Meadowbrook Manor

especially breasts and perineal area, and all types of sexual assault or battery.

Sexual contact was nonconsensual if the residents appeared to want the contact to occur but lacked the cognitive ability to consent.

Residents had the right to engage in consensual activity however anytime there was reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse including evaluating whether the resident had the capacity to consent to sexual activity.

Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2025 revealed the purpose of the policy was to ensure residents were free from abuse.

Residents had the right to engage in consensual sexual activity; however, anytime the facility had reason to suspect that a resident may not have the capacity to consent to sexual activity the facility would take steps to ensure that the resident was protected from abuse.

These steps shall include evaluating whether the resident had capacity to consent to sexual activity.

When the facility identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse.

The policy revealed the facility would report the alleged violation and investigate within the required timeframes pursuant to Federal and State statutes and regulations.

The policy revealed the facility would report the results of all investigation to the Administrator or designee and to other officials including the state survey agency within five working days of the incident.

365902 04/28/2026

Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418

get it from the facility.

She was not sure what monitoring standards they had in place.

This surveyor read the incident that had occurred on 12/11/25 and PCP #610 stated the incident did not sound familiar and did not feel she was notified.

She was not familiar with who Former Resident #54 was and did not feel she ever met him, so she was unable to provide whether he was able to give informed consent for sexual activity.

She revealed after both incidents were reviewed what recommendations and/or interventions were needed to ensure safety.

She stated if she had known about the second incident, to be honest it was not feasible to keep Resident #22 and other residents safe especially with only having two aides on the second floor. Resident #22 almost needed one-on-one because whenever she was at the facility, Resident #22 ambulated all over, and was fast as she had to chase her around just to get an assessment completed.

She stated either one-on-one or a facility with all women as, I do not see how to keep her and others safe otherwise.

Interview on 04/23/26 at 10:15 A.M. with Regional Nurse/RN #600, DON and Infection Control/ADON #609 verified they were not aware of a protocol that the facility implemented if an incident of alleged sexual abuse occurred or standard protocols that were to be implemented including specific monitoring.

They verified per the care plan Resident #22 was to be on 15-minute checks but on staff interviews staff were not completing it.

They revealed they felt it was a documentation error as Resident #22 was to be no longer on 15-minute checks and that was why staff were not doing them.

They stated they were unaware PCP #610 was not aware of the incident on 12/11/25 involving Resident #22 and Former Resident #54, and unaware PCP #610 felt the only way to keep Resident #22 safe, as well as others, was with one-on-one or a facility with all women since PCP #610 had not shared that with them.

Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2025 revealed the purpose of the policy was to ensure residents were free from abuse.

Residents had the right to engage in consensual sexual activity; however, anytime the facility had reason to suspect that a resident may not have the capacity to consent to sexual activity the facility would take steps to ensure that the resident was protected from abuse.

These steps included evaluating whether the resident had the capacity to consent to sexual activity.

When the facility identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse.

The facility would develop written procedures to determine whether the resident was protected, risk factors that contributed to the abuse, whether there is further need for systemic action such as insight on needed revisions to procedures, increased training, measure and verify the implementation of corrective actions, and tracking patterns for similar occurrences.

365902 04/28/2026

Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418

Review of the staffing tool from 04/05/26 to 04/11/26 completed on 04/21/26 at 12:00 P.M. with Administrator, Human Resource (HR) #624, and Scheduler/HR Assistant #623 revealed there was no RN coverage for at least eight consecutive hours on 04/05/26.

Interview on 04/21/26 at 12:00 P.M. and 1:47 P.M. with Administrator, HR #624, and Scheduler/HR Assistant #623 verified per the staffing schedules from 01/01/26 to 04/21/26 and the staffing tool completed from 04/05/26 to 04/11/26, there was no RN coverage for at least eight consecutive hours for two days on 01/24/26 and 04/05/26.

Review of the Facility assessment dated [DATE] revealed under the staffing plan there would be two RNs and/or Licensed Practical Nurses (LPN) for each shift.

There was nothing per the assessment regarding ensuring there was a RN at least eight consecutive hours a day, seven days a week.

This deficiency represents non-compliance investigated under Complaint Numbers 2966092, 2667528 and 2650567.

365902 04/28/2026

Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418

either one-on-one or a facility with all women as, I do not see how to keep her and others safe

12/11/25 involving Resident #22 and Former Resident #54, and unaware PCP #610 felt the only way

PCP #610 had not shared that with them.

365902 04/28/2026

Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418

Review of the medical record for Resident #39 revealed an admission date of 05/06/24 and her diagnoses included chronic obstructive pulmonary disease with acute exacerbation, schizoaffective disorder, and bipolar disorder.

Review of the Quarterly MDS assessment dated [DATE] revealed Resident #39 had intact cognition but had delusions.Review of progress note dated 03/27/26 at 4:28 P.M. completed by Nurse Practitioner (NP) #630 revealed Resident #39 was examined due to sinus symptoms and acute cough. Resident #39 had stated she had sinus pressure, nasal congestion and a nonproductive cough. NP #630 ordered Augmentin (ATB) 500-125 mg by mouth twice a day for seven days.

Review of March 2025 Physician Orders revealed Resident #39 had an order dated 03/28/26 for Augmentin 500-125 mg tablet give one tablet by mouth two times a day for seven days for acute frontal sinusitis.

Review of March 2025 MAR revealed an order for Augmentin 500-125 mg give one tablet by mouth two times a day for acute frontal sinusitis dated 03/28/26 at 8:00 A.M.

The MAR was blank on 03/28/26 at 8:00 A.M. and 4:00 P.M., and 03/29/26 at 8:00 A.M. and 4:00 P.M. which indicated Resident #39 did not receive the medication.

The first dose of Augmentin Resident #39 received was on 03/30/26 at 8:00 A.M.Interview on 04/21/26 at 8:38 A.M. with Resident #39 denied any concerns with medication administration.

Interview on 04/22/26 at 3:47 P.M. and 4:15 P.M. with DON and Infection Control/ADON #609 verified Resident #39 was ordered Augmentin 500-125 mg by mouth twice a day for seven days per NP #630's progress note dated 03/27/26 and she had not received the first dose until 03/30/26 at 8:00 A.M.

They revealed NP #630 had put the order in her progress note on 03/27/26 but the facility was not aware.

They verified an order was written on 03/28/26 at 8:00 A.M. for Augmentin but stated most likely because it was the weekend the nurse did not take the initiative to follow through.

They revealed most weekends the facility staffs the facility with agency nurses, and they do not have access to the emergency medication box (a box the facility had at the facility of common medication including ATBs) and that was the reason the medication was not pulled from the emergency medication box to start it on time and/or the agency nurse did not contact pharmacy to check on the delivery.

They verified the Augmentin was in the emergency medication box.

They confirmed all ATBs were to be administered right away unless there was an order from the physician approving the ATB to be given later.

Review of facility policy labeled, Administering Medication dated 2001 revealed medications were to be administered in a safe and timely manner as prescribed.

Medications were administered in accordance with orders including required time frame including within one hour of prescribed time unless otherwise specified. If the drug was withheld, refused or given at a time other than scheduled time the individual administering the medication would initial and circle the MAR space provided.

There was nothing in the policy regarding notifying the physician of withheld doses of medications.

This deficiency represents non-compliance investigated under Complaint Number 2655931.