Crystal Pines Rehab & Hcc

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

interview and record review the facility failed to ensure a resident remained free of sexual abuse. This applies to one of three residents (Resident R5) in the sample of eight reviewed for abuse. Findings include:The facility face sheet for Resident R5 shows diagnoses to include dementia and psychosis. The facility assessment dated [DATE REDACTED] shows Resident R5 to have severe cognitive impairment and requires maximum staff assistance with her activities of daily living, and uses a wheelchair for ambulation.The facility face sheet for Resident R4 shows diagnoses to include Parkinson's Disease, depression and psychotic disorder. The facility assessment dated [DATE REDACTED] shows Resident R4 to be cognitively intact and requires supervision for his activities of daily living and uses a wheel chair for his ambulation. The facility state report dated 8/9/2025 shows an incident between Resident R4 and Resident R5 while in the dining room of the facility. A staff observed the two residents sitting closely to each other and the male residents (Resident R4) arm was moving back and forth over the female residents (Resident R5) lap. The staff then went and separated the residents and noticed Resident R5's pants were unbuttoned and Resident R4 left the area immediately after being asked what was going on. On 8/20/2025 at 11:00 AM, V4 Certified Nursing Assistant (CNA) said she was walking past the dining room and noticed Resident R4 and Resident R5 sitting real close to each other and Resident R4 had his hand over Resident R5's lap and was moving his hand back and forth. V4 said she walked into the dining room and asked Resident R4 what he was doing. V4 said Resident R4 backed up quickly and nearly fell out of his wheelchair and denied doing anything. V4 said she looked over at Resident R5 and noticed her pants were unbuttoned. V4 said when she turned her attention back to Resident R4, he was gone. V4 said she took Resident R5 from the dining room and took her to the nurse and told them what she had seen. On 8/20/2025 at 11:10 AM, V3 Registered Nurse (RN) said V4 came to him with Resident R5 and told him that Resident R4 and Resident R5 were seen sitting very close to each other and Resident R4's hand was moving over Resident R5's lap and Resident R5's pants were unbuttoned. V3 said he immediately called the Administrator and the Director of Nursing and assessed Resident R5 for any harm.On 8/20/2025 at 1:30 PM, V1 Administrator said he was notified of the incident the day it happened, and he notified the police right away. V1 said Resident R4 was placed on a one-to-one observation and will remain on one until an alternate living arrangement can be made. The care plan for Resident R4 dated 3/25/25 shows Resident R4 was showing interest in a female peer and would sit outside her room and try to enter her room. Interventions were put into place. On 6/24/25 Resident R4's care plan was updated to show the potential to be inappropriately touching another female resident. Resident R4's care plan was updated again with new interventions put into place. (A state report dated 6/24/25 shows this was Resident R5. An investigation was completed and could not be substantiated.)The undated facility policy for abuse prevention shows each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone including other residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID: