Health inspection·June 6, 2025

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, interview, and facility policy review, the facility failed to ensure Resident #13 was free verbal and emotional abuse. This affected one resident (#13) of one resident reviewed for abuse. The facility census was 51. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, bipolar disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13's cognition was intact and she had no behaviors. Review of a social service note dated 06/03/25 at 9:40 A.M. by the Social Services Director revealed Resident #13, Activities Director (AD) #101, and Ombudsman #66 met and came up with a resolution everyone was agreeable with regarding puzzles in the activity room. Interview on 06/04/25 at 1:48 P.M. with Ombudsman #66 revealed Resident #13 had kept puzzles in the activity room for ten years since she admitted to the facility. Facility staff told Resident #13 she was no longer allowed to keep her puzzles in the activity room anymore, even though it disrupted her routine. Ombudsman #66 stated Resident #13 only requested one table be available to complete puzzles in the activity room but AD #101 argued with Resident #13 and stated she would not be told what to do in her activity room and told Ombudsman #66 you don't know how long I've put up with her. Interview on 06/04/25 at 2:30 P.M. with Resident #13 revealed she liked to do puzzles in the activity room but was told she would not be able to any longer. Resident #13 stated AD #101 yelled at her in front of everyone during an activity so she expressed her concerns to Ombudsman #66. Resident #13 stated during the conversation involving Ombudsman #66, the Director of Nursing (DON) and AD #101, the resident felt AD #101's tone of voice was very to the point, it made her feel bad, and she felt horrible being yelled at in front of her peers. Resident #13 stated she felt AD #101 was emotionally abusive and as a result of the incident she could not eat or sleep, she had anxiety, and her nerves were getting bad. Additionally, Resident #13 stated the Administrator had yelled at her for cussing at AD #101 near the nurses' station in front of the staff and other residents. Resident #13 stated she felt disrespected and undignified. During the interview, Resident #13 became tearful and stated her feelings were hurt. Interview on 06/04/25 at 3:04 P.M. with Administrator revealed he had spoken with Resident #13 near Page 1 of 5 365780 365780 06/06/2025 Marietta Heights Post Acute 5001 State Route 60 Marietta, OH 45750

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the DON's office door, across from the nurses' station, as he informed Resident #13 she could not swear at AD #101. The Administrator stated his voice was light and casual and he did not feel anyone overheard the conversation. Interview on 06/04/25 at 3:42 P.M. with AD #101 revealed she had a conversation with Resident #13, Ombudsman #66 and the DON regarding puzzles in the activity room. AD #101 stated she was quiet and listened throughout the conversation but Resident #13 began to yell at her. AD #101 stated she had said the issue was Resident #13 yelling and she was not sure what else to do. Review of a statement dated 06/02/25 from Ombudsman #66 revealed she spoke with the DON and Resident #13 about concerns regarding space for puzzles in the activity room and AD #101 was invited to join the conversation. Resident #13 was upset she would not have space for puzzles because it had been her routine for 10 years. The Ombudsman requested if one table could be made available in the activity room and AD #101 rolled her eyes, turned to Resident #13, and began arguing that she had more residents than just her to think about, and she would not hold up the activity room for puzzles. Ombudsman #66 interjected and stated Resident #13 was asking for one table and AD #101 stated Resident #13 was rude and always wanting to argue. Resident #13 stated she did not want to argue but AD #101 had been rude to her and she did not feel comfortable with her. AD #101 then told Resident #13 she was lying, and the puzzles would be removed from the activity room on 07/01/25. The Ombudsman then asked if she, AD #101, the DON and Administrator could have a conversation away from the resident due to Ombudsman #66 being uncomfortable with AD #101 arguing with the resident. Interview on 06/04/25 at 3:12 P.M. with the Director of Nursing (DON) revealed she had been talking with Ombudsman #66 and Resident #13 about the concerns with puzzles when AD #101 joined the conversation. The DON stated Resident #13 raised her voice at AD #101 and stated she felt belittled and bullied. The DON stated AD #101 had to raise her voice slightly to speak over Resident #13 who was yelling at her. The DON stated AD #101 waved her hand in a gesture towards Resident #13 and stated I can't even do my job because of this whole situation and she wasn't going to be told what to do in her office. The DON stated she did not feel the comment and gesturing was very professional and it was not the right thing to do. Review of a policy titled Abuse, Neglect, Exploitation or Misappropriation dated 2001 revealed mental and verbal abuse was the use of verbal or non-verbal conduct which causes or has the potential to cause a resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse includes verbal, written, or gestured communications, or sounds to residents within hearing distance. An example is isolating a resident from social interaction or activities. Allegation of abuse should be investigated and reported. 365780 Page 2 of 5 365780 06/06/2025 Marietta Heights Post Acute 5001 State Route 60 Marietta, OH 45750

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, and policy the facility failed to ensure an allegation of resident sexual abuse was reported to the state survey agency and the facility administrator within the required timeframes. This affected one resident (#43) of three residents reviewed for abuse. Findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia, thrombocytopenia, contractures, depression, and insomnia. Review of Resident #43's medical record revealed a psych note dated 05/14/25 that identified the resident was oriented times three and the resident's memory was intact times three. The resident had appropriate judgment concerning daily activities and social judgement, normal range of thought, and no abnormal psychotic thoughts, aware of current events, past history, and vocabulary. Resident #43 reported she had difficulty dressing due to arthritis, was toileting on her own with occasional assist if needed. Review of Resident #43's late entry progress note dated 06/23/25 for 06/20/25 at 2:00 P.M., and authored by the Director of Nursing (DON) revealed the resident self-propelled wheelchair to the DON's office and reported to the DON that a male resident (#40) came into her room while she was on the toilet and touched her inappropriately. The DON asked the resident When did this occur? and the resident stated, just now. At the time of the alleged occurrence, the male resident was observed by two Licensed Practical Nurses (LPNs) and Administrator in Training (AIT) standing at the nurses' station, going with nurse to get chocolate milk, drinking milk in the DON's doorway, and being assisted by Certified Nurse Aide (CNA) back to his room and bathroom. Social Service Designee (SSD) #112 was notified of accusations and was to speak with the resident. Resident #43 gave three different descriptions regarding the same incident (one to the nurse, one to the SSD, and one to the DON). The DON immediately started an internal investigation at which time the DON verified by staff that the accused resident (#40) had not been on the hallway or in the resident's room and several staff were assisting him over the past few hours. Resident #43 refused to go to the emergency room and stated that she knows everything is okay down there. Resident #43 refused law enforcement intervention as well. The resident's physician was updated. No new orders were received. The resident's Psychiatrist was notified. The resident's care plan was reviewed and updated. Review of Resident #43's social service note authored by SSD #112 dated 06/20/25 at 4:18 P.M., revealed the resident was making false accusation against a male resident (#40). Accusations were of a mature nature. Resident talked about the male resident coming into her room and touching her inappropriately while she used the bathroom. Review of Resident #43's plan of care for paranoia and unrealistic fears dated 01/26/25 and updated 06/23/25 revealed the resident believed staff were hurting her. On 06/23/25 the care plan was updated to reflect the resident was noted to accuse staff of being inappropriate with her when providing care and also noted to accuse residents of being inappropriate with her. The new intervention was to add a Velcro stop sign to the door. Review of Resident #40's medical record revealed the resident was admitted to the facility on 365780 Page 3 of 5 365780 06/06/2025 Marietta Heights Post Acute 5001 State Route 60 Marietta, OH 45750

F 0609 Level of Harm - Minimal harm or potential for actual harm [DATE] with diagnoses including dementia, disorientation, adjustment disorder with anxiety, antisocial personality disorder, and cognitive communication deficit. Review of Resident #40's progress notes revealed the resident had resided on the secure unit until 03/01/25 when the resident was moved to the 400 hall due to the secure unit being closed. Residents Affected - Few Resident #40's medical record revealed the following: On 04/17/25 the resident was referred to psych services for inappropriate sexual behaviors. Review of Resident #40's psych services note dated 04/17/25 revealed the resident was seen for increased sexual behaviors. He was observed kissing staff on the check. The resident had a history of domestic violence and felonious assaults. The resident has two sons but no contact with them. The resident had abnormal thoughts, unable to abstract reason, violent impulses, poor behavior judgement and insight, impaired cognition, attention span, and concentration. On 06/03/25 the resident's physician ordered monthly Depo-Provera 300 milligrams (mg) injection for hypersexuality was not administered due to the medication was not available. (Review of the resident's medication administration record revealed that as of 06/24/25 there was no evidence the resident had received the Depo-Provera injection). On 06/09/25 the resident was observed wandering in other resident rooms. On 06/14/25 a female resident (unidentified) reported to nursing that Resident #40 had walked into the room without knocking as the female resident was in the process of changing her pants. The female resident reported it took several verbal attempts to get the resident to leave the room. The male resident had been going from exit door to exit door throughout the day, also had been seen entering multiple resident rooms. Redirection to little effect. The DON was made aware. On 06/15/25 the nurse was passing medication when the nurse heard a resident's family (unidentified) ask the resident to leave the room. Resident #40 had to be re-directed three times. Also reported by other residents he had entered rooms and would not leave. Staff were asked to shut door so this resident would not enter rooms. Resident states he made me nervous. On 06/22/25 Resident #40 wandered into several resident room and had to be redirected out. Interview on 06/24/25 at 9:50 A.M., with Resident #43 revealed Resident #40 wanders in people's rooms. Resident #43 reported she was frequently incontinent of urine due to she was taking medication that caused her to go more frequently, and Resident #40 was like a magnet and came in her room frequently when she was changing. Resident #43 reported she couldn't remember the exact date, however around a week ago Resident #40 came into her room while she was in the bathroom and he asked her if she needed help with her pants. She told him no and he came in anyways and tried to pull up her pants and wiggled his fingers over her private areas. Resident #43 confirmed she told nursing staff, the DON, and SSD. Resident #43 reported she doesn't feel safe with him around. The resident (#40) was starting to become more aggressive, and he had started going through her things. There was other residents concerned as well, including Resident #34. The staff had put a stop sign across her door this week and room [ROOM NUMBER]. The resident in room [ROOM NUMBER] can't defend himself, but she told staff they better do something because someone was going to get hurt and it wasn't going to be her. Interview with Resident #34 on 06/24/25 at 9:52 A.M. confirmed Resident #40 wanders the hallways 365780 Page 4 of 5 365780 06/06/2025 Marietta Heights Post Acute 5001 State Route 60 Marietta, OH 45750

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and enters resident's rooms uninvited. The resident had been known be inappropriate with female residents. Resident #40 had tried to enter her room several times, but she tells him to go away and eventually he will leave. Resident #40 had been observed urinating in the hallways. Resident #34 reported she felt safe because she could defend herself if needed. Interview on 06/24/25 from 6:58 A.M. to 3:00 P.M., with anonymous Staff Members #140 and #145 confirmed Resident #40 had touched Resident #43 inappropriately last week and nothing was done or charted until yesterday (06/23/35). Resident #40 had attacked another female resident while in the female resident was in bed and management tried to sweep everything under the rug. The anonymous staff members reported there weren't enough staff to keep residents safe and provide adequate care. Interview on 06/24/25 at 8:52 A.M., with the DON and Administrator revealed there had been no allegations of abuse reported from 06/20/25 to 06/24/25. Interview on 06/24/25 at 10:39 A.M., with the DON confirmed she didn't report the allegation of abuse to the state agency due to after interviewing staff Resident #40 was not observed around Resident #43 at the time the resident alleged the incident occurred. The DON confirmed she didn't interview other residents on the hall, and she only had statements from two staff members and the Administrator in Training. The DON reported that the Certified Nursing Assistant (CNA) working on the hall last Friday (06/20/25) was working today and she could have her write a statement. The facility did not have a timeline of events, but the DON reported Resident #43 had reported the incident originally to the floor nurse and the floor nurse had the resident come and speak to her around 3:30-4:00 P.M., then she had the SSD follow-up with the resident. The DON confirmed the allegation should have been reported to the state agency within 24 hours. Interview on 06/24/25 at 2:10 P.M., with SSD #112 confirmed he spoke to Resident #43 after the alleged incident and didn't feel like the incident occurred due to the resident (#40) had never had inappropriate behaviors in the past. This surveyor reviewed Resident #40's medical record with SSD #112 that indicated in April (2025) the resident was referred to psych services for inappropriate sexual behaviors and on 06/14/25 there was documentation the resident was in a female resident's room while she was trying to change and on 06/15/25 the resident was in two residents' rooms and the family had asked the resident to leave one of them. SSD #112 reported he was not aware of those incidents and the surveyor would have to speak to the DON. SSD #112 confirmed he was directed to interview the resident (#43) today and he believed the facility administrator was going to submit the self-reported incident today. Interview on 06/24/25 at 2:17 P.M. with the DON confirmed she was not aware Resident #40 was referred to psych services in April 2025 for inappropriate behaviors. The DON stated she was not aware of the incident on 06/14/25 and 06/15/25 when the resident was documented being in other residents' rooms. Review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 2001 revealed resident had the right to be from abuse, neglect, misappropriation of resident property and exploitation. The facility would identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within time frames required by federal requirements. Protect residents from any further harm during investigation. 365780 Page 5 of 5