Health inspection·December 22, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies, clinical record review, review of facility-provided documentation, and staff interviews, it was determined that the facility failed to protect and maintain personal privacy and dignity when staff recorded a resident receiving incontinence care without consent. This failure resulted in a violation of personal privacy protection for 1 of 5 sampled residents (Resident 1). This concern represents past non-compliance, as the facility identified, addressed, and corrected the issue before the survey.Findings include: A review of a select facility policy for Use of Employee Telephones, last reviewed December 8, 2025, revealed it is the policy of the facility that cellular phones may be used for personal calls and text messaging only when the employee is on authorized meal and break periods, and employees' cell phones will remain off or on silent during all other work hours. A review of a select facility policy for Dignity, last reviewed December 8, 2025, revealed it is the policy of the facility that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Further review revealed that staff should promote, maintain, and protect resident privacy, including bodily privacy, during assistance with personal care and during treatment procedures. A review of a select facility policy for Videotaping, Photographing, and Other Imaging of Residents, last reviewed December 8, 2025, revealed it is the policy of the facility that residents will be protected from invasion of privacy and abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. Further review revealed that staff may not take or release images or recordings of any resident without explicit written consent. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and cerebral infarction (brain damage that results from a lack of blood). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 1 dated November 06, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 01 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A clinical record review for Resident 1 of a care plan initiated on October 26, 2021, revealed the resident had urinary and bowel incontinence (involuntary loss of urine or stool) related to disease processes, impaired mobility, and physical limitations, and interventions included providing assistance with toileting and providing incontinent care as needed.A review of facility-provided documentation showed that on December 16, 2025, at 2:00 AM, Employee 1, NA (nurse aide), used her personal cell phone to record video footage of Resident 1 in Resident 1's room while incontinence care was being provided by Employee 3, NA. Employee 1 NA and Employee 2, NA, were Residents Affected - Few Page 1 of 2 395298 395298 12/22/2025 Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few positioned in another location across the facility courtyard (73 yards across the courtyard) and recorded through a window where the blinds had not been lowered. The recording was made without consent, and neither Resident 1 nor Employee 3 were aware that they were being recorded. During an interview with Employee 3, CNA, on December 22, 2025, at 11:15 AM, it was stated the window shade had not been lowered during incontinence care at the time of the incident.During an interview with the Nursing Home Administrator (NHA) on December 22, 2025, at 2:00 PM, it was acknowledged that Employee 1 and Employee 2 admitted to making the video recording. The NHA confirmed it is the facility's responsibility to ensure residents at the facility have a right to personal privacy. The NHA revealed that both Employee 1 and Employee 2 have been terminated from employment at the facility as of December 17, 2025. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, and there were no other facility staff or residents reporting any unauthorized videos. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to facility staff regarding HIPAA (Health Insurance Portability and Accountability Act) regulations and policy and usage of cell phones and electronic devices. To monitor and maintain ongoing compliance, the NHA/designee will perform audits twice a week for 4 weeks to ensure that staff are following HIPAA regulations and policy. Any negative findings will be immediately corrected. Results of audits will be forwarded to facility QAPI for review and recommendation as indicated. The facility's immediate corrective action plan was completed on December 18, 2025. 28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (c) Nursing services. 395298 Page 2 of 2