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
record review, policy review, witness statements, physician notes and staff interviews, the facility failed to
prevent sexual abuse of one Resident (#11) of three reviewed. The facility census was 82. Findings
include:1.Review of the medical record for Resident #11 revealed an admission date of 06/05/25. The
resident was admitted with diagnoses including aphasia following stroke, paraplegia, anxiety and
neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE]
revealed Resident #11 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition.
Resident #11 required set up for eating and was dependent for bed mobility, transfers, and toileting
hygiene. Review of the progress note dated 11/11/25, written by Registered Nurse (RN) #111, revealed an
unnamed Certified Nursing Assistant (CNA) alerted a female resident (Resident #10) was observed in
Resident #11's room with her hand on his penis stroking up and down. Resident #11 was documented to
inform the unnamed CNA he was awoken by the female resident and did not ask for it to happen. The
residents were separated immediately. Review of the social service progress note dated 11/12/25 at 9:27
A.M. revealed the social worker spoke to Resident #11 and offered a telehealth visit from Company #1 and
he agreed. Additional review of social service progress notes revealed on 11/12/25 at 12:53 P.M., social
services offered a second service from Company #2 and Resident #11 agreed to this as well. The note
further documented an unnamed counselor with Company #2 informed social services Resident #11 was
feeling embarrassed and felt the incident was his fault.Review of the 11/21/25 psychiatric evaluation from
Company #1 revealed Resident #11 reported a female resident was sexually inappropriate with him the
previous evening. The residents were separated and the facility was monitoring the situation closely and he
was pleased with that.Review of the written statement of RN #111 revealed CNA #103 informed RN #111,
Resident #10 was in Resident #11's room, with her hand on his penis stroking up and down. The residents
were separated, and Resident #10 was placed on one-on-one supervision. RN #111 interviewed Resident
#11 who informed her he was awoken from his sleep by Resident #10 touching his penis, he stated he did
not ask for it to happen, and he asked her to stop. Resident #10 stopped when CNA #103 entered the
room.Review of the written statement of CNA #103 revealed while doing rounds, he observed Resident #10
go into Resident #11's room and CNA #103 observed Resident #10 stroking Resident #11's penis. Once
CNA #103 was observed entering the room, Resident #10 immediately stopped and covered up Resident
#11. Resident #10 was removed and returned to the Memory Support Unit (MSU).2. Review of the medical
record for Resident #10 revealed admission date of 03/15/22. The resident was admitted with diagnoses
including alcohol dependence with alcohol induced persisting dementia, stroke, aphasia following stroke,
schizophrenia and Wernicke's encephalopathy. Review of the quarterly Minimum Data Set (MDS) dated
[DATE] revealed Resident #10 had a BIMS score of 15 indicating intact cognition. She required set up
assistance with eating, bed mobility, transfers, and toileting hygiene. Review of the care plan revealed
Resident #10 was a
(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 3
Event ID:
365743
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
365743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wright Rehabilitation and Healthcare Center
829 Yellow Springs - Fairfield Rd
Fairborn, OH 45324
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
supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress note
dated 11/11/25 at 8:45 P.M. RN #111 documented an unnamed CNA alerted her Resident #10 was
observed in another resident's room (Resident #11) with her hand on his penis stroking up and down.
Resident #11 asked Resident #10 to stop, and she did not stop until the staff member entered the room.
The residents were separated immediately, and Resident #10 was placed on one-on-one
supervision.Review of the progress note dated 11/12/25 at 1:57 P.M. revealed Resident #10 had a
telehealth appointment with Company #1 regarding the recent sexual incident. Resident #10 agreed not to
touch another resident inappropriately and monitoring would continue.Review of the 11/21/25 psychiatric
evaluation from Company #1 revealed Resident #10 stated she and Resident #11 had been in a
relationship but if he didn't want to date anymore, she would not bother him. She agreed not to touch
Resident #11 if he did not want to be touched. The note documented staff had reported Resident #10
touched Resident #11 inappropriately and he did not want it to occur.Interview on 11/19/25 at 9:12 A.M.
with Assistant Director of Nursing (ADON) #102 revealed staff reported Resident #10 was observed
entering Resident #11's room by CNA #103. It was reported to ADON #102, CNA #103 witnessed
inappropriate touching of Resident #11 and Resident #10 mirrored in the window. ADON #102 verified
Resident #10 resided in MSU which he acknowledged was a locked unit. ADON #102 explained the
incident occurred during a smoke break and ADON #102 explained Resident #10 reported she was cold,
so staff permitted her to go back into the facility unsupervised, which allowed her the opportunity to enter
Resident #11's room.Interview on 11/19/25 at 11:25 A.M. with Laundry Assistant (LA ) #108 revealed there
were two residents on the MSU who were smokers. She shared the residents were to be observed at all
times while they are out of the unit.Interview on 11/19/25 at 11:31 A.M. with Social Worker (SW) #110
revealed she was informed during morning meeting on 11/12/25 of an incident of inappropriate touching by
Resident #10 to Resident #11, an investigation was initiated, and the police were contacted. SW #110
spoke to both residents, and both agreed to a telehealth appointment with Company #1. SW #110 denied
knowledge of a previous incident by Resident #10 of sexual behavior towards any resident at the
facility.Interview on 11/19/25 at 12:36 P.M. with the Director of Nursing (DON) and Administrator revealed
on 11/11/12, the DON was contacted by CNA #103 and informed of inappropriate touching of Resident #11
by Resident #10. CNA #103 reported he witnessed Resident #10 enter Resident #11's room and when he
went to investigate, he observed Resident #10 touching Resident #11's penis mirrored in the window.
Resident #10 stopped as he entered the room and she was escorted back to the MSU and placed on
one-on-one supervision. Upon investigation, it was discovered during the 8:30 P.M. smoke break on
11/11/25, Resident #10 informed LA #112 she was cold and wanted to wait inside the activity room (right
inside the smoke door) until smoke break was over. LA #112 agreed, and after smoke break when Resident
#10 was not in the activity room it was assumed, she had gone back to the unit. The police were notified on
11/12/25 and a report was filed. The Administrator shared Resident #11 had stated he did not wish to file
charges; however the police chose to proceed with charges. The case remains open. Both residents
received an assessment by Company #1, and Resident #10 was discharged on 11/12/25 to Behavioral
Hospital #3. The DON and Administrator each verified it was the expectation of the staff assigned to smoke
breaks observe the MSU residents at all times until returned and secured back inside the unit.Interview on
11/19/25 at 1:04 P.M. with Resident #11 revealed Resident #10 had come into his room after smoking and
touched him inappropriately. He shared he was disturbed by this action as he was asleep and was awoken
by her touching him.Review of the facility policy, Abuse Investigation and Reporting dated 11/21
documented residents had the right to be free from abuse, neglect and misappropriation.This deficiency
represents non-compliance investigated under Complaint Number 2671345.
Event ID:
Facility ID:
365743
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
365743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wright Rehabilitation and Healthcare Center
829 Yellow Springs - Fairfield Rd
Fairborn, OH 45324
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interviews, the facility failed to ensure residents residing in a secure memory care
unit were observed when outside the unit. This affected one Resident (#10) of three reviewed. The facility
census was 82. Findings include:Review of the medical record for Resident #10 revealed admission date of
03/15/22. The resident was admitted with diagnoses including alcohol dependence with alcohol induced
persisting dementia, stroke, aphasia following stroke, schizophrenia and Wernicke's encephalopathy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a
Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required set up assistance
with eating, bed mobility, transfers, and toileting hygiene.Review of the care plan revealed Resident #10
was a supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress
note dated 11/11/25 at 8:45 P.M., Registered Nurse (RN) #111 documented an unnamed Certified Nursing
Assistant (CNA) alerted her Resident #10 was observed in another resident's room (Resident #11) with her
hand on his penis stroking up and down. Resident #11 asked Resident #10 to stop, and she did not stop
until the staff member entered the room. The residents were separated immediately, and Resident #10 was
placed on one-on-one supervision.Interview on 11/19/25 at 9:12 A.M. with Assistant Director of Nursing
(ADON) #102 revealed staff reported Resident #10 was observed entering Resident #11's room by CNA
#103. ADON #102 verified Resident #10 resided in the Memory Support Unit (MSU), which he
acknowledged was a locked unit. ADON #102 explained during a smoke break, Resident #10 reported she
was cold, so staff allowed her to go back into the facility unsupervised, which allowed her the opportunity to
enter Resident #11's room.Interview on 11/19/25 at 11:31 A.M. with Social Worker #110 revealed she was
informed Resident #10 had entered Resident #11's room after she was left unattended by staff. She
explained Resident #10 required the locked MSU due to her elopement risk.Interview on 11/19/25 at 12:36
P.M. with the Director of Nursing (DON) and Administrator revealed on 11/11/12 the DON was contacted by
CNA #103 and informed he witnessed Resident #10 enter Resident #11's room. Upon investigation, it was
discovered during the 8:30 P.M. smoke break on 11/11/25 Resident #10 informed Laundry Aid (LA) #112
she was cold and wanted to wait inside the activity room until smoke break was over. LA #112 agreed, and
after smoke break when Resident #10 was not in the activity room it was assumed, she had gone back to
the unit. The DON and Administrator each verified it was the expectation of the staff assigned to smoke
breaks observe the MSU residents at all times until returned and secured back in the unit.
Event ID:
Facility ID:
365743
If continuation sheet
Page 3 of 3