Health inspection·August 30, 2023

F 0600 transferred to a psychiatric hospital due to behavioral symptoms of agitation and psychosis. Level of Harm - Actual harm Review of a facility Self-Reported Incident (SRI) dated 08/22/23 related Staff Member #100 reported to the Director of Nursing (DON) at 12:55 P.M. he saw Resident #26 standing in Resident #13's room. Staff Member #100 reported Resident #26 had one hand on Resident #13's breast, on top of the sheet, and the resident's other hand was on the bed. Staff Member #100 reported Resident #26 was fully clothed at the time. Staff Member #100 told Resident #26 he was not supposed to be in that room and Resident #26 immediately left the room. Resident #26 was immediately placed on one-on-one supervision until he was transferred from the facility to a psychiatric hospital. The DON notified the administrator at 1:02 P.M. and an investigation began. The investigation noted Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, (indicating he had intact cognition). A follow up interview was performed with Resident #26 regarding the alleged incident, and he would not respond to the questions. A nursing assessment was completed, and Resident #26 displayed no signs or symptoms of injury and was at baseline for his mood and behavior. During a subsequent interview with Resident #26, he admitted to touching Resident #13's breast but stated he did nothing else. Resident #13 was not able to be interviewed. A nursing assessment was completed for Resident #13. Resident #13 displayed no signs or symptoms of discomfort and no had obvious injuries noted, no signs or symptoms of distress were noted. Resident #13 was at baseline for mood and behavior. However, there was blood seen on her sheet and on her brief. The [NAME] County Sheriff's office was called, and the Medical Director was notified. The Sheriff Deputy arrived at the scene at 2:12 P.M., assessed Resident #13, collected evidence and Resident #13 left the facility by squad at 2:55 P.M. to be transferred to the emergency room (ER) for an evaluation. Residents Affected - Few Review of the hospital ER report dated 8/22/23 at 5:40 P.M. revealed Resident #13 had vaginal blood after possible sexual assault. A sexual assault examination was performed by a nurse. Resident #13 had very rigid extremities and performing a speculum exam required the assistance of four people therefore the examining nurses did not believe an individual would be able to separate the resident's legs to have sexual intercourse. The person that was witnessed (to have been assaulted Resident #13) was not unclothed per report and had only manually grabbed her breasts. A pelvic exam was performed with a nurse, and the resident seemed to have red blood in her vaginal vault. There were no obvious lacerations or a clear source of the bleeding. Review of the signed witness statement from Registered Nurse #101 revealed on 08/22/23 at 1:00 P.M. she was called to the room of Resident #13 by the housekeeper, who stated he found Resident #26 leaning over Resident #13 beds with his left hand fondling her right breast and with his right hand over her gown, When she entered the room of Resident #13 she noticed what appeared to be blood on the sheet next to the resident's right leg, When she pulled the sheet down to perform a body check it was noted her Depend (incontinence brief) was not fastened on the right side. While unfastening the brief completely, blood was noted on the left side of the resident's brief that was bright red in color and she also had blood on her left groin area. The brief was removed and wrapped up in a Chux (disposable pad). The statement indicated the resident appeared to be in no distress. Review of the signed witness statement Staff Member #100 dated 08/22/23 at 12:50 P.M. revealed another resident told him that Resident#26 had walked into another resident's room. When he went into the room, Resident #26 had his right hand on a female resident's right breast. He stated he told Resident #26 he did not belong in that room, and he went back to his own room. Resident #13 did not show any sign of distress. Resident #26 had his left hand on the bed. Review of the signed witness statement from Social Service Director #102 dated 08/22/3 at 3:30 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365922 If continuation sheet Page 2 of 4 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 365922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 revealed Resident #26 admitted to touching the breast of Resident #13. Level of Harm - Actual harm Review of the police report dated 08/22/23 at 1:22 P.M. revealed the Sheriff's department received a call from the facility and responded. A female resident was being transported to the hospital and two pieces of evidence were collected . Residents Affected - Few On 08/29/23 at 12:00 P.M. an interview with Staff Member #100 revealed he had seen Resident #26 standing on the side of Resident #13's bed so he walked into the room so he could see him face to face and he saw Resident #13 massaging the breast of Resident #16. He stated Resident #26's other hand was on the resident's bed. He stated he told Resident #26 to stop, he did not belong in Resident #13's room and the resident left the room. He stated he had never seen Resident #26 inappropriate with anyone else. On 08/29/23 at 2:36 P.M. an interview with the DON revealed Resident #26 was admitted from another facility and had not been having any sexual behaviors at that facility. The DON stated Resident #26's niece had seen him at the other facility and Resident #26 did have some inappropriate behaviors which were care planned. The DON indicated Resident #26 would be returning to the prior facility after his current hospitalization. When asked about the possible source of the vaginal blood, the DON said Resident #13 had never had a menses prior to the incident, but the physician stated they could not rule it out. She indicated no one checked Resident #26's hands after the incident to see if there was any blood on his hands. Observation of incontinence care on 08/29/23 at 3:40 P.M. revealed State Tested Nursing Assistant (STNA) #103 and STNA #104 provided incontinence care to Resident #13 with no concerns. The resident was relaxed, and they had no issues being able to spread the resident's legs open and access her peri-area. The resident was able to open her legs about two feet apart without difficulty. An interview at this time with STNA #103 revealed that sometimes if the resident did not want you touching her, she would cross her legs and hold them together but normally there were no issues with being able to access her peri-area for hygiene. On 08/30/23 at 9:30 A.M. an interview with LPN #150 revealed the LPN was unaware of any prior issues with Resident #26 acting inappropriate, as he just walked up and down the halls, sat in the dining room or sunroom looking out the windows. On 08/30/23 at 11:00 A.M. an interview with Registered Nurse #101 revealed (following the incident on 08/22/23) she had gone into the room of Resident #13 to do an assessment and noticed blood on the resident's sheet. She stated at first, she did not know what was on the sheet because the resident had green sheets on her bed, and it was not bright red because of the sheet. She stated there was an area on the sheet that looked like someone had wiped blood off of it because it was smeared on the sheet. She stated when she pulled back the top sheet, the resident's brief was opened on the left side which was very unusual because the staff always fastened all briefs up on the residents. She stated there was bright red blood on the resident's brief and on the left side of the resident's groin. She stated it was bright red with no clots in it. She stated she assessed the resident's vagina and rectum but could not tell where the blood was coming from. She indicated she never looked at Resident #26's hand to see if he had blood on them. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016 revealed the facility would not tolerate abuse, neglect, exploitation, and misappropriation of resident property. It was the facility's policy to investigate all alleged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365922 If continuation sheet Page 3 of 4 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 365922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 violations involving abuse, neglect, exploitation, and misappropriation of resident property. Sexual abuse was defined as any nonconsensual sexual contact of any type with a resident. Level of Harm - Actual harm This deficiency represents non-compliance investigated under Control Number OH00145890. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365922 If continuation sheet Page 4 of 4