Health inspection·August 21, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, Self-Reported Incident (SRI) review, and interviews, the facility failed to provide documented evidence of a thorough investigation and report allegations of sexual abuse to the State survey agency. This affected two residents (Resident #19 and Resident #45) of three residents reviewed for abuse. The facility census was 51.Findings Include:1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, vascular dementia, alcohol use, flaccid bladder, hydronephrosis, major depressive disorder, hypertension, and anxiety.Record review of Resident #19's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 had severe cognitive impairment and could independently walk at least 150 feet.Record review of Resident #19's assessment for behaviors completed 06/13/25 revealed Resident #19 wandered freely without interruption. Additional factors affecting the resident's behaviors included the resident would become frustrated due to problems communicating discomfort or unmet needs.Review of Resident #19's care plan completed on 07/09/25 revealed the resident had behaviors including increased sexual behaviors. Interventions included, if reasonable, discussing the resident's behavior, explaining/reinforcing why the behavior was inappropriate and/or unacceptable to the resident, and praise any indication of the resident's progress/improvement in behavior.Review of Resident #19's visit and progress note from Psychiatric Mental Health Nurse Practitioner (PMHNP) #105 dated 07/22/25 stated that nursing staff reported the previous week that Resident #19 had pulled a female resident into a room and attempted to pull down her pants. He was caught and re-directed. Resident #19 was a poor historian and had speech issues. The DON reported he roamed around the facility most of the day. Resident #19 focused on female residents, one particular who was bedbound and had end stage dementia. They have found him several times in her room with his hand under the blanket. Resident #19 was not allowed alone in female (resident) rooms. Resident #19 was continually re-directed.Review of Resident #19's record revealed a progress note dated 08/14/25 at 4:00 P.M. stating 15-minute checks were initiated by the Administrator. There was no additional information indicating why the resident was receiving 15-minute checks/increased monitoring. There was no documented evidence of sexual behaviors on 08/14/25 or 08/15/25. Record review revealed Resident #19 received an order on 08/14/25 for Cimetidine with instructions to give 400 milligrams (mg) by mouth two times a day for a decrease in sexual behaviors for 14 days.Review of Resident #19's record revealed a progress note dated 08/16/25 at 10:30 A.M. that stated the resident was being sent to the emergency room due to behaviors.Review of the facility Self-Reported Incidents revealed the facility had not reported an incident since 08/07/25.2. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including femur fracture, anxiety, hyperlipidemia, dementia, depression, anxiety, constipation, and emphysema.Review of Resident #45's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and was dependent on staff for activities of daily living (ADL) care. Review of the care plan dated 08/19/25 revealed Resident #45 had Residents Affected - Few Page 1 of 3 365559 365559 08/21/2025 Rolling Hills Rehab and Care Ctr 68222 Commercial Drive Bridgeport, OH 43912

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included supervising and reorienting as needed. Additionally, the resident had a care plan for a past traumatic event of exposure to sexual assault. Interventions included to encourage social interactions, observe for signs and symptoms of post-traumatic stress disorder (PTSD) (such as anxiety, flashbacks, nightmares, or sleep disturbances), reduce emotional distress, and to increase engagement in meaningful activities to reflect an overall improvement in the patient's well-being. Further review of the medical record revealed no documented evidence of any inappropriate behaviors between Resident #45 and Resident #19 on 08/14/25 and 08/15/25.Phone Interview on 08/20/25 at 10:07 A.M., Licensed Practical Nurse (LPN) #100 reported that Resident #19 had previously had inappropriate behaviors towards Resident #45. She was told that Resident #19 had previously tried to put his hands down Resident #19 pants. She stated the facility moved Resident #45 to another area in the facility and staff were advised to redirect him away from her. Interview on 08/20/25 at 10:15 A.M., Certified Nursing Assistant (CNA) #101 reported she worked on 08/15/25 and 08/16/25 with Resident #45 and Resident #19. She reported the facility staff had to continuously redirect Resident #19 away for Resident #45. She continued that he would become agitated and aggressive when he was redirected away from her. Interview on 08/20/25 at 10:31 A.M., CNA #102 reported she witnessed Resident #19 grab Resident #45's breast while at the nursing station on 08/14/25. She continued that she reported the incident to the Assistant Director of Nursing (ADON) #103. She went on to say throughout the day Resident #19 was hovering over Resident #45 and had to be redirected, which was reported to the Administrator. CNA #102 stated the hovering was so bad that staff had to bring Resident #45 with them during their rounds to ensure Resident #19 did not reach Resident #45. She stated after she reported the inappropriate touch to the administration, the Administrator and ADON #103 pulled her into a room and asked her if she was sure of what she saw and she replied yes. She continued that they did not have her write a statement regarding the situation. Interview on 08/20/25 at 11:20 A.M., Registered Nurse (RN) #104 reported while sitting at the nurse's station on 08/15/25 with Resident #45, the resident stated, [explicit], he took my clothes off me and indicated that Resident #19 was the perpetrator as he was present in the nurse's station during the statement. RN #104 stated that she went to the Administrator and reported the allegation. She went on to say she was told to complete a skin assessment on Resident #45 but was told not to chart the incident. She stated she was never made to write a statement regarding the incident. Interview on 08/20/25 at 1:27 P.M., the facility Administrator stated that on 08/15/25 it was reported to her that Resident #45 told a nurse that Resident #19 took her clothes off, she stated he was placed on one-on-one staffing. She stated she interviewed the nurse and completed a body assessment but did not open an investigation or report the incident as an SRI. At this time, the Administrator denied ever receiving a report that Resident #19 touched Resident #45's breast on 08/14/25. Interview on 08/20/25 at 2:20 P.M., ADON #103 reported staff came to her on 08/14/25 with concerns that Resident #19 was fixated on Resident #45. She reported that he was not doing anything malicious but did want to be near Resident #45. She stated later the same day, CNA #102 came to her and reported Resident #19 reached from behind Resident #45 and touched her breast while at the nurse's station. She stated she did not believe this was done in a sexual manner, as Resident #19 was severely cognitively impaired, but she did report it on to the Administrator. She stated she believed the Administrator then put Resident #19 on 15-minute checks. Interview on 08/20/25 at 2:57 P.M., the facility Administrator was reinterviewed and reported she now remembered staff coming to her on 08/14/25 reporting that they believed Resident #19 attempted to touch Resident #45's breast. She stated she did not believe he was cognitively intact enough to do this purposefully and that was why she 365559 Page 2 of 3 365559 08/21/2025 Rolling Hills Rehab and Care Ctr 68222 Commercial Drive Bridgeport, OH 43912

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not complete an investigation or make a report to the State agency. She reported she did initiate 15-minute checks for Resident #19 after the report. She stated on 08/16/25, Resident #19 was sent to the hospital for behavioral issues and had not yet returned. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/01/19 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of a resident property, including injuries of unknown source, in accordance with this policy. Facility staff should immediately report all such allegations to the administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. Immediately report to the administrator or designee, and to the Ohio Department of health of alleged violations involving abuse, neglect, exploitation, mistreatment of a resident or misappropriation of a resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Sexual abuse was defined as non-consensual sexual contact of any type with a resident.This deficiency demonstrates an example of continued non-compliance investigated under Master Complaint Number 259319 and Complaint Number 2593176. 365559 Page 3 of 3