Meadowbrook Manor

Review of SRI tracking number 264021 dated 08/13/25 revealed on 08/13/25 at approximately 9:00 P.M., Licensed Practical Nurse (LPN) #200 observed Resident #16 in Resident #49's room sitting on her bed. Resident #16 was observed rubbing Resident #49's private area inappropriately. LPN #200 asked Resident #16 to leave the room, and he was placed on one-to-one supervision.

The Administrator and DON were notified. LPN #200 and the DON performed a full body assessment on Resident #49, and no injuries were noted. Resident #49's physician was notified, and she was placed on 15-minute checks.

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.

Interview on 08/26/25 at 10:14 A.M. with the DON revealed he received a call from LPN #200 on 08/13/25 informing him Resident #16 was sitting on Resident #49's bed. Resident #49 was described as sitting on the edge of her bed with her incontinence brief down. Resident #16 was touching her private area. LPN #200 immediately separated the residents and assessed Resident #49; no negative findings were discovered. Resident #16 was placed on one-to-one supervision, and Resident #49 was placed on 15-minute checks.

Both residents' physicians and families were notified. A referral was made to a psychiatric inpatient facility for Resident #16; Resident #16 remained on one-to-one supervision until the transfer to the inpatient psychiatric facility took place. Resident #49 was seen by her psychiatric care team the following day and was assessed with no changes in psychiatric or mental status noted.

The DON denied having any knowledge Resident #16 had any history of sexually inappropriate behaviors.

Interview on 08/27/25 at 7:25 A.M. with Social Service Designee (SSD) #208 revealed she was aware Resident #16 had a history of wandering but was generally redirectable.

She could not verify when the resident had last been checked on prior to the incident and confirmed the resident was not on any type of increased supervision or checks at the time of the incident.

She verified 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.

Interview on 08/28/25 at 3:57 P.M. with LPN #200 revealed she entered Resident #49's room to give her medications and saw Resident #16 sitting on her bed. Resident #49's incontinence brief was open, and his fingers were in her vagina.

She could not recall if she asked him what he was doing or what Resident #49's reaction was to the situation.

She could not verify what time she had seen either resident prior to the incident.

The facility did not have a policy related to investigation of SRI's.

This deficiency represents noncompliance investigated under Complaint Number 2959789.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowbrook Manor

3090 Five Points Hartford Fowler, OH 44418

SUMMARY STATEMENT OF DEFICIENCIES