Health inspection·June 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #10 and Resident #15 was free from resident to resident sexual abuse. This finding affected two residents (Resident #10 and Resident #15) of three residents reviewed for abuse. Findings include: Review of the Self-Reported Incident Investigation (SRI) tracking number #261364 dated 06/08/25 at 1:38 P.M. revealed the nurse was advised by the Certified Nursing Assistant (CNA) that Resident #10 was in his wheelchair with his pants down while Resident #15 had his head in Resident #10's lap performing oral sex. The facility unsubstantiated the SRI for abuse. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, manic episode and depression. Review of Resident #10's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #10's Behavioral Care Plan revealed to administer medications as ordered, allow the resident to discuss his feelings, approach/speak to the resident in a calm voice, encourage the resident to attend activities of choice, provide resident privacy/re-direct the resident to his room when pleasuring himself, provide the resident with diversional activities, psych/counseling, staff to anticipate the needs of the resident, staff to provide 1:1 as needed, staff to redirect the resident as able. Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia in other diseases classified elsewhere, major depressive disorder and high-risk heterosexual behavior. Review of Resident #15's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #15's Behavioral Care Plan revealed two staff for hands on care, administer medications as ordered, offer counseling services, provide psychiatry services, redirect/educate the resident as needed. Attempted interview on 06/18/25 at 6:29 A.M. with Resident #10 and the resident was not Page 1 of 2 366231 366231 06/18/2025 Roselawn Gardens Nursing & Rehabilitation 11999 Klinger Avenue NE Alliance, OH 44601

F 0600 interviewable. Level of Harm - Minimal harm or potential for actual harm Attempted interview on 06/18/25 at 6:33 A.M. with Resident #15 and he stated he could not recall the incident of inappropriate sexual contact. The resident reported he was in the hospital when questioned where he was currently located. Residents Affected - Few Interview on 06/18/25 at 6:45 A.M. with CNA #805 revealed on 06/08/25 (Sunday) the facility had several call-offs of staff and there was one nurse and two aides for 42 residents. She stated Resident #10 was in his room and in bed and she went to check on him and found Resident #10 in his wheelchair with Resident #15 in a wheelchair near the resident performing oral sex on Resident #10. She stated the residents were separated. She could not recall anything like this happening before for these two residents and she was educated on abuse. Interview on 06/18/25 at 7:08 A.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #806 indicated she had worked on 06/08/25 but left around 11:00 A.M. prior to the incident between Resident #10 and Resident #15. LPN ADON #806 confirmed Resident #15 was a registered sex offender who had lived in the facility for over one year and Resident #10 had increased sexual behaviors but was not a registered sex offender. LPN ADON #806 denied concerns with staffing and stated Resident #15 was inappropriate with staff and says some very inappropriate sexual comments to staff. Interview on 06/18/25 at 7:43 A.M. with the Director of Nursing (DON) revealed Resident #10 had increased sexual tendencies. The DON revealed both Resident #10 and Resident #15 were placed on cimetidine (used to improve inappropriate sexual behaviors in demented residents) to try and reduce their sexual behaviors following the incident on 06/08/25. The DON denied concerns with staffing and stated the residents receive good care. The DON confirmed a sexual act occurred between Residents #10 and #15 who both had cognitive impairment. Review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy revised 01/27/23 revealed the facility would not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00166709. 366231 Page 2 of 2