Inspection·January 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility self-reported incidents (SRI's), medical record review and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was timely reported to the Administrator and to the state agency. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record for Resident #36 revealed an admission date of 12/02/18 with diagnoses including hemiplegia affecting left side, adjustment disorder with anxiety, major depressive disorder, anxiety disorder, deaf, dysphagia, and history of unspecified adult abuse. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #67's medical record revealed an admission date of 05/17/17 with diagnoses including schizophrenia, type two diabetes mellitus, schizoaffective disorder, major depressive disorder, sleep disorder, mild intellectual disabilities, mixed receptive-expressive language disorder, dysphagia, hypertension, and unspecified macular degeneration. Review of Resident #67's comprehensive MDS assessment dated [DATE] revealed moderate cognitive impairment. Review of the SRI created 12/24/24 at 8:33 A.M. revealed on 12/22/24 at 11:45 P.M. the night shift nurse found Resident #67 lying in Resident #36's bed on top of the covers with his pants down. Resident #36 was dressed and under the blankets. Resident #67 got out of bed and was directed out of the room. During subsequent interviews Resident #36 reported she was touched on the breast, but no sexual penetration took place. She reported she had been okay with it at the time but did not want it to happen again. Resident #67 was unable to be interviewed due to his cognition at the time but was moved to another hallway. Review of the printed texts to Licensed Piratical Nurse (LPN) #101 revealed on 12/24/24 a statement about the incident between Resident #67 and Resident #36 was requested and LPN #101 was told to always write a witness statement for similar situations. Interview on 01/21/25 at 10:11 A.M. with LPN #101 verified he did not timely report an incident of potential abuse. LPN #101 reported the night it occurred he got busy and distracted. In the morning, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365421 Printed: 05/15/2026 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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)