Health inspection·September 11, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a Self-Reported Incident (SRI), facility investigation interviews, police report and facility policy review, the facility failed to ensure Resident #22 was free from suspected resident-to-resident sexual abuse by Resident #63. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 69. Finding include: Review of the medical record for Resident #22 revealed an admission date of 05/24/21. Diagnoses included adult failure to thrive, dementia, hearing loss, psychosis, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was rarely or never understood. She was totally dependent on two people for toileting and hygiene and required extensive assistance of two people for bed mobility, transfers, and dressing. She displayed behavioral symptoms not directed toward others such as disrobing in public, scratching, or hitting herself and disruptive sounds daily. Review of the care plan dated 02/18/22 revealed Resident #22 had a self-care deficit due to dementia. Interventions included assistance with activities of daily living (ADL) such as dressing, grooming, and toileting, Review of the progress note dated 08/29/23 at 8:09 P.M. revealed Resident #63 was in her room displaying sexually explicit behavior, to which Resident #22 could not consent. Resident #63 was removed and told not to return. Review of the medical record for Resident #63 revealed an admission date of 12/18/21. Diagnoses included alcohol abuse, hearing loss, adjustment disorder, anxiety, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 was cognitively intact. He displayed verbal aggression toward others and a rejection of care. Review of the progress noted dated 08/29/23 at 9:53 P.M. revealed Resident #63 was in a female Resident #22's room attempting to sit on her bed. He had been educated several times about being in the residents' room without supervision due to inappropriate behavior. He was escorted out of the room and told not to return. Review of the facility's SRI tracking number 238642 submitted to the State Survey Agency on Page 1 of 3 365705 365705 09/11/2023 Aventura at Walton Hills 19859 Alexander Rd Walton Hills, OH 44146

F 0600 Level of Harm - Minimal harm or potential for actual harm 08/29/23 at 9:30 P.M. revealed an allegation of sexual abuse. The residents identified in the allegation were Resident #22 and Resident #63. The person making the allegation was Licensed Practical Nurse (LPN) #206. Review of the narrative summary of the incident revealed Resident #63 was witnessed in Resident #22's room standing next to the bed with one of his hands on the outside of her brief. Resident #22 was fully clothed. Residents Affected - Few Review of the facility's summary investigation revealed the police were contacted and Resident #63 was placed on one-to-one supervision. Both residents were seen by a medical provider within a few days. None of the employees who were interviewed as part of the investigation had seen sexual abuse occur. The investigation was determined to be inconclusive because there were no bruises on Resident #22, no one had witnessed Resident #63 touching Resident #22, and the amount of time between when Resident #63 was last seen and when he was seen in Resident #22's room was five to seven minutes. Review of police report number 23-07582 dated 08/29/23 revealed LPN #206 called the police to the facility on [DATE] because a resident [Resident #22] has been sexually abused by another resident [Resident #63]. She reported she told Resident #63 he could not go beyond the hallway doors and not to enter Resident #22's room. Resident #63 went toward Resident #22'm room anyway, and LPN #206 called the police. When she went to Resident #22's room, Resident #63 was out of his wheelchair reaching Resident #22 whose brief was down below her buttocks. LPN #207 reported to police she witnessed a similar incident as the one described above on 08/28/29. Her statement also corresponded with LPN #207's statement regarding the incident on 08/29/23. The police report further revealed they made contact with Resident #22's legal guardian did not want a rape kit performed and would not be pursuing criminal charges. Interview on 09/07/23 at 12:40 P.M. with the Administrator revealed Resident #63 had been educated several times about being in Resident #22's room without supervision due to inappropriate behavior. Residents #22 and #63 had been friends before, but Resident #22's health had declined significantly in the past few months, and staff did not feel it was appropriate for Resident #63 to be in Resident #22's room since she could no longer speak for herself or consent to any visitation. She revealed neither resident had any history of sexual behaviors. Interview on 09/07/23 at 1:26 P.M. with LPN #205 revealed she saw Resident #63 in Resident #22's room with his hand near her incontinence brief. When she saw LPN #205, he sat in his wheelchair and tried to leave. Resident #22's brief was pulled half off oh her bottom and tucked in the front. LPN #205 held the opinion Resident #63 had been attempting to engage in sexually inappropriate behavior with Resident #22, but staff had intervened. Interview on 09/07/23 at 1:53 P.M. with LPN #206 revealed she was passing medications when Resident #63 propelled his wheelchair past her toward Resident #22's room. She closed the double doors to the hall where Resident #22's room was, but Resident #63 opened them and went through. LPN #206 went into Resident #22's room and found Resident #63. She said during the time she worked from 7:00 P.M. until 7:00 A.M., she found Resident #63 in Resident #22's room two times. He was placed on one-to-one supervision after the second time. LPN #206 revealed she had told the Director of Nursing (DON) approximately one week before the incident on 08/29/23 that she felt Resident #63 shouldn't be in Resident #22's room. Interview on 09/07/23 at 2:08 P.M. with the DON revealed staff called her on 08/28/23 and told her Resident #63 was in Resident #22's room. She instructed staff to keep him out of her room, and she 365705 Page 2 of 3 365705 09/11/2023 Aventura at Walton Hills 19859 Alexander Rd Walton Hills, OH 44146

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called the Administrator. On 08/29/23, she was again called and told Resident #63 was in Resident #22's room. She instructed staff to call the physician, keep Resident #22 safe and again called the Administrator. She denied receiving any concerns from staff prior to 08/28/23 about concerns with Resident #63 entering Resident #22's room. Interview on 09/08/23 at 6:55 A.M. with LPN #207 revealed she was told by another nurse Resident #63 was in Resident #22's room. When she got there, Resident #63 was leaning over Resident #22's bed. She did not see Resident #22's brief pulled down and could not explain why it might have been. She had no knowledge of a prior romantic relationship between Residents #22 and #63 and Resident #63 had no history of sexually inappropriate behaviors. Review of the facility policy titled Abuse policy, dated 04/20/23, revealed residents would not be subjected to abuse. 365705 Page 3 of 3