Health inspection·June 12, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility Self-Reported Incident (SRI) and review of the facility policy, the facility failed to ensure comprehensive person center care plans were updated to include identified resident needs and appropriate interventions. This affected two (#48 and #60) of three residents reviewed for comprehensive care plans. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, cerebrovascular disease, essential hypertension, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 05/02/25, revealed the resident was severely cognitively impaired. Review of a facility SRI, completed on 06/05/25, revealed on 05/30/25 at 6:15 P.M. a Certified Nursing Assistant (CNA) was picking up dinner trays and entered Resident #60's room and found Resident #48 and Resident #60 in bed together, naked. The facility initiated an investigation for resident to resident sexual abuse. At the end of the investigation, the facility unsubstantiated sexual abuse. All staff were re-educated on the facility's sexual expression policy and Resident #48's care plan was reviewed and updated. Review of the care plan, revised on 06/11/25, revealed Resident #48 had impaired cognitive function or impaired thought processes due to dementia. Interventions included the resident would reach out to people to hold and kiss hands and faces. Further review revealed no additional interventions or information to address Resident #48's reaching out to people to hold and kiss hands and faces, including any needs related to sexual behavior/expression. Interview on 06/12/25 at 2:15 P.M. with the Administrator verified the investigation stated Resident #48's care plan was updated and further confirmed the resident's care plan did not include any information specific to the resident's sexual behavior/expression or interventions related to behavior identified in the SRI. 2. Review of the medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with diabetic polyneuropathy, essential primary hypertension, chronic diastolic congestive heart failure (CHF), major depressive disorder, neoplasm of prostate, and hyperlipidemia. Page 1 of 2 366039 366039 06/12/2025 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0636 Review of the MDS assessment, dated 03/18/25, revealed Resident #60 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Review of a facility SRI, completed on 06/05/25, revealed on 05/30/25 at 6:15 P.M. a CNA was picking up dinner trays and entered Resident #60's room and found Resident #48 and Resident #60 in bed together, naked. The facility initiated an investigation for resident to resident sexual abuse. At the end of the investigation, the facility unsubstantiated sexual abuse. All staff were re-educated on the facility's sexual expression policy and Resident #60's care plan was reviewed and updated. Residents Affected - Few Review of the care plan, revised on 06/02/25, revealed Resident #60 subjected behavior symptoms of verbal aggression, refusing medication, argumentative behaviors, inappropriate sexual comments related to inadequate coping skills. Interventions included to redirect the resident when he made inappropriate sexual comments. Further review revealed no additional information or interventions related to the resident's behaviors, including sexual behavior/expression. Interview on 06/12/25 at 2:15 P.M. with the Administrator verified the investigation stated Resident #60's care plan of care was updated following the facility investigation and further confirmed the resident's care plan did not include any information specific to the resident's sexual behaviors or interventions related to the incident identified in the SRI. Review of the policy, Comprehensive Care Plan, dated 11/01/24, verified the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, including measurable objectives and timeframes. The care planning process would include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. This deficiency was an incidental finding identified during the complaint investigation. 366039 Page 2 of 2