Inspection·September 16, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few to move out of the presence of Resident #10. HKs #110 and #115 stated they were not sure if they were witnessing a consensual event or a nonconsensual event so they decided one of them would stay in the room for safety and the other would go and seek immediate assistance. While HK #115 was in the room, Resident #10 stopped the touching and proceeded to adjust Resident #12's clothing and walk away from her bed. Physician #120 examined Resident #12 on 08/29/25 following the incident and found no injuries. Registered Nuse (RN) #105 assessed Resident #12 and noted the resident showed no verbal or non-verbal signs of pain or discomfort. When staff interviewed Resident #12 she did not recall the incident and stated that she had been sleeping in bed all day. The facility notified the local police department of the incident on 08/29/25. Police interviewed Resident #12 who was pleasant and cooperative and lacked any distress during the interview, but she could not provide any meaningful information. Police interviewed Resident #10 who was also cooperative and told police he was trying to start a friendship with Resident #12 when and he thought the sexual contact with her was consensual. Resident #10 was monitored by the staff after the incident until he was removed and taken into custody by the police. Review of an interview statement dated 08/29/25 with Resident #12 conducted by Social Service Designee (SSD) #200 revealed the resident did not remember a man coming into her and she had been sleeping all day. Review of an interview statement dated 08/29/25 with Resident #10 conducted by SSD#200 revealed Resident #10 acknowledged he had touched Resident #12, because he was trying to make friends with her. Review of HK #110's witness statement dated 08/29/25 revealed she was coming down the hall to clean a room when she noticed Resident #10 in Resident #12's room and observed Resident #10 rubbing Resident #12 all over her body. HK #110 went to find an aide or nurse while her co-worker HK #115 stayed by Resident #12's room. Housekeeper #115 witnessed Resident #10 pull Resident #12's shirt up and then Resident #10 began sucking Resident #12's breast. Then Resident #10 pulled Resident #12's shirt down and covered her back up. RN #105 then arrived in the room and questioned Resident #10. Review of HK #115's witness statement dated 08/29/25 revealed Resident #10 was in Resident #12's room rubbing her upper body and proceeded to lift Resident #12's shirt up. He went from the right side of her body and started sucking her breasts on both sides and when he was done he pulled her shirt down, closed her cardigan and folded her hands on the top of it, like nothing ever happened. When Resident #10 was asked what he was doing he said he was asking Resident #12 if she was going to the cookout, but Resident #12 did not respond. Review of RN #105's witness statement dated 08/29/25 revealed she was called to Resident #10's room and found Resident #10 standing next to Resident #12 who was lying in her bed. RN #105 asked Resident #10 what he was doing in Resident #12's room and told him he wasn't supposed to be in her room. Resident #10 told the nurse he was going to ask Resident #12 if she wanted to go to the cookout. Resident #10 then walked out of the room. HK #110 and #115 reported to RN #105 that they saw Resident #10 pulling Resident #12's clothes up and putting his hand on her and sucking on her breasts. Review of the local law enforcement person in custody report dated 09/02/25 revealed Resident #10 was being held in custody at the county jail on a charge of gross sexual imposition related to the incident with Resident #12 in her room on 08/29/25. During an interview on 09/10/25 at 9:53 A.M., Resident #12 responded to simple questions but could not remember what she had for breakfast. During an interview on 09/10/25 at 1:19 P. M., Resident #12 was alert to name only, she could not recall the month, who the president of the United States was or what she had for lunch. Resident #12 did not recall any man being in her room alongside of her bed, lifting her shirt, and touching her breast and or her body. She denied ever talking to a police officer. During an interview on 09/10/25, at 9:57 A.M., Activity Director (AD) #100 stated Resident #12 was confused and needed to be reminded where her room was located. During an interview on 09/10/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 2 of 3 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at 11:27 A.M., RN #105 stated she was working the day of the incident. She was passing medications in the opposite hall when two housekeepers called for her. She stopped passing medications and went to Resident #12's room with HK #110 and observed HK #115 was standing outside the door. RN #105 observed Resident #10 standing by the side of Resident #12's bed. Resident #12 was lying in her bed awake, with no expression on her face and not talking. RN #105 asked Resident #10 what he was doing in Resident #12's room and instructed him to leave. Resident #10 used his walker and left. After Resident #10 left the room, RN #105 asked Resident #12 if she was ok and the resident said she was fine. RN #105 did a full body assessment on Resident #12 and there were no areas of concern. During an interview on 09/10/25, at 1:00 P. M., the Administrator stated HK #110 and #115 were no longer employed with the facility because they did not follow the Health Insurance Portability and Accountability Act (HIPAA) privacy rules and discussed the incident between Resident #10 and Resident #12 with other staff and residents. Attempts to reach HK #110 and #115 on 09/10/25 and 09/11/25 via telephone for interview were unsuccessful. During an interview on 09/10/25, at 3:15 P. M., Detective #118 stated he arrived at the facility on 08/29/25 and interviewed Resident #12 and he realized within minutes the resident had severe dementia as she could not recall a male resident had been in her room and touched her. Detective #118 stated he then interviewed Resident #10 who confirmed he did touch Resident #12 with his mouth on her breast, chest and stomach area. Resident #10 reported he was unaware Resident #12 suffered from dementia. Detective #118 confirmed he then read Resident #10 his rights and handcuffed and arrested the resident for gross sexual imposition. Resident #10 left the facility with Detective #118. Review of facility policy titled Resident Rights to Freedom from Abuse. Neglect, and Exploitation undated revealed the facility residents had the right to be free from abuse. The facility would ensure residents were free from sexual aggressive behavior such as inappropriate sexual touching and grabbing. Anytime the facility had reason to suspect a resident might not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse. This deficiency represents non-compliance investigated under Complaint Number 2610266. Event ID: Facility ID: 365716 If continuation sheet Page 3 of 3