F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI), review
of the facility's investigation, and policy review, the facility failed to timely report an incident of potential
sexual abuse. This affected two (#11 and #12) of three residents reviewed for abuse. The facility census
was 81.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 08/12/15 with diagnoses of
bipolar disorder, schizophrenia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment,
dated 03/20/25, revealed Resident #11 had intact cognition. Further review of the record revealed Resident
#11 had a guardian.
Review of the current care plan, updated August 2023, revealed Resident #11 displayed behaviors of
showing interest in physical affection/intimacy with male peers.
Review of a nursing progress note dated 05/11/25 at 2:38 A.M. revealed Resident #11 was found by staff in
her room performing oral sex on a male resident. The two residents were separated.
2. Review of the medical record for Resident #12 revealed an admission date of 04/15/22 with diagnoses of
schizoaffective disorder, bipolar disorder and hallucinations. Review of the comprehensive annual MDS
assessment completed 04/16/25 revealed Resident #12 had impaired cognition.
Review of a nursing progress note dated 05/11/25 at 2:39 A.M. revealed Resident #12 was found by staff in
another resident's room receiving oral sex from a female resident. Residents were separated.
Review of SRI #260263 revealed the facility initiated the investigation on 05/12/25 at 9:30 A.M.
Review of the facility's investigation into SRI 260263 revealed witness statements were obtained on
05/10/25 from Certified Nursing Assistant (CNA) #101 and Registered Nurse (RN) #203.
Interview on 06/04/25 at 10:04 A.M. with the Director of Nursing (DON) confirmed she initiated the
investigation on 05/12/25. The DON stated the incident occurred on third shift on 05/11/25.
Interview on 06/04/25 at 10:55 A.M. with RN #203, and concurrent observation of her cell phone text
messages revealed she notified the Assistant Director of Nursing (ADON) via text of the incident between
Resident #11 and Resident #12 on 05/11/25 at 12:01 A.M. Further interview with RN #203 confirmed the
incident happened before midnight on 05/10/25 and RN #203 confirmed she and CNA #101
(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 2
Event ID:
365756
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
365756
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitehouse Country Manor
11239 Waterville St
Whitehouse, OH 43571
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 0609
completed witness statements on 05/10/25.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 06/04/25 at 11:21 A.M. with the ADON confirmed she received a text from RN #203 on
05/11/25 at 12:01 A.M. The ADON stated she did not see the message until later in the morning when she
notified the DON of the incident. Concurrent observation of the ADON's cell phone text messages revealed
she notified the DON on 05/11/25 at 10:05 A.M.
Residents Affected - Few
Two attempts to contact the DON via telephone at the facility were unsuccessful on 06/04/25 at 4:37 P.M.
and 4:52 P.M. regarding her receipt of the text message from the ADON on 05/11/25 at 10:05 A.M. and her
initiation of the SRI on 05/12/25 at 9:30 A.M., reflecting a 33.5 hour time span between the incident and the
initiation of an investigation.
Review of the policy titled, Abuse Policy, revised 01/27/23, revealed if abuse or serious bodily injury is
alleged, it should be reported to the State Agency immediately, but not later than two hours after the
allegation is made. Further review revealed the Administrator or designee will notify the State Agency of all
alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of
Resident Property and Injuries of Unknown Source as soon as possible but no later than 24 hours.
The was an incidental finding during the course of the complaint investigation/ self-reported incdent
investigation completed 06/04/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365756
If continuation sheet
Page 2 of 2
