Meadowbrook Manor

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

on her bed. Resident #49's incontinence brief was opened and down. Resident #16 was observed rubbing Resident #49's private area inappropriately. Resident #16 was asked to leave the room and placed on one-to-one supervision. Both Resident #16 and Resident #49's physicians and responsible parties were notified. 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.

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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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowbrook Manor

3090 Five Points Hartford Fowler, OH 44418

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

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 08/26/25 at 1:19 P.M. with LPN #203 revealed Resident #16 did have a history of wandering, he typically wandered into other people's bedrooms and bathrooms. She said the facility did the best they could in redirecting and monitoring him, but she had no knowledge of the resident being on any type of increased supervision prior to the incident with Resident #49. Interview on 08/26/25 at 1:25 P.M. with Certified Nurse Aide (CNA) #204 revealed she had no knowledge of Resident #16 ever being sexually inappropriate with any other resident; however, she was aware that he wandered and while it was difficult at times, the facility attempted to redirect him as much as possible. She confirmed there was no increased level of supervision immediately prior to the incident occurring with Resident #49, and no tracking in place to verify when Resident #16 had last been checked on. Interview on 08/26/25 at 2:07 P.M. with Resident #49's sister revealed she was aware Resident #16 had

a history of wandering, and during her visits to the facility, she felt he had been wandering more frequently prior to the incident, in and out of people's rooms and sitting on their beds. She visited Resident #49 the morning after the incident was reported to her and revealed Resident #49 gave no indication of the incident

the night prior and did not seem in any distress. She spoke with the former Administrator who confirmed Resident #16 was being transferred for psychiatric care but may return to the facility upon discharge.

Resident #49's sister spoke with her family and felt it was in Resident #49's best interest to have her moved to a different facility. 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 on 08/13/25, and confirmed there was no discussion of the need for Resident #16 to be on any kind of increased supervision or checks after his visit from psychiatric NP #202 on 07/02/25. Interview on 08/27/25 at 12:48 P.M. with Corporate Risk Manager #207 revealed the psychiatric NP #202 note dated 07/02/25 regarding Resident #16 being sexually inappropriate was in reference to the resident being found sitting naked on his bed on 06/21/25. At that time the facility implemented 15-minute checks while the resident was in his room and discontinued those checks on 07/02/25 when psychiatric NP #202 saw him and started him on medications. 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 last seen either resident. She confirmed neither resident was on 15-minute checks, one to one supervision or any other type of additional supervision or monitoring immediately prior to this incident. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated March 2019, revealed The interdisciplinary team (IDT) put evaluate behavioral symptoms to determine the degree of severity, distress and potential safety risk to the resident.

Safety strategies would be implemented to protect the resident and others from harm. Interventions would be adjusted based on the impact of the behavior. This deficiency represents noncompliance investigated under Incident Number 2600512 and Complaint Number 2595789.

Event ID:

Facility ID:

If continuation sheet