Wright Rehabilitation And Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress note dated 11/11/25 at 8:45 P.M. RN #111 documented an unnamed CNA alerted her Resident #10 was observed in another resident's room (Resident #11) with her hand on his penis stroking up and down.

Resident #11 asked Resident #10 to stop, and she did not stop until the staff member entered the room.

The residents were separated immediately, and Resident #10 was placed on one-on-one supervision.Review of the progress note dated 11/12/25 at 1:57 P.M. revealed Resident #10 had a telehealth appointment with Company #1 regarding the recent sexual incident. Resident #10 agreed not to touch another resident inappropriately and monitoring would continue.Review of the 11/21/25 psychiatric evaluation from Company #1 revealed Resident #10 stated she and Resident #11 had been in a relationship but if he didn't want to date anymore, she would not bother him. She agreed not to touch Resident #11 if he did not want to be touched. The note documented staff had reported Resident #10 touched Resident #11 inappropriately and he did not want it to occur.Interview on 11/19/25 at 9:12 A.M. with Assistant Director of Nursing (ADON) #102 revealed staff reported Resident #10 was observed entering Resident #11's room by CNA #103. It was reported to ADON #102, CNA #103 witnessed inappropriate touching of Resident #11 and Resident #10 mirrored in the window. ADON #102 verified Resident #10 resided in MSU which he acknowledged was a locked unit. ADON #102 explained the incident occurred during a smoke break and ADON #102 explained Resident #10 reported she was cold, so staff permitted her to go back into the facility unsupervised, which allowed her the opportunity to enter Resident #11's room.Interview on 11/19/25 at 11:25 A.M. with Laundry Assistant (LA ) #108 revealed there were two residents on the MSU who were smokers. She shared the residents were to be observed at all times while they are out of the unit.Interview on 11/19/25 at 11:31 A.M. with Social Worker (SW) #110 revealed she was informed during morning meeting on 11/12/25 of an incident of inappropriate touching by Resident #10 to Resident #11, an investigation was initiated, and the police were contacted. SW #110 spoke to both residents, and both agreed to a telehealth appointment with Company #1. SW #110 denied knowledge of a previous incident by Resident #10 of sexual behavior towards any resident at the facility.Interview on 11/19/25 at 12:36 P.M. with the Director of Nursing (DON) and Administrator revealed

on 11/11/12, the DON was contacted by CNA #103 and informed of inappropriate touching of Resident #11 by Resident #10. CNA #103 reported he witnessed Resident #10 enter Resident #11's room and when he went to investigate, he observed Resident #10 touching Resident #11's penis mirrored in the window.

Resident #10 stopped as he entered the room and she was escorted back to the MSU and placed on one-on-one supervision. Upon investigation, it was discovered during the 8:30 P.M. smoke break on 11/11/25, Resident #10 informed LA #112 she was cold and wanted to wait inside the activity room (right inside the smoke door) until smoke break was over. LA #112 agreed, and after smoke break when Resident #10 was not in the activity room it was assumed, she had gone back to the unit. The police were notified on 11/12/25 and a report was filed. The Administrator shared Resident #11 had stated he did not wish to file charges; however the police chose to proceed with charges. The case remains open. Both residents received an assessment by Company #1, and Resident #10 was discharged on 11/12/25 to Behavioral Hospital #3. The DON and Administrator each verified it was the expectation of the staff assigned to smoke breaks observe the MSU residents at all times until returned and secured back inside the unit.Interview on 11/19/25 at 1:04 P.M. with Resident #11 revealed Resident #10 had come into his room after smoking and touched him inappropriately. He shared he was disturbed by this action as he was asleep and was awoken by her touching him.Review of the facility policy, Abuse Investigation and Reporting dated 11/21 documented residents had the right to be free from abuse, neglect and misappropriation.This deficiency represents non-compliance investigated under Complaint Number 2671345.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wright Rehabilitation and Healthcare Center

829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interviews, the facility failed to ensure residents residing in a secure memory care unit were observed when outside the unit. This affected one Resident (#10) of three reviewed. The facility census was 82. Findings include:Review of the medical record for Resident #10 revealed admission date of 03/15/22. The resident was admitted with diagnoses including alcohol dependence with alcohol induced persisting dementia, stroke, aphasia following stroke, schizophrenia and Wernicke's encephalopathy.

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required set up assistance with eating, bed mobility, transfers, and toileting hygiene.Review of the care plan revealed Resident #10 was a supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress note dated 11/11/25 at 8:45 P.M., Registered Nurse (RN) #111 documented an unnamed Certified Nursing Assistant (CNA) alerted her Resident #10 was observed in another resident's room (Resident #11) with her hand on his penis stroking up and down. Resident #11 asked Resident #10 to stop, and she did not stop until the staff member entered the room. The residents were separated immediately, and Resident #10 was placed on one-on-one supervision.Interview on 11/19/25 at 9:12 A.M. with Assistant Director of Nursing (ADON) #102 revealed staff reported Resident #10 was observed entering Resident #11's room by CNA #103. ADON #102 verified Resident #10 resided in the Memory Support Unit (MSU), which he acknowledged was a locked unit. ADON #102 explained during a smoke break, Resident #10 reported she was cold, so staff allowed her to go back into the facility unsupervised, which allowed her the opportunity to enter Resident #11's room.Interview on 11/19/25 at 11:31 A.M. with Social Worker #110 revealed she was informed Resident #10 had entered Resident #11's room after she was left unattended by staff. She explained Resident #10 required the locked MSU due to her elopement risk.Interview on 11/19/25 at 12:36 P.M. with the Director of Nursing (DON) and Administrator revealed on 11/11/12 the DON was contacted by CNA #103 and informed he witnessed Resident #10 enter Resident #11's room. Upon investigation, it was discovered during the 8:30 P.M. smoke break on 11/11/25 Resident #10 informed Laundry Aid (LA) #112

she was cold and wanted to wait inside the activity room until smoke break was over. LA #112 agreed, and

after smoke break when Resident #10 was not in the activity room it was assumed, she had gone back to

the unit. The DON and Administrator each verified it was the expectation of the staff assigned to smoke breaks observe the MSU residents at all times until returned and secured back in the unit.

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