Rolling Hills Hospital, LLC

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure: 1. Prevention of nonconsensual sexual contact for two (Patients #4 and #5) of six patients reviewed. 2. Exercise of patient rights for one (Patient #4) of six patients reviewed. This failed practice had the likelihood to result in the contraction of sexually transmitted infection, pregnancy, loss of dignity and loss of trust in the caregivers. (See Tag 0145)”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 39648 The hospital failed to ensure review of the sending facility’s available records for one (Patient. #2) of six patients reviewed. This failed practice had the likelihood to result in treatment plan decisions that did not address patient needs, thereby incresing patient risk for hospital readmission. (See Tag 0800)”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure: 1. Prevention of nonconsensual sexual contact for two (Patients #4 and #5) of six patients reviewed. 2. Exercise of patient rights for one (Patient #4) of six patients reviewed. This failed practice had the likelihood to result in the contraction of sexually transmitted infection, pregnancy, loss of dignity and loss of trust in the caregivers PREVENTION OF NONCONSENSUAL SEXUAL CONTACT Findings: Patient #4 Review of an evening shift nursing note dated 07/17/25 at 9:30 PM showed Patient #4 had a distracted and disoriented thought process. Review of a progress note dated 07/17/25 at 9:30 PM showed Patient #4 received a Haldol shot. Review of a progress note dated 07/18/25 at 10:00 AM read in part, “[Patient #4] confused and is unaware.” Review of an internal hospital document dated 07/18/25 at 10:39 AM showed Patient #1 fondled the genitals of Patient #4 on 07/18/25 at 10:00 AM. On 08/08/25 from 12:15 PM to 12:25 PM, Staff Q stated the incident occurred in the geriatric unit dayroom in the line of sight of the nurses’ station and two nurses were present in the nurses’ station at the time. On 08/11/25 at 10:51 AM, Staff F stated the geriatric unit was fully staffed that day. Patient #5 A review of an internal hospital document dated 07/31/25 showed Patient #2 went into the room of Patient #5, who was asleep, and had nonconsensual sexual contact with Patient #5. A review of an internal hospital document dated 07/30/25 at 5:30 am read in part, “[Patient #2] says he went into [Patient #5’s] room and stuck his penis in [Patient #5’s] butthole. He says [Patient #5] was asleep. He said [Patient #5] did not give permission. He said there was blood on his penis.” A review of the handwritten law enforcement Voluntary Witness Statement by Patient #5 dated 07/30/25 at 9:00 am read in part, “I was asleep in my bed and a client woke me up by fingering me in my butthole and when he noticed me waking up he darted out of my room. 5-10 minutes after the incident, I was pooping out blood and my butthole is sore.” A review of a policy titled “Patient Rights” last revised 09/2023 read in part, “Patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation.” On 08/12/25 at 11:57 AM, Patient #2 stated Patient #5 did not agree to have sexual intercourse. On 08/12/25 at 2:12 PM, Staff CC stated the following: 1. It was easy for the BHAs to get laxed and start talking in the middle of the hallways instead of being where they could see the whole length of the hallways. 2. The BHAs behavior should have been corrected and was not. EXERCISE OF PATIENT RIGHTS Findings: Patient #4 Review of hospital records showed non-consensual sexual contact between patients and did not show law enforcement was contacted. Specifically: 1. An evening shift nursing note dated 07/17/25 at 9:30 PM showed Patient #4 had a distracted and disoriented thought process. 2. A progress note dated 07/17/25 at 9:30 PM showed Patient #4 received a Haldol shot. 3. A progress note dated 07/18/25 at 10:00 AM read in part, “[Patient #4] confused and is unaware.” 4. An internal hospital document dated 07/18/25 at 10:39 AM showed Patient #1 fondled the genitals of Patient #4 on 07/18/25 at 10:00 AM. The document read in part, “POLICE INVOLVEMENT?” and “no” was marked. 5. A policy titled “Special Precautions” dated 09/2024 read in part, “In the event of a non-consensual sexual encounter involving a patient ...Nurse/Clinical Nurse Leader/Supervisor will notify law enforcement.” 6. A policy titled “Patient Rights” dated 09/2023 read in part, “Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse.” On 08/11/25 at 10:54 AM, Staff F stated law enforcement was not contacted. On 08/12/25 at 3:25 PM, Staff F reviewed the Special Precautions policy and stated what occurred with Patient #1 and #4 was a sexual encounter and law enforcement should have been contacted.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 39648 The hospital failed to ensure review of the sending facility’s available records for one (Patient. #2) of six patients reviewed. This failed practice had the likelihood to result in treatment plan decisions that did not address patient needs, thereby incresing patient risk for hospital readmission. Findings: Patient. #2 Review of hospital records showed documentation of SAO behaviors by the sending facility prior to the patient’s hospital admission and did not show documentation of SAO behaviors on the receiving hospital’s intake forms or initial treatment plan. Review of records faxed on 07/23/25 from the sending facility showed the patient had behavior concerns for sexually inappropriate behavior. A review of records showed that Patient #2 was admitted to the ID Unit at Rolling Hills on 7/29/25. Review of a hospital document titled “ADMISSION ORDER” dated 07/29/25 at 8:45 PM read in part, “Precautions for:...Sexual Acting Out” and the box was not checkmarked. Review of a hospital document titled “INTAKE” dated 07/29/25 at 9:50 PM read in part, “sexual impulsivity” and the box was not checkmarked. Review of a hospital document titled “HIGH RISK NOTIFICATION FORM” dated 07/29/25 at 10:00 PM read in part, “Sexually Acting Out Risk,” and the box was not checkmarked. Review of a hospital document titled “Initial Treatment Plan (Nursing)” dated 07/30/25 1:57 AM showed no problem, goal or intervention for impulsivity or SAO. A review of a policy titled, “Admisions Process” last revised 01/2023 read in part, “Admissions personnel will review the admissions documents.” A review of a policy titled, “Assessment/Reassessment” last revised 07/2025 read in part,”The Intake process assissts in determining the treatment needs of a patient...The information obtained on initial inquiries includes: Information about the caller’s current physician, condition/situation, including safety.” A review of a plicy titled “Observations, Patient” last revised 02/2025 read in part, “At admit, the attending physician may also order a special precaution level for...Sexual Acting Out.” On 08/08/25 at 10:06 AM Staff GG stated: 1) SAO precautions were not ordered, to my knowledge Patient #2 was coming in for aggression. 2) If SAO had been documented, Patientt #2 would have been a 1:1 observation level at admission and would have been on a different unit; On 08/11/25 at 11:29 am Staff T stated: 1) The agency did send documents showing Patient #2 had SAO. 2) SAO was not listed on the patient’s intake/admission documents. 3) The admission intake nurse should read all records sent from a referral source. On 08/12/25 at 10:07 am Staff V stated: 1) The Patient #2 had no SAO precautions prior to 07/30/25 at 5:40 AM.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure notice of patient rights for five (Patients # 1, 2, 3, 4, and 5) of five records reviewed. Findings: A Review of a facility document titled, “Welcome Packet” (page 8) located in the admissions paperwork showed an incorrect address and telephone number for the State Survey Agency (SSA). The address provided was for a location vacated by the SSA in November 2020. The telephone number was disconnected. On 03/12/25 at 11:58 am Staff B stated the address and phone number was not correct on the form provided to patients.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39648 Based on observation and interview, the hospital failed to ensure one (Pt #6) of six patients were safe from possible accidental or purposeful injury. Findings: On 05/12/25 at 1:23 pm the surveyor observed a patient ouside the dining area in an enclosed area (fenced) with a concrete floor. The surveyor observed what appeared to be pieces of wood in varying sizes which could have caused an accidental or self injury or could have been used to injure another person. Pt #6 05/12/25 at 1:24 Pt #6 was observed to be pacing around the enclosed area with only socks on his feet. After Staff A and B were made aware of what appearted to be pieces of wood on the ground, they had patients removed from the area and placed a sign on the door for it to be locked. On 05/12/25 at 1:25 pm, Staff A stated it was a safety risk. On 05/12/25 at 1:25 pm, Staff B stated it was a safety risk to have a patient walking in an area with something on the ground.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to meet the nutritional needs of one (Pt #3) of five patients . Findings: Pt #3 1) A review of the weight flowsheet showed Pt #2 had a weight loss at the hospital. A review of weekly weights showed the following: a. Initial weight 3/10/25 was 133 lbs, b. 3/17/25 134 lbs, c. 3/24/25 130.4 lbs, d. 3/31/25 125 lbs, e. 4/7/25 refused weight; 2) 3/14/25 the patient had a dietary evaluation with the recommendation that Glucerna be administered if the patient failed to eat less than 50% of meals. Meal intake: a. 3/14/25 breakfast refused - no supplement documented; b. 3/15/25 breakfast 35% - no supplement documented; c. 3/16/25 lunch 25% - no supplement documented; d. 3/17/25 lunch 10% - no supplement documented; e. 3/18/25 breakfast 25% - no supplement documented; f. 3/19/25 breakfast refused - no supplement documented; g. 3/20/25 breakfast 5% - no supplement documented; h. 3/21/25 breakfast 2 bites, lunch 25%, dinner 30% - no supplement documented; i. 3/22/25 breakfast 25% - no supplement documented; j. 3/23/25 breakfast 30%, dinner 15% - no supplement documented; k. 3/24/25 breakfast 20%, lunch 25% - supplements documented twice; l. 3/25/25 breakfast 20%, lunch 25% - no supplements documented; m. 3/26/25 no documentation n. 3/27/25 no documentation o. 3/28/25 no documentation p. 3/29/25 no documentation q. 3/30/25 no documentation r. 3/31/25 dinner 25% - no supplement documented; s. 4/1/25 no documentation t. 4/2/25 no documentation u. 4/3/25 no documentation v. 4/4/25 breakfast 25%, lunch 25%, dinner 25% - no supplement documented; w. 04/5/25 no documentation x. 04/6/25 breakfast 25%, lunch 25%, dinner 25% - no supplement documented; y. 04/7/25 no documentation z. 04/8/25 no documentation (was discharged this date) On 05/13/25 1:40 pm at 9:40 AM Staff E stated Glucerna was not offered each time the patient ate less than 50% of a meal.”