Health inspection·June 12, 2025

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, resident and staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the police report, policy review, and review of the Sexual Assault Nurse Examiner (SANE) exam, the facility failed to ensure a resident was free from sexual abuse. Actual Harm occurred to Resident #71 when Resident #88 sexually assaulted Resident #71, leaving Resident #71 with internal injuries after the sexual assault and psychosocial harm when Resident #71 had significant decline in her mental condition with increased anger, depression, and scared, disclosed a history of sexual trauma, and reported flashbacks, nightmares, and increased anxiety triggered by a male resident (Resident #88). The facility census was 85. Findings include: Review of the medical record for Resident #71 revealed an admission date of 09/08/22 with diagnoses including cerebral palsy, intellectual disabilities, schizoaffective disorder bipolar type, psychosis not due to a substance or known physiological condition, major depressive disorder recurrent moderate, generalized anxiety disorder, and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. Resident #71 had moderate symptoms of depression, and verbal behavioral symptoms were noted one to three days during the look-back period. Resident #71 required extensive to total assistance from staff with most activities of daily living, including hygiene, dressing, toileting, and transfers. Review of the care plan for Resident #71 revealed she has a past traumatic event of exposure to sexual assault (rape/attempted rape/made to perform any type of sexual act through for or threat of harm/other unwanted or uncomfortable sexual experiences). Interventions included monitoring for residual emotional effects Review of the progress notes revealed on 05/08/25 at 12:41 P.M., Resident #71 reported to Certified Nursing Assistant (CNA) #115 that a male resident (Resident #88) had sexually assaulted her. The nurse immediately assessed Resident #71, who confirmed the allegation, stating the male resident had touched her inappropriately and against her will. A CNA remained with Resident #71 while the nurse reported the incident to facility management. Page 1 of 4 366199 366199 06/12/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0600 Level of Harm - Actual harm Residents Affected - Few The social services note dated 05/08/25 at 1:00 P.M. revealed Resident #71 stated she felt safe in the facility, especially knowing the male resident (#88) was placed on one-on-one supervision. She expressed fear about being transferred to another facility, as she had lived there for over 20 years. She was resting comfortably, watching television, and was aware that emergency medical services (EMS) would arrive soon to transport her to the hospital per her request. The progress note dated 05/08/25 at 3:20 P.M. revealed Resident #71 was transferred to the hospital for a sexual assault kit and further evaluation. The progress note dated 05/08/25 at 9:55 P.M. revealed Resident #71 returned from the hospital and was transferred to bed with staff assistance. The resident was crying, requested as needed anxiety medication, and expressed fear about the male resident (#88) still being in the facility. She stated she never wanted to see him again. Review of the facilities SRI control number 260173 dated 05/08/25 revealed Resident #71 alleged a male resident (#88) touched her inappropriately and wanted it reported to the police. Resident #71 reported Resident #88 had attempted to put his hand under her shirt and had touched her genital area. Resident #88 denied the incident occurred. Review of the police report for Resident #71 dated 05/08/25 revealed the related offense was gross sexual imposition of substantial impairment. Resident #88 (alleged assailant) denied anything happened then stated he went into Resident #71's room to just talk. Resident #88 stated that he would never do anything like that, knowing Resident #71's condition (unable to move from her waste down). Resident #88 stated that this was his second time he has been accused of this. Resident #71 stated Resident #88 came into her room asking for a relationship with her and Resident #71 did not know what that meant. Resident #88 stuck his fingers in her vagina and then groped her breast. Resident #71 told Resident #88 no but Resident #88 continued to do it anyway. Resident #71 began to cry and stated she shouldn't have to feel scared living in her home because of this incident. Review of the SANE exam conducted on 05/08/25 for Resident #71 (State Survey Agency received on 06/06/25) revealed there was vaginal penetration by assailant's fingers completed by direct visualization from the examiner. There were mild abrasions showed with Toluidine blue dye application (a diagnostic tool used to highlight microscopic tears or abrasions on the genital or anal areas that may not be visible to the naked eye). Resident #71 reported in the examination that she was lying in her bed in her room between 7:00 A.M. and 8:00 A.M. Resident #71 stated she was eating a bagel with cream cheese and Resident #88 entered her room and they were talking. Resident #88 stated 'I would like to do some stuff with you' and wanted Resident #71 to date Resident #88. Resident #71 responded maybe we will just watch television or something. Resident #71's roommate was in the room sleeping and Resident #71 didn't want to interrupt her roommate's sleep. Resident #71 told Resident #88 that they cannot do anything as her was roommate was sleeping and Resident #71 did not feel well and was not going to get out of bed that day. Resident #88 stated to Resident #71 that she did not have to get up and Resident #88 will return to her room later. Resident #71 felt better after she ate and Resident #88 returned to her room. Resident #71's roommate was not in the room and staff were also not in her room. Resident #88 asked Resident #71 if she was feeling better and Resident #88 replied that she was feeling better. Resident #88 stated Resident #71's roommate was not in the room so they can be alone now. Resident #88 proceeded to put his hands down Resident #71's adult brief and put his fingers in Resident #77's vagina. Resident #71 said Ouch, that hurts, stop that. I don't like that.Resident #88 stopped after that. A CNA (#115) walked into Resident #71's room and saw Resident #88's chair and said get out of the room. The CNA asked Resident #71 how long Resident #88 was in her room. 366199 Page 2 of 4 366199 06/12/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0600 Level of Harm - Actual harm Residents Affected - Few Resident #71 was unable to see her clock and couldn not state how long Resident #88 was in her room. The CNA said it was 45 minutes when she was last in Resident #88's room. The CNA said Resident #88 has been doing this to all the women, and told Resident #71 she needed to press charges. The police came to the facility and Resident #71 talked to the police to press charges and then the police brought Resident #71 to the hospital for a sexual assault kit. The social services note dated 05/09/25 revealed Resident #71 agreed to resume counseling services. Review of psychiatric progress notes revealed on 05/06/25, Resident #71 reported a good mood with no signs of depression, anxiety, psychosis, or suicidal ideation. However, following a SRI incident, the 05/20/25 the progress note documented a significant decline in her condition-she described feeling angry, depressed, and scared, disclosed a history of sexual trauma, and reported flashbacks, nightmares, and increased anxiety triggered by a male resident. A treatment plan was developed, and she agreed to initiate low-dose Ativan (treats anxiety) and Prazosin (treats PTSD-associated nightmares). By 06/03/25, her symptoms had improved; she described her mood as good, denied depression, anxiety, or hallucinations, and noted that scheduled Ativan had reduced her anxiety. Staff also observed an improved mood, reduced anxiety, and continued medication compliance with no signs of psychosis or worsening symptoms. Prior interview on 05/19/25 at 2:52 P.M. with Resident #71 reported Resident #88 came into her room just to talk initially then began to touch her breast and told Resident #88 to stop and didn't want to be touched. Resident #88 continued to sexually abuse her and put his hands down her adult brief and Resident #71 yelled stop. A CNA (#115) came into her room and Resident #88 then stopped. Interview on 06/10/25 at 7:45 A.M. with Assistant Director of Nursing (ADON) #183 stated Resident #88 no longer resided in the facility and was transferred out on 06/02/25. Interview on 06/10/25 at 9:48 A.M. with Director of Nursing (DON) revealed Resident #88 was on one-on-one supervision after the incident until he was transferred to another facility. Interview on 06/10/25 at 10:37 A.M. with CNA #115 revealed she had been walking down the hall when she observed a wheelchair outside of Resident #71's room. CNA #115 entered the room and saw Resident #88's hand near Resident #71's waist. Resident #71 stated they were not doing anything. CNA #115 asked Resident #88 to leave Resident #71's room. Then Resident #71 reported that Resident #88 had been playing with her breast and sticking his hands down her pants. Interview on 06/10/25 at 11:08 A.M. with Resident #75 revealed she and other female residents were on edge with Resident #88 being in the building and were happy when they put him on a 24-hour watch and eventually transferred to another facility. Review of the facilities Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 11/01/19 revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. As a result of the incident, the facility took the following action to correct the deficient practice by 06/02/25: • 366199 Page 3 of 4 366199 06/12/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0600 On 05/08/25, Resident #88 was placed on 1:1 supervision to prevent him from entering any rooms, Level of Harm - Actual harm • Residents Affected - Few On 05/08/25, a SANE exam was completed. • On 05/08/25 a Police report was filed and investigation was ongoing as of 06/16/25. • Counseling services started with Resident #71 on 05/20/25. • Resident #88 was transferred to another facility as of 06/02/25. • All staff abuse education and resident rights training was completed on 05/29/25 and 06/02/25. This deficiency represents non-compliance investigated under Complaint Number OH00165920. 366199 Page 4 of 4