Shea Post Acute Rehabilitation Center

Based on record review and staff interviews, the facility failed properly maintain doors. Failure to properly maintain maintenance could lead to harm to residents and staff in the event of an emergency.

Based on clinical record review, facility documentation, policy review and interviews, the facility failed to ensure two residents (#71 and #51) were free from abuse from other residents ( #263 AND #261). Findings include: Regarding Resident #51 and #261: - Regarding Resident #51: Resident #51 was admitted to the facility on September 5, 2023 with a diagnosis of schizophrenia, anxiety disorder, cognitive functions, traumatic brain injury and bipolar disorder. A review of the residents current MDS (Minimum Data Set) dated August 29, 2024, revealed a BIMS (Brief Interview of Mental Status) score of 00, which indicates severe cognitive impairment. - Regarding Resident #261: Resident #261 was admitted to the facility on January 9, 2024 with a diagnosis of atrial fibrillation and major depressive disorder. A review of the residents current MDS, dated January 16, 2024, revealed a BIMS score of 14, which indicates no cognitive impairment. A facility reported incident was reported to the state agency claiming a staff member had witnessed an inappropriate interaction between two residents. The report stated that resident #261's hand was on the left thigh, under the shorts of resident #51. An interview was conducted on December 11, 2024 at 11:22 AM with staff member #42. She stated that on Thursday, February 29, 2024 at approximately 12:00 PM she was walking down the hall looking around, walking past the day room where she saw resident #261 with his hand on resident #51's left thigh but it was under resident #51's shorts. She stated she stopped and was shocked at what she saw, and as soon as resident #261 realized staff #42 saw it, he immediately removed his hand from under resident #51's shorts. She stated she separated them and went to the DON (Director of Nursing) and the ED (Executive Director) and told them what she saw. Review of a physician's progress note dated February 29, 2024 at 12:55 PM stated "Staff reported that the patient was found resting his hand on another resident's thigh recently. When asked about this, the patient states that he placed his hand on his thigh but did not touch any other areas of the patient's body. Staff made the DON aware who reported this incident. Both the DON and I had a lengthy conversation with the patient regarding inappropriate behaviors to include touching someone on their thigh without consent and the patient understands and states that he will not do this again. The patient appears apologetic for his actions." An interview was conducted on December 12, 2024 at 8:54 AM with Social Services Director (staff #163). She stated that resident #261 said he was only trying to comfort resident #51 because he was tremoring. She stated even though his hand was under his shorts, he claimed he was only trying to comfort him. When she asked why resident #261 was discharged to another facility on March 7, 2024, staff #163 stated that it was a direct result of the incident. Regarding Resident #71 and Resident # 263: - Regardi