Inspection·October 23, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to report an allegation of abuse to the state agency. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State Tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first time the facility took the information, the complainant informed the facility it was agency STNA #170 who works for an agency. Community Member #1 stated she called 3 weeks ago and was told by the Director of Nursing (DON); the facility took care of it. Community Member #1 could not identify the resident's name. Interview on 10/23/23 at 10:56 A.M., with the Social Services Designee #105 revealed the DON did receive a call from an anonymous caller about an agency nurse taking pictures of a resident and posting them on social media. Interview on 10/23/23 at 11:00 A.M., with the DON confirmed she received an anonymous call about Agency STNA #170. The anonymous caller accused STNA #170 of taking a picture of a blind black lady while smoking in her wheelchair and posted it on social media. The DON explained, because they do not have a blind black lady in the facility, she did not investigate the allegation. She interviewed the seven smokers and they all denied getting their picture taken. She reported the incident to the contracted staffing agency. The DON stated the Human Resources Manager #120 confirmed the agency also received the same complaint and will address the situation. The DON confirmed she did not report the abuse allegation to the state agency, file a Self-Reported Incident or investigate the allegation of abuse. She has no documentation of any interviews with her residents who smoke. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #64, who smokes, stated witnessing Resident #63, as the person who was in a wheelchair and a STNA let go and Resident #63 slid down (continued on next page) 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 Page 1 of 4 Event ID: 365666 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Lake Rehabilitation Center 14442 State Route 33 West Lakeview, OH 43331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)