standing in front of her. The woman had severe cognitive impairment. She could not reliably consent to or initiate anything. The facility's own records acknowledged the cognition concerns while simultaneously using them to justify inaction, noting that "due to resident cognition/memory concerns, interventions were put into place," without specifying what those interventions were or whether they were ever documented in either resident's care plan.
They were not.
The inspection was triggered by two complaints, filed separately and investigated together. Inspectors reviewed ten residents' records for abuse-related concerns. The findings about Resident #160 and Resident #49 were the ones that resulted in a cited deficiency. The level of harm was assessed as minimal harm or potential for actual harm, the lower end of the federal harm scale, though inspectors noted the failure affected two residents directly.
The facility census at the time of the inspection was 164 residents.
What the record does not contain is any account from Resident #160 herself. Her cognitive score of four out of fifteen means she was operating with profound memory and reasoning impairment at the time of the incident. The Unit Manager told inspectors both residents appeared not to know who each other were. A woman who does not know who is in her room with her, who cannot reliably communicate what has happened to her, and who requires staff assistance to dress herself is precisely the kind of person an abuse investigation process exists to protect.
The previous administrator decided the process wasn't necessary. Nobody completed an incident report. Nobody filed with the state. The care plans went unchanged for months.
By the time inspectors arrived and began asking questions in August, the woman who had been found on her bed with her clothes on the floor had been living in the same facility as the man who had been standing over her for more than three months, with no documented plan in either of their records addressing what had happened or how to prevent it from happening again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Nursing and Rehabilitation Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH was cited for abuse-related violations during a health inspection on September 2, 2025.
A male resident was standing in front of her at the end of the bed, fully clothed.
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.