Social worker SW #38 confirmed during an October 7 interview that he was aware of "complaints Resident #161 going into female resident's rooms and being inappropriate with them." The complaints had been handled by SW #304, the former Director of Social Services who retired about a month before the inspection.
SW #38 told inspectors he assumed the retired social worker "would have submitted a report to OHFLAC and APS if she had deemed it necessary." OHFLAC is Ohio's Long-Term Care Ombudsman program, and APS refers to Adult Protective Services — both agencies that must be notified when nursing home residents face potential abuse.
But no reports were filed.
When asked what he would have done about the complaints, SW #38 said he "would have consulted with the Administrator and deferred to her judgment on filing a report."
The facility's own documentation shows the problematic behavior continued. A note from May 15 at 5:30 PM by RN #73 stated: "Resident was observed entering room [ROOM NUMBER]. Bed 1 (Resident #5) was asleep and bed 2 (Resident #84) told him to leave."
Resident #84 had to tell the male resident to leave her room while her roommate slept.
During the same day, care plan meetings were held for Resident #161. Notes from SW #38 at 1:37 PM on May 15 documented a quarterly care conference where "social services, nursing, and activities" discussed the resident's status. The resident himself attended the meeting.
The notes show discussions about his code status, funeral arrangements, diet, and weight gain. Staff "reviewed and discussed" his care plan, and the resident "stated he has no concerns or questions."
Nowhere in those care plan discussions was there mention of the inappropriate behavior toward female residents.
The Administrator and Director of Nursing confirmed this gap during their October 7 interview with inspectors. They acknowledged "that the resident's Care Plan had not been updated to reflect implementations to prevent further abuse of other residents."
No interventions. No behavioral modifications. No restrictions on room access.
The care plan did include other behavioral approaches. Staff were instructed to "approach resident in a calm manner to avoid frustration and behavior escalation" and "if resident becomes agitated and shows signs of escalation, re-approach later."
But nothing about protecting other residents from his inappropriate advances.
The facility's own care plan system showed multiple interventions created and revised by the MDS Coordinator throughout late 2024 and into 2025. Tasks included administering medications "per physician order" and monitoring "for effectiveness and side-effects."
Several interventions were cancelled on June 9, 2025, but new protections for female residents were never added.
SW #38 told inspectors he was "currently responsible for submitting reports to OHFLAC and APS when necessary." The responsibility had shifted to him after SW #304's retirement, but the complaints about Resident #161's behavior predated that transition.
The inspection found the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were immediately reported to the administrator and other officials in accordance with state and local laws.
Federal regulations require nursing homes to report suspected abuse within 24 hours to the administrator and immediately notify appropriate state and local authorities. The facility must also ensure a thorough investigation and take steps to prevent further abuse.
Peterson Rehabilitation and Healthcare did none of these things systematically.
The male resident continued accessing female residents' rooms months after complaints were first raised. Staff documented him entering rooms where women told him to leave, but no formal reporting occurred.
The retired social worker who originally handled the complaints was no longer available to explain her decisions. Her replacement assumed she had made appropriate reports but never verified this or followed up on the ongoing behavior.
Meanwhile, female residents remained vulnerable to unwanted intrusions in their private spaces.
The care plan meetings for Resident #161 focused on medical issues, dietary concerns, and end-of-life planning while ignoring the safety of other residents. Staff discussed his weight gain and medication effectiveness but not his pattern of inappropriate behavior toward women.
The facility's Administrator deferred reporting decisions to social services staff who were either retired or assumed someone else had handled the matter. This created a gap where serious allegations fell through administrative cracks.
Federal inspectors found the facility's approach constituted a violation of resident rights and safety protections. The deficiency was classified as causing "minimal harm or potential for actual harm" affecting "few" residents.
But for the female residents who had to tell an inappropriate male visitor to leave their rooms, the harm was immediate and personal. Their private spaces became sites of unwanted encounters that facility management knew about but failed to address through proper channels.
The inspection revealed a facility where serious behavioral issues could persist without systematic intervention, where reporting responsibilities shifted without clear handoffs, and where care planning focused on individual medical needs while overlooking risks to other residents.
Resident #161's case demonstrated how nursing home administrative gaps can leave vulnerable residents exposed to ongoing inappropriate behavior, even when staff are aware of the problem and have the tools to address it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peterson Rehabilitation and Healthcare from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
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