Health inspection·July 10, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview, the facility failed to prevent a potential incident of resident-to-resident sexual abuse for Resident #44. Actual harm occurred on 06/24/23 at 2:45 P.M. when Resident #25 was found lying in bed on top of Resident #44 in a physical manner that was sexual in nature, but which Resident #44 had not consented to. As a result of the incident, Resident #44 voiced pain and fearfulness and was transferred to the hospital for examination. This affected one resident (#44) of six residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #44 revealed an admission date of 05/04/23 with diagnoses including seizures, anemia, myocardial infarction, hypothyroidism, depression, anxiety, and history of a traumatic brain injury due to aneurysm. Review of Resident #44's plan of care, dated 05/22/23 revealed Resident #44 was on antipsychotic medication and medication should be given as ordered. The care plan was silent from any noted behavioral issues or accusatory behaviors until an entry was made on 06/30/23 indicating Resident #44's aunt reported Resident #44 had a history of making false allegations of sexual assault by men and promiscuity. Review of Resident #44's Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 06/03/23, revealed Resident #44's Brief Interview for Mental Status (BIMS) assessment indicated she had severely impaired cognition with a BIMS score of zero out of 15. The assessment revealed Resident #44 was dependent on one staff member for bed mobility, transfers, and ambulation. The assessment also noted the resident was able to be understood by others and others were able to understand her. There were times when staff had difficulty understanding Resident #44 due to her only being able to speak in whispered tones. Review of Resident #25's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 07/03/23. Resident #25 had diagnosis including epilepsy, hyperlipidemia, mild intellectual disabilities, other psychoactive substance dependence, cocaine dependence, paranoid schizophrenia, alcohol use, and history of a traumatic brain injury (TBI). Review of Resident #25's annual MDS 3.0 assessment, dated 06/28/23, revealed Resident #25 had Page 1 of 9 365834 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0600 intact cognition and was aware of all the decisions he was making. Level of Harm - Actual harm Review of Resident #25's medical record revealed no evidence of sexually inappropriate/sexually abusive behaviors involving the resident prior to 06/24/23. Residents Affected - Few Review of an incident report dated 06/24/23 at 2:45 P.M. authored by Director of Nursing (DON) #308 revealed the charge nurse (Registered Nurse (RN) #324) walked into Resident #44's room to find a male resident (Resident #25) lying on her. The male resident was removed from the room. Resident #44 was clothed in a hospital gown and brief and the male resident was fully clothed in a white t-shirt and blue shorts. Resident #44 was asked by RN #324 what happened and Resident #44 just smiled and continued to have a grin on her face. The RN assessed Resident #44 and found no visible signs of injury and sent her to the local emergency room after contacting the physician. Resident #44's aunt was notified at 4:00 P.M. In the section other info on the document it was noted by DON #308 that Resident #44's aunt reported Resident #44 had a history of being promiscuous when she lived at Mill House. Review of a nursing progress note, dated 06/24/23 at 3:20 P.M. and authored by RN #324, revealed RN #324 found Resident #44 laying in bed with another resident assigned to adjacent hall. Resident assessed; no physical injuries noted. IDT (interdisciplinary team) notified, and resident sent to the emergency room. Review of a document from the local ([NAME]) Fire Department revealed a Pre-Hospital Care Report Summary, dated 06/24/23 at 3:17 P.M. which indicated an emergency call was dispatched to the fire department at 3:09 P.M. for a sexual assault. Staff arrived at the facility at 3:17 P.M. Upon arrival to the facility, Resident #44 was found sitting in a wheelchair at the front desk and was alert to the arrival. Resident #44 was stating a male resident penetrated her vagina with his hands and penis lasting five to 10 minutes before anyone came into the room. Resident #44 complained of genital pain. The report noted the staff had changed the resident out of the original clothing she was wearing. Resident #44 was able to communicate verbally as well as typing on an iPad. She was alert to the event, person and place but not oriented to the time. Review of a Criminal Case Report Summary provided by local law enforcement revealed on 06/24/23 at 3:10 P.M. the police were called to the facility for a resident-to-resident sexual assault. Upon arrival [NAME] paramedics were standing at the nurse's station with Resident #44. The suspect (Resident #25) was in the lobby with the nurse. The [NAME] fire department transferred Resident #44 to the hospital for assessment (sexual assault kit). An interview with RN #324 reported he was making rounds and noticed Resident #44's door was shut, and it concerned him because it was not normal for the resident to have her door shut. When he opened the door, he found Resident #44 laying on her back in bed and Resident #25 laying on top of her. He stated they were laying face to face and Resident #25 had his hands beside Resident #44 on the bed holding himself up. Resident #25 was wearing a white t-shirt and blue shorts which were up around his waist and his genitals were not exposed. Resident #44 was wearing a hospital gown and brief and there was no exposure of her breast or genitals. The brief and gown were in place. RN #324 said he had Resident #25 leave the room and placed Resident #25 on one-to-one observation. Resident #25 looked shocked like he had been doing something he should not have been doing. RN #324 then spoke with Resident #44 who told RN #324 it was not consensual. RN #324 had another nurse come in to assess Resident #44 while he made notifications to supervisors, ambulance and the police. The nurses took Resident #44 out to the nurse's station for one-to-one observation while waiting for the fire department and police to arrive. Additional information on the police report included an interview with State Tested Nursing 365834 Page 2 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0600 Level of Harm - Actual harm Assistant (STNA) #379 who reported hearing RN #324 yell get the (expletive) off her so she went to see what was going on. STNA #379 then saw Resident #25 walk out of Resident #44's room and adjusting his shorts. STNA #379 said she asked Resident #44 what happened and Resident #44 told her Resident #25 touched her and she did not want him to because she did not know who he was. Residents Affected - Few The police report continued with a statement from STNA #333 who reported being with Resident #25 after the incident. Resident #25 told her he was walking down the hall and Resident #44 motioned for him to come in, patted the bed and told him to lay down. He got on top of her, and they had sex. STNA #333 asked him if he put his penis in her and he replied no they just had sex. STNA #333 said she did not know what he meant by that. The police also collected statements from Resident #44. When asked if she was able to talk about what happened she replied, not really. She affirmed she was touched with the penis and hands in her genital area. When asked by who she was touched she pointed towards the 200 hall and said, by him. It was noted each response was said loudly and not in a whisper which was her usual speaking tone. The police questioned Resident #25 who reported Resident #44 motioned for him to go in her room because she can't talk or nothing and he got on top of her, but they did not have sex. The report noted Resident #25 had diagnosis of mild intellectual disability, paranoid schizophrenia, cognitive communication deficit and traumatic brain injury. Review of a facility self-reported incident (SRI), dated 06/24/23 at 4:23 P.M. and completed 06/30/23 at 3:52 P.M. revealed the facility reported and investigated this incident of resident to resident abuse. Details of the SRI included a nurse finding both residents fully clothed with Resident #25 laying on top of Resident #44 face-to-face in the bed. Resident #44's aunt reported Resident #44, when caught having sex, had a history of claiming sexual assault. The aunt added Resident #44 had a known history of sexual promiscuity and had multiple incidents prior to being admitted to the facility. Resident #25 denied the allegation and Resident #44 just smiled and kept grinning when asked what had happened. Resident #44 was sent to the emergency room as a precaution. Witness statements were obtained from RN #324 who found the residents in bed together. The facility investigation did not contain a witness statement from STNA #379 who spoke with Resident #44 immediately following the incident and who cleaned Resident #44 before going to the emergency room. Therefore, the surveyor found the investigation to be incomplete. Due to alleged sexual assault incident, Resident #25 was placed on one-on-one supervision until he was seen by Physician #386 on Monday 06/26/23. One on One supervision was discontinued on 06/26/23 with no other changes made to the resident's plan of care. Observations made at various times throughout the survey from 06/27/23 through 07/06/23 revealed Resident #44 was a frail woman with very thin upper extremities with limited range of motion and unable to raise her arms very high or for long periods of time. Resident #44 was to receive nothing by mouth (NPO) and utilized a gastrostomy tube (G-Tube) for all meals and medication. She was able to smoke with supervision and with assistance by staff to light her cigarette. She was observed sitting at the nurse's station during most of the observations made, so she was in constant eyesight of staff. Attempts to interview Resident #25 on 06/29/23 at 11:45 A.M. were unsuccessful as the resident refused to talk with the surveyor. 365834 Page 3 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0600 Attempts to interview Resident #44's aunt were made on 06/29/23 at 11:59 A.M. and 07/05/23 at 10:00 A.M. which were unsuccessful. Level of Harm - Actual harm Residents Affected - Few On 06/29/23 at 3:30 P.M. Resident #25 was observed sitting in the front lobby by himself and staring at Resident #44 who was sitting by the nurse's station. There were no staff present in the area at that time. Resident #44 appeared to be nervous, with a scared look on her face, and when asked by the surveyor if she felt safe, she stated no because Resident #25 was staring at her and there were no staff around. On 06/29/23 at 4:10 P.M. interview with Resident #44 revealed she was alert and oriented to person, place, time and able to carry on a reciprocal conversation with the surveyor answering both open ended and close ended questions simple to complex. During the interview, Resident #44 stated she was sexually assaulted by Resident #25. She was able to provide Resident #44's name and information regarding the incident that took place on 06/24/23. Resident #44 stated she did not feel safe in the facility if she had to be around Resident #25 without staff present. She stated she was intimidated by Resident #25. Resident #44 stated Resident #25 physically inserted his penis in her, and physically touched her breasts and kissed her. She stated he was in her room too long, she stated he shut the door when he entered the room. She stated he took her brief off enough to insert his penis, and then moved it back when he was done. She also stated she was not washed when the STNA changed her clothing and brief. Resident #44 stated she did not tell or waive for Resident #25 to come in her room, he just came in and shut the door. Resident #44 stated she tried to push him away but does not have the upper body strength to do so and was unable to scream for help due to not being able to speak above a whisper. Interviews conducted throughout the survey from 06/27/23 through 07/07/23 with RN #324 revealed he was working on 06/24/23 and the nurse for Resident #44. He stated he was passing medications to other residents on the 100 hall and when he came back into the hallway, he saw Resident #44's door was shut, which it never was and when he opened the door, he observed Resident #25 laying face to face on top of Resident #44. He admitted to yelling at Resident #25 to Get the (expletive) off of her and leave, Resident #25 was startled and left in a hurry while he was fixing his blue shorts. RN #324 stated he immediately went to the nurse's station and notified the DON, Administrator, Resident #44's family, the physician, and the police. Interview on 07/05/23 at 12:33 P.M., with the local hospital staff Sexual Assault Nurse Examiner (SANE) RN #386 revealed upon arrival to the hospital, Resident #44 was able to consent for the sexual assault exam and stated she was alert and oriented to person, place, time and situation. She was dressed in a hospital gown and had on a brief that was wet with urine, she stated there were no obvious signs of sexual assault, such as cuts, scrapes, or bruising, however she stated Resident #44 named Resident #25 as the alleged perpetrator and she stated he put his penis in her vagina. SANE RN #386 stated Resident #44 said she did not want Resident #25 to do this and was not able to tell him to stop or to push him away due to poor upper body strength and the inability to yell. Interview on 07/05/23 at 2:13 P.M. with STNA #379 revealed on 06/24/23 she was coming out of another resident's room and heard RN #324 yelling for Resident #25 to get off Resident #44. She then saw Resident #25 come out of Resident #44's room and was walking down the hallway adjusting his shorts. STNA #379 stated she then entered Resident #44's room and began to get the resident ready to go to the emergency room. STNA #379 revealed she did not clean her up, she just took the brief which was wet with urine and placed it in a plastic bag and set to the side but did not wash the resident off in any way. The resident was dressed in a new gown and brief. STNA #379 stated Resident #44 said she 365834 Page 4 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0600 Level of Harm - Actual harm Residents Affected - Few was ok but did not know Resident #25 and did not want him in her room. STNA #379 stated she asked Resident #44 if Resident #25 touched her down there and she answered yes. STNA #379 stated the brief she removed was moved to the side to expose Resident #44's genital area. As of 07/10/23 the results of the rape kit collected by the SANE RN #386 were not available for review by the State agency surveyor. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed sexual abuse was defined as any non-consensual sexual contact of any type with a resident. This deficiency substantiates Complaint Number OH00144113, OH00144073, and OH00144016. 365834 Page 5 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for Resident #2, #20 and #48. This affected three residents (#2, #20 and #48) out of four residents reviewed for mental health services. The facility census was 49. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 11/27/22 and diagnoses included major depressive disorder and bipolar disorder. Review of the care plan, dated 11/29/22, revealed Resident #48 used antidepressant medication related to depression diagnosis with an intervention to provide psychiatric/psychological consult as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23, revealed Resident #48 felt down, depressed or hopeless seven to 11 days. Review of the quarterly MDS 3.0 assessment, dated 06/02/23, revealed Resident #48 was cognitively intact and felt bad about self, had thoughts she would be better off dead, or could hurt self 12 to 14 days which showed an overall decline since the MDS assessment dated [DATE]. Review of the Psych 360 counseling progress note, dated 05/03/23, revealed the purpose of the psychotherapy counseling for Resident #48 was for depression management. Resident #48 had shown some backsliding since baseline and was engaged in counseling for supportive mental health services to sustain mental health. The plan was to proceed with weekly session of individual cognitive behavioral treatments. There were no further counseling progress notes from Psych 360 after 05/03/23. Review of the facility service agreement for psychotherapy services revealed a new consultant service agreement was entered into as of 04/24/23 with Psycho Social Therapies Ltd with the facility and the consultant would provide medically necessary behavioral health services to the facility's residents. Review of the document titled Consent to Treatment, signed by Resident #48 on 05/12/23 revealed Resident #48 voluntarily requested for Psycho Social Therapies Ltd to provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the service was to achieve important benefits including a decrease in mental health symptoms, and improved ability to cope with stressors, improved relationships, and overall well-being Review of the 06/05/23 Physician Assistant progress note revealed Resident #48 admitted her mood was sad and had been having issues with her son. Resident #48 attributed her depressed mood and anxiety over wanting to get out of the facility. Resident #48 denied any suicidal intentions. Resident #48 reported her sleep was poor and her energy level was terrible. Nursing reported Resident #48 had a very depressed mood. The plan was to increase Buspar (antianxiety) to 10 milligram (mg) twice a day and increase Amitriptyline (antidepressant) to 50 mg before bedtime for worsened anxiety and 365834 Page 6 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0740 depression and to add Vistaril (antianxiety) 25 mg every six hours as needed for breakthrough anxiety. Level of Harm - Minimal harm or potential for actual harm Review of physician orders for Resident #48 revealed on 06/05/23 an order for Amitriptyline HCI 25 mg give 25 mg at bedtime was discontinued , an order for Amitriptyline 25 mg give 50 mg at bedtime was started, buspirone HCI tablet 5 mg give one tablet by mouth two times a day was discontinued, buspirone HCI tablet 5 mg give two tablets by mouth two times a day was started, and an order for hydroxyzine pamoate capsule 25 mg give one capsule every six hours as needed for 14 days was written. Residents Affected - Few Further review of the medical record for Resident #48 revealed there was no evidence supportive mental health counseling services by a licensed clinical counselor or licensed social worker were provided from 05/04/23 to 07/05/23. Interview on 07/06/23 at 8:14 A.M. with Resident #48 revealed she had been seeing a counselor and didn't understand why the counseling sessions had stopped. Resident #48 confirmed she felt better when she had talked with a counselor and wished the sessions had continued. Resident #48 stated she had anxiety issues and have been talking with her friends instead. 2. Review of the medical record for Resident #20 revealed an admission date of 09/14/21 and diagnoses which included quadriplegia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, and major depressive disorder. Review of the 04/14/23 quarterly MDS 3.0 assessment revealed during the previous two weeks of the assessment reference period, for seven to 11 days, Resident #20 showed little interest or pleasure in doing things, had trouble falling or staying asleep or slept too much, felt tired or had little energy, and had a poor appetite or was overeating. Review of 05/10/23 Psych 360 counseling progress note revealed Resident #20 had been receiving counseling services to address the problems of depression and low self-esteem. Resident #20 had shown some backsliding in the severity of depression since baseline. The plan was to proceed with weekly sessions of individual cognitive behavioral treatments. There were no further counseling progress notes from Psych 360 after 05/10/23. Review of document titled Consent to Treatment, signed with an X by Resident #20 and witnessed by SSD #343 on 05/12/23 revealed Resident #20 voluntarily requested that Psycho Social Therapies Ltd provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the services was to achieve important benefits, including a decrease in mental health symptoms, an improved ability to cope with stressors, improved relationships, and overall well-being. Review of 05/22/23 Physician Assistant progress note from Psycho Social Therapy Ltd revealed Resident #20 reported her mood was iffy and admitted to feeling depressed from missing her kids. Resident #20 admitted to general feelings of anxiety, poor appetite and sleep. The plan was to increase Remeron (an antidepressant) to 30 milligrams before bedtime for improvement of sleep and appetite. Review of Resident #20's physician orders revealed on 05/22/23 Mirtazapine (Remeron) was increased from one 15 milligram tablet to one 30 milligram tablet before bedtime. Further review of medical record for Resident #20 from 05/11/23 to 07/06/23 revealed there was no 365834 Page 7 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0740 evidence Resident #20 had received counseling services. Level of Harm - Minimal harm or potential for actual harm Interview on 06/28/23 at 12:08 P.M. with Resident #20 revealed she would like to speak with someone since Resident #20 felt she was depressed. Resident #20 confirmed her counseling sessions had stopped in May 2023. Residents Affected - Few 3. Review of medical record for Resident #2 revealed an admission date of 08/21/21. Diagnoses included Parkinson's disease, depression, and anxiety disorder. Review of 06/29/22 care plan revealed Resident #2 had a mood problem related to the diagnoses of depression and anxiety with interventions which include behavioral health consults as needed. Review of 10/10/22 Patient Health Questionnaire (PHQ) assessment, a multipurpose instrument for screening, diagnosing, monitoring, and measuring the severity of depression, revealed over the previous 14 days, Resident #2 had felt down, depressed, or hopeless never or one day. Review of 03/31/23 annual MDS 3.0 assessment revealed Resident #2 was cognitively intact, felt down, depressed, or hopeless two to six days over the fourteen day look back period for the assessment, and received seven days of antianxiety and antidepressant medications. Review of 04/26/23 Psych 360 counseling note revealed the severity of her nervousness was at baseline and Resident #2 needed the emotional support counseling provided to sustain mental health and weekly sessions would continue. Review of 05/03/23 Psych 360 counseling note revealed Resident #2 was hospitalized so no service was rendered. Review of document titled Consent to Treatment, signed by Resident #20 on 05/12/23 revealed Resident #2 voluntarily requested that Psycho Social Therapies Ltd provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the services was to achieve important benefits, including a decrease in mental health symptoms, an improved ability to cope with stressors, improved relationships, and overall well-being. Review of the 06/30/23 Patient Health Questionnaire (PHQ) revealed over the previous 14 days Resident #2 had felt down, depressed, or hopeless and had poor appetite or overate seven to 11 days. Further review of Resident #2's medical record revealed no evidence counseling services were provided from 04/27/23 to 07/05/23. Interview on 07/06/23 at 8:24 A.M. with Resident #2 revealed she felt better when she had been receiving counseling services and had not received counseling services from the new company. Interview on 06/28/23 at 4:39 P.M. with Social Services Designee (SSD) #343 regarding counseling services for Resident #2, #20 and #48 revealed there was a change in which company would be providing psychotherapy and psychiatry services. The facility had been using Psych 360, which provided someone to manage medications and someone to provide psychological counseling services. The SSD #343 verified Psycho Social Therapy Ltd had not sent any counselor or licensed social worker to provide counseling services since Psych 360 stopped providing services in May 2023. 365834 Page 8 of 9 365834 07/10/2023 Majestic Care of Kent 1290 Fairchild Avenue Kent, OH 44240

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/29/23 at 10:10 A.M. with the Administrator confirmed Psycho Social Therapy company had not sent any counselors out but were supposed to provide those services to the residents who needed it. Interview on 07/05/23 at 4:08 P.M. with the Administrator confirmed the new company had not provided counselors, and she had been under the understanding that the person who was managing medications was also counseling. The new company had been trying to obtain a counselor to provide counseling at the facility. Interview on 07/06/23 at 12:19 P.M. with Licensed Independent Social Worker (LISW) #382, who worked for Psycho Social Therapy LTD, revealed the nurse practitioners and physician assistants provided the psychiatry medication management services, and the LISWs provided the counseling services for Psycho Social Therapy LTD . LISW #382 confirmed 07/06/23 was the first day this company had provided counseling services for the facility residents, and LISW #382 planned to provide counseling services bi-weekly. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144060. 365834 Page 9 of 9