Health inspection·November 26, 2019

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of facility trust account information, and review of facility surety bond, the facility failed to ensure the surety bond was efficient to cover the total balance of the resident account balances. This affected 74 current residents identified by the facility with current trust accounts handled by the facility. Resident #5, #19, #25, #29, #46, #74, and #278 did not have personal fund accounts handled by the facility. Facility census was 81. Residents Affected - Some Findings include: Review of the resident trust accounts on 11/26/19 at 10:10 A.M. with Business Office manager(BOM) #137 identified 74 residents with current accounts. The current total balance was $66,478.02. Review of the financial surety bond dated 10/01/18 indicated the bond covered the facility for up to $50,000.00. Interview on 11/26/19 at 12:25 P.M., the Administrator verified the facility resident fund account balance exceeds the current financial surety bond total. Page 1 of 21 365756 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

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, staff interview, review of the facility investigation, and review of facility policy on abuse, the facility failed to prevent resident to resident sexual abuse when one resident (#8) was fondled without consent by another resident (#3). This affected one (#8) of four residents reviewed for abuse. The facility census was 81. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included dementia, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/03/19, revealed the resident was severely cognitively impaired. Review of Resident #8's the nurse progress notes dated 10/19/19 at 1:37 P.M. revealed an incident involving another resident fondling the private area of Resident #8. The event was discovered by a staff member who walked in to get Resident #8 up for lunch. An additional progress note dated 10/19/19 at 10:37 P.M. revealed contact was made with the resident's wife to inform her of the event. The resident's wife expressed concerns for the resident's safety and requested a room change. She was assured by staff the resident would be monitored more frequently and both residents are to be kept apart. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included mild intellectual disabilities, post traumatic stress disorder, dementia without behavioral disturbance, depression, schizoaffective disorder, obsessive compulsive disorder, and generalized anxiety. Review of the quarterly MDS 3.0 assessment, dated 08/23/19, revealed the resident was not exhibiting physical behavioral symptoms, including abusing others sexually. The resident was identified as having other behavioral symptoms not directed towards others including public sexual acts. The resident was identified by the facility to be mildly cognitively impaired. Review of the facility investigation revealed statements from Social Services Director (SSD) #105 dated 10/19/19. The nursing staff reported Resident #3 was found to be fondling Resident #8. SSD #105 interviewed Resident #3 who denied touching any of the other residents. Additionally, Resident #8 was interviewed who denied being touched by another resident. Physical assessments were completed on both residents on 10/19/19. Further review of the facility investigation revealed no interviews with any nursing staff on duty at the time of the event. Interview on 11/25/19 at 11:25 A.M., with Licensed Practical Nurse (LPN) #109 revealed on 10/19/19 State Tested Nursing Aide (STNA) #168 informed her she witnessed Resident #3 with his hand down the brief of Resident #8. Resident #3 stated to the STNA he was Just trying to help him out. The residents were then separated and placed on more frequent observation. Resident #8 eventually had a room change as a result of the incident. LPN #109 stated she informed the Director of Nursing (DON) of the incident. Interview on 11/25/19 at 1:43 P.M., the DON revealed she was made aware of the incident regarding 365756 Page 2 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #3 touching Resident #8 during report. She was unable to provide the date she was notified or any further details regarding the incident. Interview on 11/26/19 at 7:40 A.M., STNA #168 revealed she was a witness to an incident involving Resident #3 and Resident #8 on 10/19/19. She stated she walked in to Resident #8's room to find Resident #3 sitting at the bedside with his hand in Resident #8's brief. Resident #8 was positioned on his back with a blanket over top of him, Resident #3 was seen making a motion with his hand underneath the blanket. STNA #168 reported Resident #3 jumped and removed his hand immediately when he saw her enter. When the resident removed his hand, the STNA was able to see that Resident #8's brief was unfastened. She asked the resident what was happening. Resident #3 responded he was just helping the other male out. She told the charge nurse immediately, the residents were separated, frequency of observation on both residents was increased, and Resident #8 had a room change. Review of the facility policy titled Abuse Prevention Policy and Procedure, dated 01/01/16, revealed the facility shall follow state and federal guidelines on preventing abuse. Abuse shall include sexual abuse. It is the responsibility of all staff to provide a safe environment for the resident. 365756 Page 3 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policies, the facility failed to follow their policy to investigate and report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81. Residents Affected - Some Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when Housekeeper #167 observed Resident #4 touching Resident #63's penis. Both residents were in the middle of the room and the privacy curtain was not pulled. Resident #4 stated to the nurse that she was not consenting and didn't want to do it. Resident #4 was put on 15 minute checks. All parties were made aware of the situation. Review of Resident #4's care plan revised 11/19/19 revealed supports and interventions for engaged in sexual type behaviors with male peer. Interventions for Resident #4's sexual behaviors included education on safe sexual practices, intervention if both residents were not willing participants, encourage resident to change locations if demonstrating physical affection or intimacy in public area, educate resident on appropriate behaviors as well as appropriate places to spend time with her special friend/peer, encourage resident to spend time with her friend in resident areas such as day or central lounge, and remind resident to talk with staff if she has any concerns. Review of Resident #4's 11/19/19 Mental Health Provider (MHP) visit notes revealed Resident #4 was seen on 11/19/19 due to staff expressing concerns Resident #4 was having sex with a male resident and Resident #4 had indicated she was not a willing participant. Resident #4 reported to the MHP it was accurate she was not a willing participant. The MHP discussed not entering the other resident's room and not allowing him in her room. Resident #4 was reminded to go to staff with concerns if the resident is bothering her. It was noted although there was evidence Resident #4 had a cognitive impairment, Resident #4 retained sufficient capacity for engaging in the therapeutic process. Review of Resident #63's medical record revealed an admission date of 07/11/19. Diagnoses included schizophrenia, hyperkalemia, chronic kidney disease, type II diabetes, bipolar disorder, heart disease, gout, para-stoma hernia, and major depressive disorder. Review of Resident #63's MDS assessment, dated 10/25/19, revealed Resident #63 was moderately cognitively impaired. Resident #63 was independent with walking, locomotion, dressing and personal hygiene. 365756 Page 4 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0607 Level of Harm - Minimal harm or potential for actual harm Review of Resident #63's care plan revised 11/19/19 revealed supports and interventions for potential for engaging in sexual type behavior with others. Interventions for engaging in sexualized behaviors included education on safe sexual practices, intervene if both residents are not willing participants, notify guardian if necessary, encourage resident and friend to watch television in resident areas as desired, and to verify consent of both persons. Residents Affected - Some No progress note was found for the sexual incident which took place on 11/19/19 between Resident #4 and Resident #63. Information regarding this second incident was documented only in Resident #4's progress notes. Interview on 11/26/19 at 8:33 A.M., Resident #4 reported Resident #63 wanted her to call him her boyfriend and she didn't not want to do that. Resident #4 reported they both wanted to participate in the sexual acts that took place on 11/19/19. Resident #4 reported she was in Resident #63's room watching television and Resident #63 asked her to participate in the sexual act. Resident #4 said she did not want to do sexual things with him, but did agree when he asked. Resident #4 said Resident #63 was no longer able to come into her room and she was no longer able to go into his room. Resident #4 reported Resident #63 still came around though but he had not asked her to do anything sexual since the last incident. Interview on 11/26/19 at 9:44 A.M., Resident #63 reported he asked Resident #4 for the sexual favors and she cooperated. Resident #63 reported they were good friends, he asked her to come into his room, and she nodded her head yes when he asked her for more. Resident #63 said it was a mutual thing and it didn't happen very often. Review of the facility's investigation into the sexual interactions that took place on 11/19/19 revealed written statements were completed by the staff who witnessed the interaction. Fifteen minute checks were completed for Resident #4 from 11/19/19 to 11/25/19 and Resident #4 and Resident #63's care plans were updated. No evidence was found interviews were completed with Resident #4 or Resident #63, other residents, or other staff. No evidence was found Resident #4 and Resident #63 were physically assessed following the incident. Review of the facility's Self-Reported Incidents (SRI)s revealed the facility did not report the allegation of sexual assault to the state survey agency. Interview on 11/25/19 at 9:21 A.M. with the Director of Nursing (DON) verified she was informed of the sexual acts which had occurred between Resident #4 and Resident #63. The DON verified the facility did not report the initial allegation to the state survey agency. The DON verified the facility did not do a thorough interview either Resident #4 or Resident #63 when the allegation was reported. 2. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included dementia, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/03/19, revealed the resident was severely cognitively impaired. Review of Resident #8's the nurse progress notes dated 10/19/19 at 1:37 P.M. revealed an incident involving another resident fondling the private area of Resident #8. The event was discovered by a staff member who walked in to get Resident #8 up for lunch. An additional progress note dated 10/19/19 at 10:37 P.M. revealed contact was made with the resident's wife to inform her of the event. The 365756 Page 5 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's wife expressed concerns for the resident's safety and requested a room change. She was assured by staff the resident would be monitored more frequently and both residents are to be kept apart. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included mild intellectual disabilities, post traumatic stress disorder, dementia without behavioral disturbance, depression, schizoaffective disorder, obsessive compulsive disorder, and generalized anxiety. Review of the quarterly MDS 3.0 assessment, dated 08/23/19, revealed the resident was not exhibiting physical behavioral symptoms, including abusing others sexually. The resident was identified as having other behavioral symptoms not directed towards others including public sexual acts. The resident was identified by the facility to be mildly cognitively impaired. Review of the facility investigation revealed statements from Social Services Director (SSD) #105 dated 10/19/19. The nursing staff reported Resident #3 was found to be fondling Resident #8. SSD #105 interviewed Resident #8 who denied touching any of the other residents. Additionally, Resident #8 was interviewed who denied being touched by another resident. Physical assessments were completed on both residents on 10/19/19. Further review of the facility investigation revealed no interviews with any nursing staff on duty at the time of the event. Interview on 11/25/19 at 11:25 A.M., with Licensed Practical Nurse (LPN) #109 revealed on 10/19/19 State Tested Nursing Aide (STNA) #168 informed her she witnessed Resident #3 with his hand down the brief of Resident #8. Resident #3 stated to the STNA he was Just trying to help him out. The residents were then separated and placed on more frequent observation. Resident #8 eventually had a room change as a result of the incident. LPN #109 stated she informed the Director of Nursing (DON) of the incident. Interview on 11/26/19 at 7:40 A.M., STNA #168 revealed she was a witness to an incident involving Resident #3 and Resident #8 on 10/19/19. She stated she walked in to Resident #8's room to find Resident #3 sitting at the bedside with his hand in Resident #8's brief. Resident #8 was positioned on his back with a blanket over top of him, Resident #3 was seen making a motion with his hand underneath the blanket. STNA #168 reported Resident #3 jumped and removed his hand immediately when he saw her enter. When the resident removed his hand, the STNA was able to see that Resident #8's brief was unfastened. She asked the resident what was happening. Resident #3 responded he was just helping the other male out. She told the charge nurse immediately, the residents were separated, frequency of observation on both residents was increased, and Resident #8 had a room change. Review of the facility's SRIs revealed the facility did not report the allegation of sexual assault to the state survey agency. Interview on 11/25/19 at 1:43 P.M., the DON revealed she was made aware of the incident regarding Resident #3 touching Resident #8 during report. She was unable to provide the date she was notified or any further details regarding the incident. DON confirmed at this time the facility did not report the allegation of abuse to the state survey agency. DON confirmed at this time that there was no investigation following the incident. Review of the facility policy titled Abuse Prevention Policy and Procedure, dated 01/01/16, revealed the facility shall follow state and federal guidelines on preventing abuse. Additionally, the facility is to report all allegations of abuse to the Ohio Department of Health as soon as possible, but 365756 Page 6 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no more than 24 hours after the alleged incident is discovered. The facility identifies and investigations all allegations of abuse. Review of the facility policy titled Abuse Investigation Policy and Procedure, dated 01/01/16, revealed the facility shall conduct interviews with the person reporting the incident, witnesses to the incident, and any staff members having contact with the resident during the period of the alleged incident. 365756 Page 7 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policy, the facility failed to report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when Housekeeper #167 observed Resident #4 touching Resident #63's penis. Both residents were in the middle of the room and the privacy curtain was not pulled. Resident #4 stated to the nurse that she was not consenting and didn't want to do it. Resident #4 was put on 15 minute checks. All parties were made aware of the situation. Review of Resident #4's care plan revised 11/19/19 revealed supports and interventions for engaged in sexual type behaviors with male peer. Interventions for Resident #4's sexual behaviors included education on safe sexual practices, intervention if both residents were not willing participants, encourage resident to change locations if demonstrating physical affection or intimacy in public area, educate resident on appropriate behaviors as well as appropriate places to spend time with her special friend/peer, encourage resident to spend time with her friend in resident areas such as day or central lounge, and remind resident to talk with staff if she has any concerns. Review of Resident #4's 11/19/19 Mental Health Provider (MHP) visit notes revealed Resident #4 was seen on 11/19/19 due to staff expressing concerns Resident #4 was having sex with a male resident and Resident #4 had indicated she was not a willing participant. Resident #4 reported to the MHP it was accurate she was not a willing participant. The MHP discussed not entering the other resident's room and not allowing him in her room. Resident #4 was reminded to go to staff with concerns if the resident is bothering her. It was noted although there was evidence Resident #4 had a cognitive impairment, Resident #4 retained sufficient capacity for engaging in the therapeutic process. Review of Resident #63's medical record revealed an admission date of 07/11/19. Diagnoses included schizophrenia, hyperkalemia, chronic kidney disease, type II diabetes, bipolar disorder, heart disease, gout, para-stoma hernia, and major depressive disorder. Review of Resident #63's MDS assessment, dated 10/25/19, revealed Resident #63 was moderately cognitively impaired. Resident #63 was independent with walking, locomotion, dressing and personal hygiene. 365756 Page 8 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of Resident #63's care plan revised 11/19/19 revealed supports and interventions for potential for engaging in sexual type behavior with others. Interventions for engaging in sexualized behaviors included education on safe sexual practices, intervene if both residents are not willing participants, notify guardian if necessary, encourage resident and friend to watch television in resident areas as desired, and to verify consent of both persons. Residents Affected - Some No progress note was found for the sexual incident which took place on 11/19/19 between Resident #4 and Resident #63. Information regarding this second incident was documented only in Resident #4's progress notes. Interview on 11/26/19 at 8:33 A.M., Resident #4 reported Resident #63 wanted her to call him her boyfriend and she didn't not want to do that. Resident #4 reported they both wanted to participate in the sexual acts that took place on 11/19/19. Resident #4 reported she was in Resident #63's room watching television and Resident #63 asked her to participate in the sexual act. Resident #4 said she did not want to do sexual things with him, but did agree when he asked. Resident #4 said Resident #63 was no longer able to come into her room and she was no longer able to go into his room. Resident #4 reported Resident #63 still came around though but he had not asked her to do anything sexual since the last incident. Interview on 11/26/19 at 9:44 A.M., Resident #63 reported he asked Resident #4 for the sexual favors and she cooperated. Resident #63 reported they were good friends, he asked her to come into his room, and she nodded her head yes when he asked her for more. Resident #63 said it was a mutual thing and it didn't happen very often. Review of the facility's Self-Reported Incidents (SRI)s revealed the facility did not report the allegation of sexual assault to the state survey agency. Interview on 11/25/19 at 9:21 A.M. with the Director of Nursing (DON) verified she was informed of the sexual acts which had occurred between Resident #4 and Resident #63. The DON verified the facility did not report the initial allegation to the state survey agency. 2. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included dementia, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/03/19, revealed the resident was severely cognitively impaired. Review of Resident #8's the nurse progress notes dated 10/19/19 at 1:37 P.M. revealed an incident involving another resident fondling the private area of Resident #8. The event was discovered by a staff member who walked in to get Resident #8 up for lunch. An additional progress note dated 10/19/19 at 10:37 P.M. revealed contact was made with the resident's wife to inform her of the event. The resident's wife expressed concerns for the resident's safety and requested a room change. She was assured by staff the resident would be monitored more frequently and both residents are to be kept apart. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included mild intellectual disabilities, post traumatic stress disorder, dementia without behavioral disturbance, depression, schizoaffective disorder, obsessive compulsive disorder, and generalized anxiety. 365756 Page 9 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS 3.0 assessment, dated 08/23/19, revealed the resident was not exhibiting physical behavioral symptoms, including abusing others sexually. The resident was identified as having other behavioral symptoms not directed towards others including public sexual acts. The resident was identified by the facility to be mildly cognitively impaired. Review of the facility investigation revealed statements from Social Services Director (SSD) #105 dated 10/19/19. The nursing staff reported Resident #3 was found to be fondling Resident #8. SSD #105 interviewed Resident #8 who denied touching any of the other residents. Additionally, Resident #8 was interviewed who denied being touched by another resident. Physical assessments were completed on both residents on 10/19/19. Further review of the facility investigation revealed no interviews with any nursing staff on duty at the time of the event. Interview on 11/25/19 at 11:25 A.M., with Licensed Practical Nurse (LPN) #109 revealed on 10/19/19 State Tested Nursing Aide (STNA) #168 informed her she witnessed Resident #3 with his hand down the brief of Resident #8. Resident #3 stated to the STNA he was Just trying to help him out. The residents were then separated and placed on more frequent observation. Resident #8 eventually had a room change as a result of the incident. LPN #109 stated she informed the Director of Nursing (DON) of the incident. Interview on 11/26/19 at 7:40 A.M., STNA #168 revealed she was a witness to an incident involving Resident #3 and Resident #8 on 10/19/19. She stated she walked in to Resident #8's room to find Resident #3 sitting at the bedside with his hand in Resident #8's brief. Resident #8 was positioned on his back with a blanket over top of him, Resident #3 was seen making a motion with his hand underneath the blanket. STNA #168 reported Resident #3 jumped and removed his hand immediately when he saw her enter. When the resident removed his hand, the STNA was able to see that Resident #8's brief was unfastened. She asked the resident what was happening. Resident #3 responded he was just helping the other male out. She told the charge nurse immediately, the residents were separated, frequency of observation on both residents was increased, and Resident #8 had a room change. Review of the facility's SRIs revealed the facility did not report the allegation of sexual assault to the state survey agency. Interview on 11/25/19 at 1:43 P.M., the DON revealed she was made aware of the incident regarding Resident #3 touching Resident #8 during report. She was unable to provide the date she was notified or any further details regarding the incident. DON confirmed at this time the facility did not report the allegation of abuse to the state survey agency. Review of the facility policy titled Abuse Prevention Policy and Procedure, dated 01/01/16, revealed the facility shall follow state and federal guidelines on preventing abuse. Additionally, the facility is to report all allegations of abuse to the Ohio Department of Health as soon as possible, but no more than 24 hours after the alleged incident is discovered. 365756 Page 10 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

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 medical record review, resident interview, staff interview, review of facility investigations, and review of facility policies, the facility failed to thoroughly investigate allegations of sexual abuse. This affected four (#3, #4, #8, and #63), of four reviewed for abuse. The facility census was 81. Residents Affected - Some Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when Housekeeper #167 observed Resident #4 touching Resident #63's penis. Both residents were in the middle of the room and the privacy curtain was not pulled. Resident #4 stated to the nurse that she was not consenting and didn't want to do it. Resident #4 was put on 15 minute checks. All parties were made aware of the situation. Review of Resident #4's care plan revised 11/19/19 revealed supports and interventions for engaged in sexual type behaviors with male peer. Interventions for Resident #4's sexual behaviors included education on safe sexual practices, intervention if both residents were not willing participants, encourage resident to change locations if demonstrating physical affection or intimacy in public area, educate resident on appropriate behaviors as well as appropriate places to spend time with her special friend/peer, encourage resident to spend time with her friend in resident areas such as day or central lounge, and remind resident to talk with staff if she has any concerns. Review of Resident #4's 11/19/19 Mental Health Provider (MHP) visit notes revealed Resident #4 was seen on 11/19/19 due to staff expressing concerns Resident #4 was having sex with a male resident and Resident #4 had indicated she was not a willing participant. Resident #4 reported to the MHP it was accurate she was not a willing participant. The MHP discussed not entering the other resident's room and not allowing him in her room. Resident #4 was reminded to go to staff with concerns if the resident is bothering her. It was noted although there was evidence Resident #4 had a cognitive impairment, Resident #4 retained sufficient capacity for engaging in the therapeutic process. Review of Resident #63's medical record revealed an admission date of 07/11/19. Diagnoses included schizophrenia, hyperkalemia, chronic kidney disease, type II diabetes, bipolar disorder, heart disease, gout, para-stoma hernia, and major depressive disorder. Review of Resident #63's MDS assessment, dated 10/25/19, revealed Resident #63 was moderately cognitively impaired. Resident #63 was independent with walking, locomotion, dressing and personal hygiene. Review of Resident #63's care plan revised 11/19/19 revealed supports and interventions for 365756 Page 11 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some potential for engaging in sexual type behavior with others. Interventions for engaging in sexualized behaviors included education on safe sexual practices, intervene if both residents are not willing participants, notify guardian if necessary, encourage resident and friend to watch television in resident areas as desired, and to verify consent of both persons. No progress note was found for the sexual incident which took place on 11/19/19 between Resident #4 and Resident #63. Information regarding this second incident was documented only in Resident #4's progress notes. Review of the facility's investigation into the sexual interactions that took place on 11/19/19 revealed written statements were completed by the staff who witnessed the interaction. Fifteen minute checks were completed for Resident #4 from 11/19/19 to 11/25/19 and Resident #4 and Resident #63's care plans were updated. No evidence was found interviews were completed with Resident #4 or Resident #63, other residents, or other staff. No evidence was found Resident #4 and Resident #63 were physically assessed following the incident. Interview on 11/26/19 at 8:33 A.M., Resident #4 reported Resident #63 wanted her to call him her boyfriend and she didn't not want to do that. Resident #4 reported they both wanted to participate in the sexual acts that took place on 11/19/19. Resident #4 reported she was in Resident #63's room watching television and Resident #63 asked her to participate in the sexual act. Resident #4 said she did not want to do sexual things with him, but did agree when he asked. Resident #4 said Resident #63 was no longer able to come into her room and she was no longer able to go into his room. Resident #4 reported Resident #63 still came around though but he had not asked her to do anything sexual since the last incident. Interview on 11/26/19 at 9:44 A.M., Resident #63 reported he asked Resident #4 for the sexual favors and she cooperated. Resident #63 reported they were good friends, he asked her to come into his room, and she nodded her head yes when he asked her for more. Resident #63 said it was a mutual thing and it didn't happen very often. Interview on 11/25/19 at 9:21 A.M. with the Director of Nursing (DON) verified she was informed of the sexual acts which had occurred between Resident #4 and Resident #63. The DON verified the facility did not do a thorough interview either Resident #4 or Resident #63 when the allegation was reported. 2. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included dementia, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/03/19, revealed the resident was severely cognitively impaired. Review of Resident #8's the nurse progress notes dated 10/19/19 at 1:37 P.M. revealed an incident involving another resident fondling the private area of Resident #8. The event was discovered by a staff member who walked in to get Resident #8 up for lunch. An additional progress note dated 10/19/19 at 10:37 P.M. revealed contact was made with the resident's wife to inform her of the event. The resident's wife expressed concerns for the resident's safety and requested a room change. She was assured by staff the resident would be monitored more frequently and both residents are to be kept apart. 365756 Page 12 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included mild intellectual disabilities, post traumatic stress disorder, dementia without behavioral disturbance, depression, schizoaffective disorder, obsessive compulsive disorder, and generalized anxiety. Review of the quarterly MDS 3.0 assessment, dated 08/23/19, revealed the resident was not exhibiting physical behavioral symptoms, including abusing others sexually. The resident was identified as having other behavioral symptoms not directed towards others including public sexual acts. The resident was identified by the facility to be mildly cognitively impaired. Review of the facility investigation revealed statements from Social Services Director (SSD) #105 dated 10/19/19. The nursing staff reported Resident #3 was found to be fondling Resident #8. SSD #105 interviewed Resident #8 who denied touching any of the other residents. Additionally, Resident #8 was interviewed who denied being touched by another resident. Physical assessments were completed on both residents on 10/19/19. Further review of the facility investigation revealed no interviews with any nursing staff on duty at the time of the event. Interview on 11/25/19 at 11:25 A.M., with Licensed Practical Nurse (LPN) #109 revealed on 10/19/19 State Tested Nursing Aide (STNA) #168 informed her she witnessed Resident #3 with his hand down the brief of Resident #8. Resident #3 stated to the STNA he was Just trying to help him out. The residents were then separated and placed on more frequent observation. Resident #8 eventually had a room change as a result of the incident. LPN #109 stated she informed the Director of Nursing (DON) of the incident. Interview on 11/25/19 at 1:43 P.M., the DON revealed she was made aware of the incident regarding Resident #3 touching Resident #8 during report. She was unable to provide the date she was notified or any further details regarding the incident. Interview on 11/26/19 at 7:40 A.M., STNA #168 revealed she was a witness to an incident involving Resident #3 and Resident #8 on 10/19/19. She stated she walked in to Resident #8's room to find Resident #3 sitting at the bedside with his hand in Resident #8's brief. Resident #8 was positioned on his back with a blanket over top of him, Resident #3 was seen making a motion with his hand underneath the blanket. STNA #168 reported Resident #3 jumped and removed his hand immediately when he saw her enter. When the resident removed his hand, the STNA was able to see that Resident #8's brief was unfastened. She asked the resident what was happening. Resident #3 responded he was just helping the other male out. She told the charge nurse immediately, the residents were separated, frequency of observation on both residents was increased, and Resident #8 had a room change. Interview on 11/25/19 at 1:43 P.M., with DON revealed she was made aware of the incident regarding Resident #3 and Resident #8. She was unable to provide the date of notification or any further details regarding the incident. DON confirmed at this time that there was no investigation following the incident. Review of the facility policy titled Abuse Prevention Policy and Procedure, dated 01/01/16, revealed the facility shall follow state and federal guidelines on preventing abuse. The facility identifies and investigations all allegations of abuse. Review of the facility policy titled Abuse Investigation Policy and Procedure, dated 01/01/16, revealed the facility shall conduct interviews with the person reporting the incident, witnesses to the incident, and any staff members having contact with the resident during the period of the alleged 365756 Page 13 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0610 incident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365756 Page 14 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to provide written notification of hospital transfer to residents, the residents' representatives, and to the Ombudsman for one (#64) of three residents reviewed for transfer/discharge. The facility census was 81. Findings nclude: Review of Resident #64's medical record revealed an admission date of 02/01/07. Resident #64 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included contracture of right knee, hypokalemia, hypertension, paraplegia, abnormal posture, contracture of left shoulder, anemia, hernia, convulsion, chronic sinusitis, anxiety disorder, sepsis, and multiple sclerosis. Review of Resident #64's Minimum Data Set (MDS) assessments revealed a Discharge MDS assessment with return anticipated was completed on 09/03/19. Review of Resident #64's progress notes revealed on 09/03/19 Resident #64 was transferred to the hospital. There was no evidence Resident #64 or her representative were provided notification in writing of the reason for transfer to the hospital. No evidence was found the Ombudsman was notified of Resident #64's transfer to the hospital. Interview on 11/25/19 at 4:38 P.M. with the Administrator verified no written notification for transfer to the hospital was provided to Resident #64 or her representative when she was transferred to the hospital on [DATE]. The administrator also verified the Ombudsman was not notified of Resident #64's transfer to the hospital. 365756 Page 15 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy, the facility failed to provide notification of bed hold policy to one (#64) of three residents reviewed for transfer/discharge. The facility census was 81. Findings include: Review of Resident #64's medical record revealed an admission date of 02/01/07. Resident #64 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included contracture of right knee, hypokalemia, hypertension, paraplegia, abnormal posture, contracture of left shoulder, anemia, hernia, convulsion, chronic sinusitis, anxiety disorder, sepsis, and multiple sclerosis. Review of Resident #64's Minimum Data Set (MDS) revealed a Discharge MDS with return anticipated was completed on 09/03/19. An Entry MDS was completed 09/09/19. Review of Resident #64's progress notes revealed on 09/03/19 Resident #64 was transferred to the hospital. There was no evidence Resident #64 or her representative were provided notification of the bed hold policy. Interview on 11/25/19 at 4:38 P.M. with the Administrator verified no notification of the bed hold policy was provided to Resident #64 or her representative when she was transferred to the hospital on [DATE]. Review of the policy titled Bed Hold Policy, revised August 2019, revealed it was the policy of the facility to inform residents and/or their representatives in writing of of the bed hold policy and return policy prior to transfers from the facility to residents who have Medicaid. 365756 Page 16 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a pressure reducing cushion was in place as care planned for one (#69) of two residents reviewed for skin breakdown. The facility had seven residents with pressure ulcers. The facility census was 81 residents. Residents Affected - Few Findings include: Review of the medical record revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included muscle wasting and atrophy, lack of coordination, cognitive communication deficit, symbolic dysfunction, hypertension, osteoporosis, anxiety disorder, disorder of kidney and ureter, dysphagia, dysthymic disorder, vascular dementia with behavioral disturbance, bipolar disorder, chronic obstructive pulmonary disease, persistent mood disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 11/05/19, identified the resident as alert with moderate cognitive impairment, required two staff for the completion of activities of daily living, frequently incontinent of bowel and bladder, at risk for skin breakdown, and receives a diuretic seven days weekly. Review of the plan of care dated 10/22/19 identified the resident's risk for impairment to skin integrity related to impaired mobility, impaired cognition, excoriation at times, and wishes to sleep in recliner. Interventions included pressure relieving/reducing cushion to protect the skin while up in chair. Review of the skin breakdown assessment dated [DATE] identified the resident to be at risk for the development of skin breakdown. Review of nurses notes dated 11/18/19 at 2:11 P.M. documented Resident #69 was placed from her recliner to her bed this afternoon. When resident was getting care in the bed, the nurse found a small red open area on the left buttock. The area measured 0.5 centimeters (cm) by 0.3 cm. The resident complained the area was sore when nurse was measuring. The nurse put a physician order in for a hydrocolloid dressing to the buttock change every three days. The resident was educated on the importance of being changed and repositioned every 2 hours. Observation on 11/24/19 at 5:15 P.M. and 11/25/19 at 7:05 A.M. noted Resident #69 in the recliner. No cushion was applied to the seat. Interview on 11/25/19 at 7:05 A.M., State Tested Nurse Aide (STNA) #115 verified no cushion was in place to the recliner. Additional observation on 11/25/19 at 8:45 A.M., 10:45 A.M. 12:29 P.M., and 2:00 P.M., and 11/26/19 at 7:40 A.M. noted Resident #69 was in the recliner without a cushion to the seat. Interview on 11/26/19 at 7:42 A.M., Licensed Practical Nurse (LPN) #150 verified no cushion was observed in the recliner. 365756 Page 17 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, record review, staff interview and facility policy, the facility failed to implement a care plan intervention for falls. This affected one (#3) of two residents review for falls. The facility census was 81. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses included repeated falls, unsteadiness on feet, fracture of the lower end right radius, unspecified lack of coordination, post traumatic stress disorder, mild intellectual disabilities, dementia, generalized anxiety disorder, hypertension, convulsions, major depressive disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/19, revealed the resident was moderately impaired for cognition Review of Resident #3's care plan revealed the resident was at risk for falls due to behaviors, psychotropic medication, and seizures. One intervention included non-skid strips to the right side of bed. Observation on 11/26/19 at 8:47 A.M. of Resident #3's room revealed no non-skid strips on the floor near the resident's bed. Interview on 11/26/19 at 8:52 A.M. with State Tested Nursing Assistant (STNA) #128 verified there were no non-skid strips by Resident #3's bed. Review of facility policy titled Falls Policy, reviewed October 2018, verified current fall interventions will be reviewed and new interventions will be implement to reduce the risk of a fall. 365756 Page 18 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview, the facility failed to ensure a register nurse worked eight hours a day, seven days a week. This had the potential to affect all 81 resident residing at the facility. The facility census was 81. Findings include: Review of the facility staffing records from 10/25/19 to 11/24/19 revealed a registered nurse (RN) did not work or worked less than eight hours in the facility on 10/25/19, 10/31/19, 11/01/19, 11/05/19, 11/08/19, 11/11/19, 11/19/19, 11/20/19, and 11/21/19. Interview on 11/25/19 at 4:33 P.M. with the Administrator verified the facility had no RN coverage for eight hours on 10/25/19, 10/31/19, 11/01/19, 11/05/19, 11/08/19, 11/11/19, 11/19/19, 11/20/19, and 11/21/19. 365756 Page 19 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, review of daily temperature log, nd review of manufacturer's storage recommendations, the facility failed to store medication requiring refrigeration at the proper temperature in accordance with manufacturer recommendations. This had the potential to affect nine residents (# 8, #13, #18, #21, #23, ##39, #42, #68, and #128) identified by the facility as having orders for medications being stored in the refrigerator. The census was 81. Findings include: Observation on 11/25/19 at 8:14 A.M., revealed the medication refrigerator located in the East Wing nurses' station had an internal temperature of 50 degrees Fahrenheit. Additional observation on 11/25/19 at 11:38 A.M. revealed the internal temperature of the refrigerator to be 53 degrees Fahrenheit. Resident medication found to be stored in the fridge included three Lantus insulin vials, one unopened pen of Victoza insulin, and two unopened boxes containing vials of Risperdal. Review of the daily temperature log revealed no the East Wing medication refrigerator temperature was not documented as monitored on 11/23/19 and 11/24/19. Review of the manufacturer's recommendations for Victoza, Lantus, and Risperdal revealed the medications are to be stored at a temperature between 36 degrees Fahrenheit and 46 degrees Fahrenheit prior to being opened. Interview on 11/25/19 at 11:38 A.M., with Licensed Practical Nurse (LPN) #109 confirmed the refrigerated medications were being stored at temperature above the manufacturer's recommendations. The nurse also referenced stated it is the third shift nurse's responsibility to check and record the temperature and was unsure how long the temperature of the refrigerator had been out of the recommended range. The facility identified nine residents (# 8, #13, #18, #21, #23, ##39, #42, #68, and #128) to have orders for medications being stored in the refrigerator. 365756 Page 20 of 21 365756 11/26/2019 Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policies, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 81 residents who received food from the kitchen. The facility census was 81. Findings include: Observation on 11/24/19 at 8:36 A.M. of the dry stock room revealed an open, partially used, one gallon jug of teriyaki sauce labeled by the manufacturer to refrigerate after opening. The jug was labeled as opened on 10/03/19. Interview on 11/24/19 at 8:38 A.M. with Dietary Staff (DS) #104 verified the jug of teriyaki sauce was opened on 10/03/19, stored on the dry storage shelf, and not in the refrigerator as required. DS #104 threw the partially used gallon jug of teriyaki sauce in the trashcan. Observation on 11/24/19 at 3:17 P.M. of DS #127 pureeing the dinner meal found DS #127 wearing a cowboy hat on the top of his head with no hairnet containing his hair. DS #127 also had a beard and mustache and was not wearing a beard guard. Interview on 11/24/19 at 3:25 P.M., Dietary Manager #176 verified DS #127 was not wearing a hairnet or beard guard and was preparing food. Observation on 11/24/19 at 4:26 P.M. of the dinner meal serving process revealed DS #127 was taking temperatures and plating food with no hairnet or beard guard. Review of the undated facility policy titled Dietary: Food Storage, revealed cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Review of the undated facility policy titled Dietary: Personnel Standards, revealed hairnets, covering all of the hair, must be worn at all times while on duty. [NAME] guards must be worn for facial hair over 1/4 inch long. 365756 Page 21 of 21