Grafton Oaks Nursing Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
at 11:27 A.M., RN #105 stated she was working the day of the incident. She was passing medications in
the opposite hall when two housekeepers called for her. She stopped passing medications and went to Resident #12's room with HK #110 and observed HK #115 was standing outside the door. RN #105 observed Resident #10 standing by the side of Resident #12's bed. Resident #12 was lying in her bed awake, with no expression on her face and not talking. RN #105 asked Resident #10 what he was doing in Resident #12's room and instructed him to leave. Resident #10 used his walker and left. After Resident #10 left the room, RN #105 asked Resident #12 if she was ok and the resident said she was fine. RN #105 did a full body assessment on Resident #12 and there were no areas of concern. During an interview on 09/10/25, at 1:00 P. M., the Administrator stated HK #110 and #115 were no longer employed with the facility because they did not follow the Health Insurance Portability and Accountability Act (HIPAA) privacy rules and discussed the incident between Resident #10 and Resident #12 with other staff and residents.
Attempts to reach HK #110 and #115 on 09/10/25 and 09/11/25 via telephone for interview were unsuccessful. During an interview on 09/10/25, at 3:15 P. M., Detective #118 stated he arrived at the facility
on 08/29/25 and interviewed Resident #12 and he realized within minutes the resident had severe dementia as she could not recall a male resident had been in her room and touched her. Detective #118 stated he then interviewed Resident #10 who confirmed he did touch Resident #12 with his mouth on her breast, chest and stomach area. Resident #10 reported he was unaware Resident #12 suffered from dementia. Detective #118 confirmed he then read Resident #10 his rights and handcuffed and arrested the resident for gross sexual imposition. Resident #10 left the facility with Detective #118. Review of facility policy titled Resident Rights to Freedom from Abuse. Neglect, and Exploitation undated revealed the facility residents had the right to be free from abuse. The facility would ensure residents were free from sexual aggressive behavior such as inappropriate sexual touching and grabbing. Anytime the facility had reason to suspect a resident might not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse. This deficiency represents non-compliance investigated under Complaint Number 2610266.
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GRAFTON OAKS NURSING CENTER in DAYTON, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DAYTON, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAFTON OAKS NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.