Health inspection·March 14, 2025

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Resident Welcome Packet, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to have their mail delivered to them unopened. This affected two residents (#19 and #69) of three residents reviewed. Residents Affected - Few Findings include: 1. Review of Resident #19's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting his left, non-dominant side and cognitive communication deficit. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. On 03/14/25 at 10:12 A.M., an interview with Resident #19 revealed he had concerns with his mail being delivered to him already opened by the facility staff. He reported the incident occurred about two to three weeks ago and he denied that he had given the facility staff permission to open his mail. The letter that was opened was addressed to him and was sent by the Ohio Department of Jobs and Family Service (ODJFS). When asked how it made him feel when the facility opened his mail, he replied it (expletive word) him off. He felt his resident right to receive mail unopened had been violated. He reported the concern to the facility's administrative staff. He was told by the facility that he had given consent for them to open his mail. When he was told that, he immediately revoked any prior consent the facility staff thought he had given. Review of Resident #19's Mail and Package Consent Agreement provided by the facility upon request facility to open any mail and packages that arrived at the facility as a safety precaution. The agreement was to have been signed by the resident). A second Mail and Package Consent Agreement dated 02/05/25 was provided as evidence of the resident revoking his prior consent. The second agreement was hard to follow as the facility filled out the top portion of the agreement to include the resident's name indicating he hereby granted permission to the facility to open any mail and packages that arrived at the facility as a safety was written under where his signature was to be. It was unclear with the manner in which the form was completed, if the resident was consenting to allow the facility to open his mail and just refused to sign or if it was a revocation of a prior consent. Page 1 of 4 366244 366244 03/14/2025 Continuing Healthcare at Willow Haven 1020 Taylor Street Zanesville, OH 43701

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/14/25 at 10:32 A.M., an interview with Receptionist #100 revealed she was responsible for sorting the mail that was delivered by the United States Postal Service (USPS). She separated the facility's mail from the residents' mail. The residents' mail was given to the activity department for it to be delivered. She was asked if they opened any of the mail that was addressed to the residents. She stated they would open any residents' mail that was from the ODJFS or addressed to the facility in care of a resident, but only if that resident was a Medicaid (MCD) recipient. When she first started working there in January 2025, she was instructed by the corporate office to open all resident mail that was from insurance companies or from ODJFS. She stated now, some residents wanted to open their own mail that came from their insurance company, so those residents now received theirs unopened. When asked why they were opening mail addressed to residents that were sent by the ODJFS, she stated again she was instructed to do so by the corporate office. The corporate office wanted them to scan a copy of the letter that was received from ODJFS or an insurance provider and send to them. They currently had a small list of residents (who they managed their MCD for) that did not want their mail opened. Resident #19 was one of them and there were two other residents that wanted that as well. She identified the other two residents as Resident #69 and #70. She recalled Resident #19 told them he did not remember consenting to allow the facility to open his mail when he voiced the concern about his mail being opened before he received it. That incident happened towards the end of January or beginning of February 2025. He came to the front desk of the facility to complain. She was asked what the facility's process was with getting the residents' consents for allowing the facility to open mail for them. She stated every resident that came in signed a form granting the facility permission to open mail, excluding cards and packages addressed to the residents. The resident had the option to refuse to sign that form, if they did not want to give consent. Most of the residents did not want to deal with insurance companies. As a result of Resident #19's incident, the resident signed a new form revoking that consent. She indicated most of the admission paperwork was done by E-Sign (electronic signature). The Admissions Director reviewed those forms (Mail and Package Consent Agreement) with #19's consent allowing the facility to open his mail no longer worked there. On 03/14/25 at 10:44 A.M., an interview with Activity Director #125 revealed the activity department was responsible for passing mail to the residents, after it had been sorted by the receptionist. They delivered mail every day but Sunday. The activity staff did not open the residents' mail, unless a resident requested them to do so. They would often be asked to open the letters and read them to the resident it was delivered to. She confirmed there were times they would deliver mail to residents that had already been opened by the office staff. That tended to be mail that looked like it was from business type stuff. Some of the residents did voice concern when they delivered mail to the resident that had already been opened. She had heard Resident #19 complain about his mail being opened before he got it. On 03/14/25 at 11:15 A.M., a follow up interview with Resident #19 revealed he did not recall ever giving the facility consent to open his mail. He was shown what the Mail and Package Consent Agreement looked like and the one the facility provided that he allegedly signed on 12/03/24. He was not sure why he would have even been given that to sign on 12/03/24, as he was admitted to the facility in July of 2024. He was told the consent agreement showed he E-Signed the consent, which would have required him to push the button on a computer screen to signify he was signing or a staff member would have done it with his permission. He denied he had ever pushed any button on a computer to electronically sign any form. He denied knowledge of any staff being in his room reviewing any consent forms on a computer. He had not ever seen that consent agreement, until he complained of 366244 Page 2 of 4 366244 03/14/2025 Continuing Healthcare at Willow Haven 1020 Taylor Street Zanesville, OH 43701

F 0576 his mail being opened in February 2025 and that form was showed to him. Level of Harm - Minimal harm or potential for actual harm On 03/14/25 at 11:30 A.M., an interview with the facility's Administrator revealed the Mail and Package Consent Agreement was part of the facility's Welcome Packet and not part of the admission packet. She was not sure if the facility's Admissions Coordinator at the time just missed having Resident #19 fill out that form upon his admission explaining why it was obtained on 12/03/24. She denied the facility had done a whole house audit and obtained new Mail and Package Consent Agreements on all the residents in December 2024 for any reason, which would have explained why one was completed for Resident #19, five months after he was admitted . She confirmed the corporate office instructed their receptionist to open mail for resident safety and when letters were sent from insurance companies or ODJFS. The purpose of the corporate office asking them to do so was to make sure that information got up to the corporate business office for their MCD residents. The Administrator stated she and the corporate nurse that was there that morning were reviewing the mail delivery process and how they may handle it in the future. They were thinking about taking those letters to the residents to have them open them with staff present to make sure those letters sent from the ODJFS and insurance companies got to the facility and the corporate office for billing purposes. She acknowledged one of the Resident's Rights was to receive mail unopened. Residents Affected - Few Review of the facility's Welcome Packet provided to residents upon their admission to the facility revealed it included a copy of the Resident's Rights. Resident Right #28 indicated each resident had the right to send and receive unopened mail. Also included in the Welcome Packet was information on mail. The information provided informed the resident that a facility staff member would deliver their mail to their room. If they required assistance with any of the items their staff would be happy to assist them. The Welcome Packet did include a copy of the Mail and Package Consent Agreement for the resident to complete. 2. Review of Resident #69's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, anxiety disorder, bipolar disorder, and adult onset diabetes mellitus. She did not have any diagnoses that involved cognitive impairment. Review of Resident #69's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues. She was able to make herself understood and was able to understand others. She was also noted to be cognitively intact. Review of Resident #69's Mail and Package Consent Agreement dated 10/18/23 revealed the resident granted permission to the facility to open any mail and packages that arrived at the facility as a safety On 03/14/25 at 11:20 A.M., an interview with Resident #69 revealed she handled her and her husband's mail when it was delivered to them. She denied her husband, who shared same room with her, received much in the way of mail. She confirmed she has also had some of her mail opened before it was given to her. It had happened on a couple of occasions. One of the letters that had been opened was her insurance card. The other letter that had been opened came in a letter the facility thought was junk mail. She denied that she had given consent for the facility to open her mail. She did not like the fact that they opened her mail before giving it to her. The receptionist apologized to her for opening her mail and told her it was done by accident. She recalled the issue with her mail being opened occurred sometime in January 2025. The letter that was opened was addressed to her and not the facility. 366244 Page 3 of 4 366244 03/14/2025 Continuing Healthcare at Willow Haven 1020 Taylor Street Zanesville, OH 43701

F 0576 This deficiency represents non-compliance investigated under Complaint Number OH00162374. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366244 Page 4 of 4