Inspection·February 15, 2024

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 record review, staff interview, review of facility Self-Reported Incidents (SRI's), and review of facility policy, the facility failed to ensure staff reported an allegation of resident to resident sexual abuse to the administrator or designee in a timely manner. This affected two Residents (#10 and #11) of three reviewed for abuse. The facility census was 67. Findings include: Review of Resident #10's medical record revealed an admission date of 03/03/21. Diagnoses included Alzheimer's disease, dementia, cognitive communication deficit, and major depressive disorder. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #10 was severely cognitively impaired. Resident #10 required limited assistance with bed mobility and transfer. Resident #10 required partial/moderate assistance with lower body dressing. Resident #10 had hallucinations, and delusions during the review period. Resident #10 displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 01/12/24 revealed supports and interventions for risk for self-care deficit, impaired self-ambulating, risk for elopement, impaired cognition, and behavior problem of wandering on memory unit. Review of Resident #11's medical record revealed an admission date of 11/21/23. Diagnoses included dementia, anxiety disorder, prostate cancer, and cognitive communication deficit. Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating Resident #11 was severely cognitively impaired. Resident #11 required maximal assistance with toilet use, personal hygiene and bathing. Resident #11 required moderate assistance with upper and lower body dressing. Resident #11 was independent with mobility at the time of the review. Resident #11 had delusions during the review period and displayed wandering behaviors one to three days during the review period. Review of Resident #11's care plan revised 01/17/24 revealed supports and interventions for risk for elopement, dementia, self-care deficit, and delusions of believing other residents were his wife. Interventions included observe for nonverbal communication, Tagamet orders for inappropriate sexual behavior, and explain procedures during care. Review of Resident #10 and #11's progress notes revealed on 02/05/24 during nighttime care Resident (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 2 Event ID: 365498 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 365498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ottawa CO Riverview Nursing Ho 8180 W State Rt 163 Oak Harbor, OH 43449 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)