F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of police reports,
resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure
residents were free from abuse. This affected one (Resident #5) of three residents reviewed for abuse. The
facility census was 99 residents. Findings include: Review of the medical record for Resident #5 revealed
an admission date of 12/06/24 with diagnoses including chronic obstructive pulmonary disease, vascular
dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident
#5 dated 01/05/26 revealed the resident had intact cognition. and required setup or cleanup assistance for
bed mobility, transfers, and ambulation. Review of the facility SRI regarding Resident #5 dated 02/02/26 and
timed 12:06 P.M. revealed the facility investigated and substantiated an allegation of sexual abuse per
Licensed Practical Nurse (LPN) #201 towards the resident. Resident #5 reported to staff that Licensed
Practical Nurse (LPN) #201 sent the resident pictures of her exposed breasts and allowed the resident to
have sexual contact with her breasts. LPN #201 also videotaped the sexual contact between the nurse and
Resident #5 using the resident's personal cell phone. The Director of Nursing (DON) confirmed the video
which was viewable on Resident #5's personal phone lasted approximately forty-five seconds and clearly
showed LPN #201's face. Interview with Resident #5 on 02/01/26 confirmed he had consented to the
sexual contact and also confirmed LPN #201 had touched his genital before but could not recall the date.
Interview with LPN #201 denied the allegations of sexual abuse. The local police interviewed LPN #201 on
02/03/26 and reported to the facility that LPN #201 had confessed to the allegations of sexual abuse
towards Resident #5. The facility substantiated the allegation of sexual abuse and terminated LPN #201.
Review of the police report dated 02/02/26 revealed the facility Director of Nursing (DON) reported
Resident #5 sent them a video of the resident engaging in sexual contact with LPN #201. Review of the
personnel record for LPN #201 revealed the facility emailed a written termination notice to the nurse on
02/09/26. The termination notice indicated LPN #201 was terminated due to sexual misconduct with a
resident. Interview on 02/12/26 at 11:00 A.M with Detective #675 confirmed the local police were
investigating LPN #201 for possible charges of sexual battery. Interview on 02/13/26 at 10:45 A.M. with
Detective #675 confirmed LPN #201 had confessed she had sexual contact with Resident #5 and they
were going to pursue a charge of sexual battery. Interview on 02/17/26 at 11:22 A.M. with LPN #201
confirmed she was notified on 02/01/26 by phone per LPN #301 that she was suspended due to allegation
of sexual abuse towards a resident. LPN #201 denied having sexual contact with Resident #5. Observation
on 02/17/26 at 12:01 P.M. revealed Resident #5 showed the Surveyor approximately two seconds of a video
on his phone which showed LPN #201's face and her exposed breasts. Interview on 02/17/26 at 12:02 P.M.
with Resident #5 confirmed that on a date prior to 02/01/26 LPN #201 sent him pictures of her exposed
breasts and allowed the resident to suck on her breasts. LPN #201 also videotaped Resident #5 sucking on
her breasts using the resident's phone.
(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:
365530
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
365530
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/19/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Delhi Post-Acute
5999 Bender Road
Cincinnati, OH 45233
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Resident #5 confirmed he consented to sexual activity with LPN #201. Resident #5 confirmed he reported
LPN #201's actions to staff because he was upset as she was not spending as much time with him after the
sexual incident had occurred. Interview on 02/17/26 at 12:20 P.M. with the DON, Registered Nurse Manger
(RNM) #303, Assisted Director of Nursing (ADON) #306, ADON #307, and Licensed Practical Nurse
Manager (LPNM) #308 confirmed the facility investigated the allegation of sexual abuse per LPN #201
towards Resident #5 and concluded abuse had occurred. Further interview revealed LPN #201 was
suspended on 02/01/26, the facility did comprehensive assessments of all residents, and started all-staff
education on abuse. Interview on 02/17/26 at 1:25 P.M. with the DON and the Administrator confirmed on
02/01/26 they viewed a video on Resident #5's phone of LPN #201 and Resident #5 engaging in sexual
contact consisting of Resident #5 sucking on LPN #201's exposed breasts. The video was approximately 45
seconds long and both LPN #201 and Resident #5 were visible. Review of facility policy titled Abuse,
Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 revealed the residents had
the right to be free from abuse, including sexual abuse. This deficiency represents noncompliance
investigated under Complaint Number 2740112 and Complaint Number 2743935.
Event ID:
Facility ID:
365530
If continuation sheet
Page 2 of 4
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
365530
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/19/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Delhi Post-Acute
5999 Bender Road
Cincinnati, OH 45233
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on medical record review, review of facility Self-Reported Investigations (SRIs), staff interview, and
review of the facility policy, the facility failed to ensure allegations involving resident abuse were reported to
the Ohio Department of Health (ODH) in a timely manner. This affected one resident (Resident #5) of three
residents reviewed for abuse. The facility census was 99 residents. Findings include:Review of the medical
record for Resident #5 revealed an admission date of 12/06/24 with diagnoses including chronic obstructive
pulmonary disease, vascular dementia unspecified severity with other behavioral disturbance, and major
depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 12/12/25
revealed the resident had intact cognition and was dependent on staff for bathing. Review of the facility SRI
involving Resident #5 revealed it was created on 02/02/26 at 12:06 P.M and the date of discovery of the
allegation was 02/01/26.Interview on 02/18/26 P.M. at 12:24 P.M. with the Director of Nursing (DON)
confirmed the facility received the notification of an alleged incident of staff to resident sexual abuse on
02/01/26 at 11:00 AM. The DON confirmed the facility did not report the incident to the state agency until
over 24 hours later. Review of the facility policy tilted Abuse, Neglect, Exploitation, and Misappropriation
Prevention Program dated April 2021 revealed the facility should report any allegations within timeframes
required by federal requirements.
Event ID:
Facility ID:
365530
If continuation sheet
Page 3 of 4
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
365530
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/19/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Delhi Post-Acute
5999 Bender Road
Cincinnati, OH 45233
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on medical record review and staff interview, the facility failed to develop comprehensive care plans
for use of devices. This affected one (Resident #10) of 3 residents reviewed for falls. The facility census was
99 residents.Findings include: Review of medical record for Resident #10 revealed an admission date of
01/11/25 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and
osteoporosis and a discharge date of _____ Review of the care plan for Resident #10 dated 12/12/25
revealed the care plan did not include the use of a power wheelchair with a seatbelt. Review of the
Minimum Data Set (MDS) assessment for Resident #10 dated 12/15/25 revealed the resident had intact
cognition and was dependent on staff for all activities of daily living (ADLs). Review of the medical record
for Resident #10 revealed it did not include an assessment regarding the appropriateness of the use of a
seatbelt in the resident's power wheelchair.Interview on 02/18/25 at 11:34 A.M. with the Director of Nursing
(DON) and Director of Rehabilitation (DOR) confirmed Resident #10 used a power wheelchair with a
seatbelt for mobility. The DON and the DOR confirmed the facility had not conducted an assessment
regarding the use of the seatbelt nor had the facility developed a care plan for the use of the seatbelt with
Resident #10's power wheelchair. Further interview confirmed Resident #10's plan of care should have
reflected the use of the seatbelt.
Event ID:
Facility ID:
365530
If continuation sheet
Page 4 of 4