Health 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 Page 1 of 2 365498 365498 02/15/2024 Ottawa CO Riverview Nursing Ho 8180 W State Rt 163 Oak Harbor, OH 43449

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #10 was found in Resident #11's room. Resident #10's pants were in the process of actively falling down while Resident #11 was standing behind Resident #10 and had his pants down. Two aides separated the residents and assisted Resident #10 with pulling her pants up and removing her from Resident #11's room and back to her room. Resident #11 was assisted with dressing and was assisted with care and transferred to bed. There were no further incidents noted between Resident #10 and Resident #11. Monitoring was increased for safety and inappropriate behaviors. Oncoming shift was notified on 02/06/24 at approximately 6:00 A.M. Review of the facility's Self-Reported Incident (SRI) dated 02/06/24 revealed the incident occurred on 02/05/24 approximately 7:00 P.M. a female resident was found in male resident's room on Memory Care Station. The male resident was standing behind the female resident without his pants. The Administrator was notified at approximately 10:30 A.M. on 2/6/2024 that Resident #10 had been in Resident #11's room the previous evening. The two residents were separated. The State Tested Nursing Assistant (STNA) notified the Charge Nurse, who assessed Resident #10 and found her to be without any injuries. The STNA, who separated the residents, indicated that there was no resident-to-resident contact. No notification was found to be made to the Administrator or designee. Upon learning of the alleged incident, the Administrator notified the Ottawa Co. Sheriff's Office. The Sheriff's Office dispatched two detectives to the facility to interview staff as well as both residents involved in the alleged incident. The facility interviewed staff who were on duty on the station the prior evening. The Facility's Nurse Practitioner assessed Resident #10 on the morning on 02/06/24 at approximately 11:30 A.M. and found there to be no remarkable findings. Resident #10 did not display and signs/symptoms of distress, and no changes in behavior was noted. Resident #11 was put on one on one monitoring, he was evaluated by psychiatric services who ordered a medication change, and his room was moved. Interview on 02/15/24 at 11:35 A.M. with Licensed Practical Nurse (LPN) #225 revealed he received report on 02/26/24 from LPN #245 at approximately 6:00 A.M. of the incident that took place in the evening of 02/05/24 between Resident #10 and Resident #11. LPN #225 reported he was told by LPN #245 notifications were made, but when he talked with Licensed Social Worker (LSW) #200 he learned they were not made aware. LSW #200 and the Director of Nursing (DON) found out around 10:00 A.M. on 02/06/24. Interview on 02/15/24 at 11:58 A.M. with the Director of Nursing (DON) and the Administrator verified they were not informed of the 02/05/24 incident between Resident #10 and Resident #11 until 02/06/24 at approximately 10:30 A.M. The incident was believed to have occurred on 02/05/24 during nighttime care which would have been around 8:00 P.M. The DON verified the expectation was for staff to report incidents of potential sexual abuse immediately. Interview on 02/15/24 at 3:04 P.M. with Licensed Social Worker (LSW) #200 verified she had spoken to LPN #225 on 02/06/24 at approximately 9:15 A.M. and first learned of the incident between Resident #10 and Resident #11 that occurred on 02/05/24. The DON was notified around 10:00 A.M. and the Administrator around 10:15 A.M. an SRI was started and LSW #200 reported she began gathering witness statements, Resident #11 was put on one on one supervision, and Resident #10 was evaluated by the Nurse Practitioner. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/06/22 revealed staff must report all incidents/allegations immediately to the Administrator or designee. This deficiency represents non-compliance investigated under Complaint Number OH00150915. 365498 Page 2 of 2