Health inspection·October 9, 2024

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State Tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144. Findings include: Review of the medical record revealed Resident # was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, seizures, schizophrenia, and dementia The resident was discharged on 10/04/24 to a group home. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #5 had behaviors including delusions, physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, rejection of care, and wandering. Review of the SRI allegation background revealed on 09/12/24 at approximately 7:10 P.M., the Director of Nursing (DON) was notified of a video that was posted on social media by STNA #314. The video was captioned Everyday it is something new with my clients. STNA # was heard on the video making the statement what the [expletive], and then the camera view pans to a resident walking with their brief/pull up around their ankles. The resident's face was momentarily visible although unclear in the video. The video was posted without the consent of the resident. Review of SRI tracking number 251842 dated 09/12/24 revealed on 9/12/2024 at 7:30 P.M., the Administrator was made aware that STNA #314 posted a video on social media that had a blurred image of Resident #5. When STNA #314 was interviewed, she stated the image was of Resident #5. The post was deleted, and the staff member was suspended pending investigation. A message was left for Resident #5's guardian regarding this investigation. Staff were being educated on the facility's abuse and social [NAME] policies. Staff were being interviewed to determine if there was knowledge of any other videos that were posted on social media that have a resident's image. Residents were being interviewed to determine if they had knowledge of any additional posting that may have a resident's image. Resident #5 had no change in condition. The compliance division was notified of the potential breech and will initiate its own investigation. The investigation revealed the DON, Regional Director of Clinical Page 1 of 4 365832 365832 10/09/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Services (RDCS) #303, and Regional [NAME] President of Operations (RVPO) #302 were immediately made aware of the allegation. A referral was placed to the organization's compliance department to also investigate. Resident #5 was assessed and had no injuries. Due to the resident's cognitive ability, the resident had no awareness of what occurred and there were no signs of being negatively impacted. Two voicemail messages were left for the guardian to alert her of the allegation, as of 9/18/24, no return call had been received, another call was placed to the legal guardian on 9/18/24 and another voicemail message was left. When STNA #314 was interviewed, she stated she had no intention of causing any harm, distress, or pain to any resident and was simply posting a video of her work life. She stated that no other employee was part of the post, and no employee liked or commented on the post. She stated she had posted the video on 09/09/24 and only to the Tik Tok site. The post was deleted, and the staff member was suspended pending investigation. She stated the video was created on Tik Tok, was only posted to Tik Tok, and there were no copies of the video. All staff were interviewed on 09/12/24 and 09/13/24 regarding having any knowledge of this or any other breach of the social media policy, and no additional violations were committed. All residents that were able, were interviewed on 09/12/24 and 09/13/24, and no residents had any knowledge of any video of them or any other resident being taken and/or placed on social media. All staff were educated by the Administrator / Designee on the facility's Health Insurance portability and Accountability Act (HIPAA), Abuse, and Social Media policies on 09/12/24 and 09/13/24. Resident #5 has shown no change from baseline that would be indicative of any distress or harm. Social services will continue to monitor. STNA #314 was terminated. Interviews on 10/08/24 at 2:02 P.M. with the DON and Assistant Director of Nursing (ADON) #310 and on 10/09/24 at 8:21 A.M. with the Administrator verified the administrator had heard about the social media posting incident on 09/12/24, the video had been posted a couple days prior. STNA #314 was interviewed and immediately suspended. The facility worked with their corporate ethics to ensure they did everything needed to address the issue. Review of the personnel record for STNA #314 revealed the last day worked was 09/12/24. The STNA was terminated 09/19/24. Review of the Ohio Resident Abuse Policy, dated 07/11/24, revealed no concerns in relation to the allegation. The facility followed its policy. STNA #314 did not follow the policy and was terminated. Review of the undated facility [NAME] Media policy included that if an employee posted information on the Internet in any fashion, they were expected to do so responsibly and must adhere to the following guidelines: employees' communications concerning the facility must not violate any facility policies, employees may not post any material that is obscene, defamatory, libelous, threatening, harassing, abusive or hateful. Employees should expect the facility to monitor compliance with this policy, including accessing any information posted, created, or exchanged on social media, without prior notice to the employee, to the extent permitted by law. Failure to comply with these policies will lead to discipline up to and including termination. The deficient practice was corrected on 09/13/24 when the facility implemented the following corrective actions: • On 09/12/24 the DON notified the Administrator, ADON #310, and RDCS #303 of the video that was 365832 Page 2 of 4 365832 10/09/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0600 posted by staff. The Administrator notified RVPO #302. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Few On 09/12/24 the DON called the facility and spoke with STNA #314, asked about the video, and informed her she was suspended, and security escorted her from the facility. STNA #314 was terminated on 03/1/24. • 09/12/24 the Administrator called STNA #314 and instructed her to delete the video and remove the post from social media. It was determined during this conversation that the video was posted for approximately three days prior to the facility having knowledge. • On 09/12/24 the DON verified the video was removed from social media • 09/12/24 Resident #5 was assessed, as the resident was not able to participate in an interview. There were no negative findings. • 09/12/24 the Administrator called Resident #5's legal guardian, left a voicemail explaining the situation and requesting a call back. • On 09/12/24 the Administrator completed the initial SRI for alleged emotional abuse and submitted it to the state agency. • On 09/12/24 the Administrator notified the corporate compliance officer via email of the alleged HIPAA violation. • On 09/12/24 current residents who were able to participate were interviewed by the Administrator or designee related to any staff seen taking pictures or videos of them without consent, there were no negative findings. • On 09/12/24 all staff were interviewed by the Administrator or designee related to any staff seen taking pictures or videos of residents without consent. The staff interviews were completed on 09/13/24 at 1:00 P.M. There were no negative findings. 365832 Page 3 of 4 365832 10/09/2024 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0600 • Level of Harm - Minimal harm or potential for actual harm Beginning on 09/12/24, the Administrator initiated all staff education related to abuse and neglect prevention and reporting along with the social media policy and the HIPAA policy. Education for all staff was completed on 09/13/24 at 1:00 P.M. Residents Affected - Few • On 09/13/24 the Administrator called to speak with Resident #5's legal guardian again and was informed by the office that she is off. He did leave another voicemail. • On 09/13/24 Resident #5 was seen by a clinical counselor, and there was no indication of any emotional impact related to the situation. • Beginning on 09/13/24, the Administrator or designee will interview five residents three times per week for four weeks and then monthly for two months to determine if they have seen any staff taking pictures or videos of residents, or if they have heard anything of pictures or videos containing residents being posted to social media platforms. Results of the interviews will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. • Beginning on 09/13/24, the Administrator or designee will interview five staff three times per week for four weeks and then monthly for two months to determine if they have seen any staff taking pictures or videos of residents, or if they have heard anything of pictures or videos containing residents being posted to social media platforms. Results of the interviews will be submitted to the QAPI committee for further review and recommendations. • An Ad Hoc was held on 09/1324 with the Medical Director in attendance via phone to review the event and the QAPI plan implemented by the facility. This deficiency represents past non-compliance from Self-Reported Incident Control Number OH00158085. 365832 Page 4 of 4