Health inspection·March 25, 2024

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 review of self-reported incident (SRI), review of facility investigation, review of witness statements, medical record review, resident interview, staff interview, and review of the policy, the facility failed to timely report an allegation of abuse to the Ohio Department of Health and report the allegation to the local Police Department. This affected one (#93) of three residents reviewed for abuse. The facility census was 98. Findings include: Review of the SRI dated 03/14/24 at 1:12 P.M., for the category of sexual abuse, revealed on 03/14/24 at 1:30 A.M., a female resident, (Resident #93) reported that a male resident (Resident #70) who has dementia was in her bed. Staff witnessed Resident (#70) walking in the hallway fully clothed at the time of the allegation. Resident (#93) was noted to be lying in bed fully clothed and denied skin to skin contact. Upon further questioning, the female resident (#93) stated she thought he (Resident #70) was wanting to have sex with her. Immediately the Director of Nursing (DON) and Administrator were notified and began an investigation. Resident (#70) denied going into the room and was not able to give much information related to dementia status. The summary of incident included Resident #93 reported Resident #70 was in her bed lying on top of her and Resident #93 was able to remove Resident #70 herself easily with a verbal request. Resident #70 exited her room, when Resident #93 entered the hallway. Resident #93 found staff and reported what happened. Review of the SRI revealed the police were not notified. Review of the Witness Statement dated 03/14/24, no time, completed by State Tested Nurse Assistant (STNA) #300 revealed when she went to pass water on 03/13/24 (per DON, 03/13/24 was in error) Resident #70 was walking into his room. Resident #93 came running out of her room arms shaking and upset that a man was on top of her, he was too heavy to push off. STNA #300 asked Resident #93 who it was? Resident #93 said she did not remember his name, but he was tall, big, and black. STNA #300 took her to her room and got her to calm down enough, until STNA #300 could get the nurse. Review of the statement dated 03/14/24, no time, completed by DON, revealed an interview with Resident #93 was conducted this day 03/14/24 regarding incident at approximately 2:00 A.M. Resident #93 stated she awoke with a man lying on top of her making thrusting motions on top. Resident #93 denies any skin-to-skin contact, they were fully dressed, and no penetration occurred. Resident #93 states she was easily able to ask him to get off and he walked out of her room. She got herself up to get staff when she met STNA #300 in hallway. Resident #93 was not able to verbalize where Resident #70 was. I did not get raped. I don't feel threatened, I just don't want him around me. Spoke about how she loves the facility and feels safe. Claims Resident #70 has never sexually approached her before. (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 3 Event ID: 366024 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 366024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654 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)