Every finding on record at Eastwood Manor

Based on interview, facility document review, and facility policy review, the facility failed to ensure there was a registered nurse (RN) on duty for eight consecutive hours each day. This deficient practice had the potential to affect all 34 residents who currently resided in the facility.Findings included: An undated facility policy titled, Policy Regarding Facility Staffing revealed, It shall be the policy of this facility to employ sufficient, adequately trained staff, to be on duty 24 hours a day, to meet the needs of the residents residing in the facility, as determined by the Administrator and/or Director of Nursing. A facility document titled, Time & Attendance - Detail Report. TA, for the timeframe 01/01/2026 - 07/22/2026, revealed no evidence of RN coverage for eight consecutive hours on 01/17/2026, 01/18/2026, 03/08/2026, 04/12/2026, 04/16/2026, 04/17/2026, 04/19/2026, 04/26/2026, and 06/28/2026. During an interview on 07/23/2026 at 12:12 PM, the Administrator stated there was no evidence of eight consecutive hours of RN coverage on 01/17/2026, 01/18/2026, 03/08/2026, 04/12/2026, 04/16/2026, 04/17/2026, 04/19/2026, 04/26/2026, and 06/28/2026. During an interview on 07/24/2026 at 9:43 AM, the Business Office Manager stated sometimes the facility had RN coverage for eight consecutive hours each day and sometimes they did not. During an interview on 07/24/2026 at 12:20 PM, the Assistant Director of Nursing stated the facility needed to have a RN on duty for eight consecutive hours each day. During an interview on 07/24/2026 at 3:47 PM, the Director of Nursing stated her expectation was that the facility had RN coverage for eight consecutive hours every day. During an interview on 07/24/2026 at 4:14 PM, the Administrator stated her expectation was that the facility had a RN on duty for eight consecutive hours each day.

Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure followed the menu and provide a one-half cup portion of mashed potatoes during the lunch meal on 07/20/2026. This deficient practice had the potential to affect all residents who received food from the kitchen.Findings included:An undated facility policy titled, Food Preparation, indicated, Policy: Portion-control methods will be used to assure the correct quantities are served to residents to meet the nutritional specifications as determined by the menu.An undated facility document titled Conversions/Measurements posted in the kitchen, indicated a #16 scoop would yield a one quarter cup, equivalent to two ounces.The facility's weekly menu revealed that on 07/20/2026, the facility would serve one half cup of mashed potatoes for the lunch meal.During the lunch meal tray line observation on 07/20/2026 at 12:58 PM, the Dietary Manager (DM) was observed to plate mashed potatoes with a blue handled scoop.During an interview on 07/20/2026 at 1:11 PM, the DM acknowledged she used a #16 scoop to serve the mash potatoes for the lunch meal. The DM reviewed the menu and stated she made a mistake and used the wrong serving utensil for the mashed potatoes. The DM stated she should have served one-half cup of mashed potatoes but she only served the residents a two-ounce portion of mashed potatoes.During a telephone interview on 07/23/2026 at 10:19 AM, the Registered Dietician stated she expected staff to use the menu as a guide for portions and use the utensil guide that was posted in the kitchen to ensure staff used the correct utensil to serve foods in the portions recorded on the menu.During an interview on 07/23/2026 at 4:15 PM, the Administrator stated staff should follow the menus and provide food in the portion according to the menu. The Administrator stated staff should use the utensil guide and the menu together to provide the correct portions.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were stored with a date and label and expired food items were discarded. These deficient practices had the potential to affect all residents who received food from the kitchen.Findings included: An undated facility policy titled, Sanitation and Infection Control, with a subject of Refrigerated Storage indicated, 7. All refrigerated foods should be covered properly, labeled and dated. and 10. The opened, unused portions of packaged foods should be dated to assure that they will be used first. An undated facility polity titled, Sanitation and Infection Control, with a subject of Usage and Storage of Leftovers indicated, 2. Leftover food must be covered, labeled dated and refrigerated immediately. 3. Leftover foods must be used within three days of the original cooking date. The policy specified, 5. Freeze leftovers that will not be eaten within three days, label, and date. and 7. Never mix leftover food with fresh food. During a concurrent interview and observation of the reach-in refrigerator on 07/20/2026 at 9:28 AM, the surveyor noted the following:- Eleven pieces of pre-cooked sausage patties were stored in an opened bag, in a box with approximately 50 pieces of uncooked bacon. The Dietary Manager (DM) stated the pre-cooked sausage should not be stored in a box with uncooked bacon.- A five-pound unopened plastic bag of cut celery with a manufacturer best-by date of 06/03/2026. The bag of celery contained a brown liquid, and the pre-cut ends of the celery were a brown/rust color. The DM stated the celery was expired.- Five flour tortillas were wrapped in plastic wrap without a label or date. The DM stated there was no label on the tortillas.- One peeled/cut cucumber was stored in a zipped plastic bag without a label to record the use-by date (UBD). The DM stated there was no label on the bag.- Two pounds of sliced turkey was stored in a zipped plastic bag with a label that recorded an opened date of 07/10/2026 and no UBD. The DM stated she was told that all foods had a three-day shelf life once opened.- Two one-pound containers of fresh strawberries were observed and identified by the DM to have mold. The DM stated the strawberries were molded and should not be served.- Four green bell peppers were stored in a clear plastic container and observed with black, white, and green discoloration. The DM stated the green peppers were expired.- One slice of turkey deli meat was stored in a zipped plastic bag without a label or date. The DM stated there was no label to record the date the package was opened.- One pound of Swiss cheese was stored in a zipped plastic bag without a label or UBD.- A five-pound container of sour cream had a manufacturer best by date of 06/25/2026; the label recorded an opened date of 06/05/2026. Approximately one eighth of the sour cream was left. The DM stated that once the sour cream was opened, it had a seven-day shelf life.- An unopened five-pound container of sour cream had a manufacturer best by date of 05/09/2026. The DM stated the sour cream was expired.- One peeled white onion was stored in a plastic bag with a label that recorded an opened date of 07/15/2026. The DM stated the onion had a three-day shelf life once it was peeled.- A cut tomato was stored in a plastic bag with a brown liquid and white fuzzy growth with a label that recorded a storage date of 06/26/2026. The DM stated the tomato was expired.- Nine cucumbers were observed in a plastic container with black and white discolored spots. During an interview on 07/20/2026 at 9:28 AM, the DM stated she checked the reach-in cooler each morning she worked for expired items, but had been off since 07/17/2026 and she was not sure if staff checked the reach-in cooler on the days she was off. During an interview on 07/20/2026 at 9:40 AM, the Administrator stated she expected staff to monitor the refrigeration units daily for expired food items and to remove food items from refrigeration that were expired or had signs of spoilage. The Administrator stated she expected each item placed in refrigerator to have a date it was opened and a date it would expire.

Based on interview and facility document review, the facility failed to complete a performance review of every certified nurse aide (CNA) at least once every 12 months for 2 (CNA #7 and CNA #25) of 3 CNAs' personnel files reviewed.Findings included: CNA #7's personnel file revealed the CNA's hire date of 08/16/2022 and there was no evidence found to indicate an annual performance (skills) review had been completed. CNA #25's personnel file revealed the CNA's hire date of 05/08/2023 and there was no evidence found to indicate an annual performance (skills) review had been completed. During an interview on 07/24/2026 at 12:00 PM, the Assistant Director of Nursing (ADON) stated she had been the ADON since 2023. The ADON stated the CNAs were provided 12 hours of in-service training, but there was no documentation of the CNA's performance review. Per the ADON, she was not who was responsible for performance reviews, she thought it would be the Administrator, and then stated the responsibility for training and performance reviews would be a shared responsibility between her and the Director of Nursing (DON). During an interview on 07/24/2026 at 6:02 PM, the DON stated she had not completed CNAs' performance reviews, she was not aware that performance reviews were not being completed and did not know she was supposed to do them. During an interview on 07/24/2026 at 6:30 PM, the Administrator stated performance reviews were to be completed to ensure staff were up to date with the skills to perform their job. The Administrator stated she expected performance reviews to be completed upon hire and annually to ensure staff could continue to perform their assigned job.

Based on interview, facility document review, and facility policy review, the facility failed to implement their infection prevention and control program to include conducting an outbreak investigation when multiple residents were diagnosed with respiratory syncytial virus (RSV) and failed to perform respirator fit testing according to their policy. These deficient practices affected 8 (Residents #1, #3, #11, #14, #22, #28, #40, and #41) of 13 sampled residents reviewed for infection control.Findings included: A facility policy titled, Respiratory Protection Program, dated 04/28/2021, indicated, d. Fit Testing Employees required to wear tight-fitting respirators will be fit tested: * Prior to being allowed to wear any tight-fitting respirator; * Annually; and * When there are changes in employee's physical condition that could affect respirator fit. A facility policy titled, Infection Outbreak Response and Investigation, with a copyright date of 2026, revealed, The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. The policy specified, 3. Outbreak Investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all investigation activities. c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: i. Person - key characteristics the patients share in common. ii. Place - the location associated with the outbreak. iii. Time - period of time associated with illness onset for the cases under investigation. iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. A facility document titled, Respiratory Surveillance dated 02/2026, revealed Resident #40 had an onset of symptoms to include wheezing on 01/23/2026 and was diagnosed with RSV. A facility document titled, Respiratory Surveillance dated 03/2026, revealed seven residents (Residents #1, #3, #11, #14, #22, #28, and #41) were diagnosed with RSV. Resident #3 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #11 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #14 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #22 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #28 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #41 had an onset of symptoms to include a cough on 03/04/2026 and was diagnosed with RSV. Resident #1 had an onset of symptoms to include a cough, sore throat, and diminished lung sounds with slight wheezing upon exhale on 03/10/2026, and was diagnosed with RSV and pneumonia. During an interview on 07/24/2026 at 9:46 AM, the Assistant Director of Nursing (ADON), who served as the facility's Infection Preventionist (IP), stated employee health surveillance and a comprehensive outbreak investigation were important responsibilities of the IP that were not conducted during the 02/2026 - 03/2026 RSV outbreak. The ADON stated the infection prevention program did not meet expectations during the RSV outbreak, and the RSV outbreak could have been managed more effectively. The ADON stated employee health surveillance was not conducted during the RSV outbreak. During an interview on 07/24/2026 at 9:27 AM, the Director of Nursing (DON) stated there was not a comprehensive investigation conducted to determine the source of transmission during the RSV outbreak. The DON stated staff were not investigated to determine whether they might have been a source of transmission. The DON stated employee screening and monitoring activities were not conducted, and staff illnesses were not tracked through the infection prevention and control program. The DON stated employee respirator fit testing was not completed during the facility's RSV outbreak. During an interview on 07/24/2026 at 3:37 PM, the Administrator stated opportunities were missed during the RSV outbreak to conduct enhanced surveillance, employee health monitoring, and a comprehensive outbreak investigation. According to the Administrator, respirator fit testing was an essential component of the facility's infection prevention program.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident was offered an ongoing program of activities for 1 (Resident #21) of 2 sampled residents reviewed for activities.Findings included: An undated facility policy titled, Policy & Procedure on Activities Program, revealed, This facility will provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Programs shall be designed to encourage rehabilitation and restoration to self care and normal activity. An admission Record revealed the facility admitted Resident #21 on 01/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of depression and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/2026, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #21's Care Plan Report included a focus area initiated 01/12/2026, that indicated the resident was dependent on staff for meeting their emotional, intellectual, physical, and social needs. Interventions directed the staff to provide the resident a program of activities that was of interest and empowered the resident by encouraging/allowing choice, self-expression, and responsibility (initiated 01/12/2026). Resident #21's Activities - Quarterly/Annual Participation Review, dated 03/30/2026 and 06/23/2026, revealed the resident enjoyed 1:1 activities. Resident #21's Progress Notes, for the timeframe 02/01/2025 - 04/30/2026, revealed no evidence that 1:1 activities were offered and/or provided to the resident. During an interview on 07/20/2026 at 11:39 AM, Resident #21 stated no one offered any activities to them. During an interview on 07/23/2026 at 3:08 PM, the Activities Director (AD) stated she had been employed at the facility as the AD since 01/2024. The AD stated she felt bad that she had not been doing her job like she was supposed to. The AD stated she was not tracking activity participation for each resident and had not offered 1:1 activities to Resident #21. During an interview on 07/24/2026 at 3:47 PM, the Director of Nursing stated she expected the AD to ensure all residents received some type of activity on an ongoing basis. During an interview on 07/24/2026 at 4:14 PM, the Administrator stated she expected the AD to document the activity participation for all residents.

Based on observation and interview, the facility failed to post the nurse staffing data during 2 (07/20/2026 and 07/21/2026) of 5 days of the survey. This deficient practice had the potential to affect all 34 residents who currently resided in the facility.Findings included: During an observation on 07/20/2026 at 10:48 AM, 07/20/2026 at 3:18 PM, and 07/21/2026 at 8:32 AM, the required nurse staffing data was not observed posted in the facility. During a concurrent observation and interview on 07/21/2026 at 8:34 AM, Administrator observed the billboard in the facility and stated the facility did not have a post of the nurse staffing data. The Administrator stated it was her understanding the facility never posted the nurse staffing data. During an interview on 07/21/2026 at 8:35 AM, the Assistant Director of Nursing (ADON) stated she was not aware of the requirement for posting the nurse staffing data. During an interview on 07/21/2026 at 8:37 AM, the Chief Nursing Officer (CNO) stated she had not discussed the posting of the nurse staffing data yet with the ADON. The CNO acknowledged the facility did not post the nurse staffing data, but would begin. During an interview on 07/22/2026 at 9:21 AM, the Business Office Manager stated she kept track of the nurse staffing data, completed a report, but did not post the nurse staffing data. During an interview on 07/24/2026 at 3:47 PM, the Director of Nursing stated her expectation was that the nurse staffing data would be posted every day. During an interview on 07/24/2026 at 4:14 PM, the Administrator stated her expectation was that the nurse staffing data would be posted every day.

Based on observation, record review, and interview, the facility failed to ensure a resident's use of continuous oxygen was included in their care plan for 1 (#7) of 2 sampled residents reviewed for respiratory care. The ADON identified eight residents at the facility who had orders for the use of oxygen. Findings: On 02/25/25 at 12:19 p.m., Resident #7's family member was observed informing staff that the resident's oxygen concentrator was turned off and the resident was required to have continuos oxygen. The concentrator was observed by this surveyor and found the power switch to be in the off position. On 02/26/25 at 9:36 a.m., an observation of Resident #7's oxygen concentrator found it was set to 3 liters per minute. A facility policy, titled Resident Care Plan, dated 03/27/17, read in part, The care plan will be developed with measurable goals to meet the Resident's identified medical, nursing, mental and psychosocial needs. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. A Patient Care Order (Verbal Order), dated 08/29/24 at 4:32 p.m., showed Resident #7 was to be administered a continuos flow of oxygen at a rate of 2 liters every minute. A care plan focus, dated 09/11/24, showed Resident #7 had a diagnosis of chronic obstruction pulmonary disease. There were no interventions that showed the use of oxygen. On 02/26/25 at 9:20 a.m., LPN #1 stated there was no entry in the resident's care plan regarding the use of oxygen. On 02/26/25 at 9:27 a.m., ADON stated they had reviewed Resident #7's care plan and did not find any documentation regarding the use of oxygen. On 02/26/25 at 11:10 a.m., ADON stated they use temporary nursing staff and the care plan was one place they would look to find a resident's oxygen level. On 02/27/25 at 10:48 a.m., DON stated there had been a breakdown in communication in regard to the resident's oxygen order getting into the care plan and order section of the EHR.

Based on observation, record review, and interview, the facility failed to ensure a resident received the correct amount of oxygen as ordered by a physician for 1 (#7) of 2 sampled residents reviewed for respiratory care. The ADON identified eight residents at the facility who had orders for the use of oxygen. Findings: On 02/25/25 at 12:19 p.m., Resident #7's family member was observed stating the resident's oxygen concentrator was turned off. The oxygen was observed to be turned off and the cannula was observed to be in place on the resident's face. On 02/26/25 at 8:25 a.m., Resident #7's oxygen concentrator was observed to be providing the resident 3.5 liters of oxygen per minute. The resident's order was for 2 liters of oxygen per minute. On 02/26/25 at 9:36 a.m., Resident #7's oxygen concentrator was observed to be providing the resident 3 liters of oxygen per minute. On 02/26/25 at 11:14 a.m., Resident #7's oxygen concentrator was observed by the ADON and this surveyor. The concentrator was working and set to 3 liters per minute. The resident's order was for 2 liters of oxygen per minute. An undated Policy and Procedure of Respiratory Care, read in part, Record oxygen therapy on treatment record: time tanks are changed, rate of flow of concentration, tolerance, chart pertinent observations. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. A document titled Patient Care Order (Verbal Order), dated 08/29/24 at 4:32 p.m., showed Resident #7 was to be administered a continuos flow of oxygen at a rate of 2 liters every minute. On 02/25/25 at 12:20 p.m., a family member of Resident #7 stated the resident required oxygen at all times. On 02/26/25 at 9:20 a.m., LPN #1, stated Resident #7 was suppose to get 2 liters per minute of oxygen at all times. They were asked to look at the orders in the resident's medical record and confirm that oxygen level. After looking, LPN #1 stated they did not see an order for oxygen in the EHR. They were asked where else the level could be found and they stated the care plan. LPN #1 looked at the care plan and stated the oxygen level was not in the resident's care plan. LPN #1 stated there should be an order, then stated they recalled there was a standing order for newly admitted residents to get 2 liters of oxygen for every resident who required oxygen. They stated Resident #7 was not a new resident. They stated they did not know where the resident's order was. On 02/26/25 at 9:27 a.m., the ADON stated the order for oxygen should be in a resident's EHR in every case. They stated that is where staff look to find such orders. They were asked to find where the resident's oxygen use was care planned. They stated they had looked at the resident's care plan and there was not an entry for oxygen use. On 02/26/25 at 11:10 a.m., ADON stated they had located an order for oxygen use in Resident #7's EHR in the miscellaneous section. The order, dated 08/29/24, documented the resident was to have continuously received 2 liters of oxygen per minute. They were asked if temporary agency nurses work at the facility. The ADON stated they did. The ADON was asked where those nurses look to find the orders to follow when they care for a resident. They stated they look in the orders section of the EHR and the care plan. They stated they would not look in the miscellaneous section of the chart. On 02/27/25 at 10:48 a.m., DON stated they thought there had been a breakdown in communication in that case between the facility staff and hospice staff. They stated both had failed to take the hospice order and move it into the resident's EHR.

Based on record review and interview, the facility failed to ensure psychotropic medications ordered on an as needed basis were limited to a 14 day course for 2 (#7 and #31) of 5 sampled residents reviewed for unnecessary medications. The ADON stated the facility had 11 residents who had PRN psychotropic medications. Findings: A Policy and Procedure for Drug Regiment Review, dated 04/10/17, read in part, The physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is no change in the medication, the physician will document his/her rationale for the decision in the resident's medical record. 1. Resident #7 had diagnoses which included anxiety disorder. A physician's order, dated 12/18/24 at 11:15 a.m., showed Resident #7 was to be administered lorazepam (antianxiety medication) 0.5mg every 4 hours as needed. The order end date was documented as, Indefinite. A pharmacy consult report, dated 12/18/24, read in part, Please evaluate and verify the desire to use 14-day rule - Lorazepam 0.5 Q4H PRN (increased risk of sedation and falls). In addition, new PRN orders are limited to 14 days and require a prescriber to evaluate the resident prior to extending the order. The report also contained the physician response to change the order to Ativan (lorazepam] 0.5mg three times daily. Resident #7's MAR for December 2024, January 2025, and February 2025 found the order for lorazepam 0.5mg every 4 hours as needed remained on the documents. The February 2025 MAR documented the resident received two doses of the medication on 02/19/25 and 02/20/25. 2. Resident #31 had diagnoses which included insomnia. A physician's order, dated 05/24/24 at 3:00 p.m., showed Resident #31 was to be administered temazepam (hypnotic medication) 15mg every 24 hours as needed. The order end date was documented as, Indefinite. A pharmacy consult report, dated 05/27/24, read in part, Please evaluate and verify the desire to use 14-day rule - Temazepam 15 Q 24H PRN (increased risk of sedation and falls). In addition, new PRN orders are limited to 14 days and require a prescriber to evaluate the resident prior to extending the order. The report also contained the physician response that read, [They] does not sleep well. The physician did not document a rationale why the medication should have remained a PRN order or an end date. A pharmacy consult report, dated 06/27/24, read in part, Temazepam 15mg Q 24H PRN - Please note orders for PRN psychotropics are limited to 14 days then reassess . The area of the form for a physician to respond to the pharmacists report was blank. The MAR entries for the dates on and between 08/01/24 and 02/27/25 were reviewed. The MAR showed Resident #31 had received 81 doses of the medication during the reviewed time period. On 02/27/25 at 9:13 a.m., the ADON stated they had reviewed the pharmacy consult reports for the Resident #7 and #31 and did not find any where the physician had addressed the rationale for extending PRN medications beyond 14 days or where they may have given an end date. The ADON stated it was the facility's expectation physicians would address pharmacy consult reports and provide the required rationales or other response required. On 02/27/25 at 9:15 a.m., the DON stated they understood that in regards to Resident #7 and #31 the responses to the pharmacist consultation reports did not meet regulatory requirements and a rationale and end date for the PRN psychotropics should have been provided.

Based on observation, record review, and interview, the facility failed to: a. ensure the dish machine temperature and sanitizer concentration were monitored and logged daily; b. open containers of food were labeled with an opened on date; c. food was not stored on the floor; and d. food storage temperatures were documented. The ADON reported 36 residents received meals from the kitchen. Findings: On 02/25/25 at 8:20 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. the Dish Machine Monthly Check Sheet, dated 02/25, had no documented temperatures or chemical concentrations since 02/19/25; b. open containers of 2% milk, cranberry juice, mayonnaise, and ketchup were observed in a refrigerator without documentation of the date they were opened; d. a large bag of blueberry muffin mix was observed on the floor in the storage room; and c. the Regular/Pureed Meal Temperature Log, dated 02/25 did not document the holding temperatures of meals served on 02/20/25, 02/21/25, 02/22/25, 02/23/25, or 02/24/25. On 02/26/25 at 11:52 a.m., the DM stated the dish machine temperature and chemical concentration should be completed three times a day. They also stated food items should be labeled with a date the items were opened. The DM stated food holding temperatures should be monitored and recorded for each meal and food should not be stored on the floor.

Based on observation, record review, and interview, the facility failed to ensure catheter bags were not on the floor for 1 (#141) of 1 sampled resident reviewed for urinary catheters. The ADON reported one resident used a urinary catheter. Findings: On 02/26/25 at 3:44 p.m., CNA #1 and LPN #1 were observed providing catheter care for Resident #141. Upon entering the room, Resident 141's catheter bag was observed on the floor. During catheter care CNA #1 picked the catheter bag up off the floor, moved it over and set it back on the floor. After catheter care was completed LPN #1 was observed to hang the catheter bag off the floor. On 02/27/25 at 10:20 a.m., Resident #141's catheter bag was observed laying on the floor under the resident's bed. An undated facility document titled Catheter Care Policy, read in part, Avoid letting the drainage bag touch the floor. Resident #141 had diagnoses which included diabetes mellitus and urinary tract infection. A care plan, initiated on 02/24/25, showed Resident #141 had an indwelling urinary catheter. On 02/26/25 at 4:00 p.m., CNA #1 stated the catheter bag should not be on the floor, and they should have hung it back up when they noticed it was on the floor. On 02/26/25 at 4:01 p.m., LPN #1 stated catheter bags should not be on the floor. On 02/27/25 at 9:45 a.m., the ADON stated catheter bags should not be on the floor.

Based on record review and interview, the facility failed to ensure an admission MDS assessment was completed within 14 days of admission for 1 (#141) of 5 sampled residents reviewed for MDS assessments. The ADON reported the facility census was 36. Findings: An undated facility document titled Policy and Procedure for Frequency of Completion of MDS, read in part, This facility will fulfill its obligation of assessing new residents no later than fourteen (14) days after the date of admission, and may be amended through the twenty-first (21st) day. Resident #141 had diagnoses which included pulmonary fibrosis and diabetes mellitus. Resident #141 was admitted to the facility on [DATE]. An MDS 3.0 assessment summary did not show an admission MDS assessment had been completed for Resident #141. On 02/26/25 at 8:36 a.m., the ADON stated they were in the process of completing a significant change assessment for Resident #141 and it was not completed in 14 days as required. They also stated they should have completed an admission MDS assessment instead of a significant change MDS because the resident was a new admission.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (#141) of 5 sampled residents reviewed for unnecessary medications. The ADON reported that the facility census was 36. Findings: An undated facility document titled Policy and Procedure Regarding Resident Care Plan, read in part, Effective November 28,2017, the facility will establish and implement a baseline care plan that will be developed within 48 hours of admission. Resident #141 had diagnoses which included pulmonary fibrosis and diabetes mellitus. A review of Resident #141's medical record did show a baseline care plan had been completed. On 02/26/25 at 11:11 a.m., the ADON stated a baseline care plan could not be located for resident #141. They also stated baseline care plans should be completed within 48 hours of admission.

Based on record review and interview, the facility failed to ensure base line care plans were completed for two (#88, and #89) of twelve sampled residents reviewed for base line care plans. A CMS-671, dated 12/15/23, documented 35 residents resided in the facility. Findings: A policy and procedure titled Resident Care Plan, revised date 03/27/17, read in part, .The facility will insure that upon admission, each resident will receive an initial care plan that identified the basic care needs such as toileting, bathing, nourishment, personal hygiene, fall prevention, wound prevention, and medical care . 1. Resident #88 had diagnoses which included acute respiratory failure, atherosclerotic heart disease, and chronic combined systolic and diastolic heart failure. The resident was admitted to the facility on [DATE]. A review of Resident #88's medical record did not find a base line care plan. The resident was admitted to the facility on [DATE]. 2. Resident #89 had diagnoses which included atrioventricular block, cardiac arrhythmia, and developmental disorder of speech and language. A review of Resident #88's medical record did not find a base line care plan. On 12/15/23 at 11:58 a.m., the ADON stated the base line care plans for Residents #88 and #89 had not been done. They stated it had been their job to create the base line care plans when each had been admitted but their creation had been overlooked.

Based on record review and interview, the facility failed to fully develop comprehensive care plans for two (#28 and #31) of fourteen residents reviewed for care plans. The DON reported the facility census was 35. Findings: The facility's Resident Care Plan policy, revised date 03/27/17, read in part, .The care plan will be developed with measurable goals to meet the Resident's identified medical, nursing, mental and psycho-social needs. It will include any services that are identified as needed to be provided and any services the Resident refuses or chooses not to receive . 1. Resident #28 had diagnoses which included dementia and hypertension. A significant change assessment, dated 8/7/23, documented Resident #28 had moderately impaired cognition and required extensive assistance from staff. A physician order, dated 08/07/23, documented the resident was admitted to hospice care. A review of the resident's comprehensive care plan did not document hospice care had been incorporated into the resident's comprehensive plan of care. On 12/18/23 at 10:00 a.m., the ADON stated that hospice care should be included in a resident's plan of care. On 12/19/23 at 9:00 a.m., the DON stated hospice care should be included on the resident's comprehensive care plan. 2. Resident #31 had diagnoses which included age-related physical debility and depression. An admission assessment, dated 07/17/23, documented in the behavioral section the resident rejected care one to three days during the assessment period. A review of the resident's current comprehensive care plan, revised date 10/20/23, did not find a focus or goal dedicated to rejection of care. On 12/18/23 at 10:52 a.m., the ADON stated when rejection of care had triggered on the admission assessment, dated 07/17/23, a focus, goal, and interventions should have been created in the resident's comprehensive care plan.

Based on record review and interview the facility failed to ensure that a physician order was clarified and administered for one (#1) of one resident reviewed for following physician orders. The DON reported the census was 35. Findings: Resident #1 had diagnoses including neuromuscular disfunction of bladder and hypertension. An annual assessment, dated 11/14/23, documented the resident had severe cognitive impairment and was always incontinent. A physician order, dated 12/10/23, documented Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1000 mg intravenously every 12 hours every 5 days . A treatment administration record for December 2023 documented Meropenem was administered at 9:00 p.m. on 12/10/23, this was the only dose documented to be administered or held on the MAR or TAR. On 12/18/23 at 12:06 p.m., the ADON displayed 3 doses of meropenem and stated they had ordered ten doses from the pharmacy so 7 doses had been administered to the resident. On 12/18/23 at 12:53 p.m., RN #1 stated they were on duty when Resident #1 returned from the hospital on 12/10/23 and that they put in the order for meropenem as every 12 hours every 5 days when it should have been every 12 hours for 5 days. They also stated that they informed the oncoming nurse of this but did not change the order. On 12/18/23 at 1:00 p.m., LPN #1 stated they noticed the order on 12/13/23 and spoke with the ADON about it but did not contact the physician to clarify. They also stated they were unable to administer the medicine because Resident #1 had pulled out their IV. They did document the medicine was held on the MAR or TAR. On 12/19/23 at 08:38 a.m. RN #2 stated they had administered a dose of meropenem. They also stated they did not contact the physician for clarification, and they did not document the medicine was given on the MAR or TAR. On 12/19/23 at 9:00 a.m., the DON stated if a nurse had a question about an order the physician should be contacted and that all medications that were given or held should be documented on the MAR or TAR.

Based on observation, record review, and interview the facility failed to ensure a resident's digoxin and diltiazem were not withheld without a physician's orders for one (#5) of nine sampled residents reviewed for medications administration. A CMS-671, dated 12/15/23, documented 35 residents resided in the facility. Findings: Resident #5 had diagnoses which included acute on chronic combined systolic and diastolic congestive heart failure and chronic atrial fibrillation. A physician's order, dated 11/07/23, documented the resident was to be administered diltiazem HCl ER coated beads oral capsule extended release 24 hour 240 mg one time in the morning related to essential hypertension. The order did not document any blood pressure parameters which would indicate wether to administer or hold the medication. A physician's order, dated 11/07/23, documented the resident was to be administer digoxin oral tablet 125 mcg by mouth once in the morning related to essential hypertension. The order did not document heart rate parameters which would indicate wether to administer or hold the medication. A medication administration record, dated 11/01/23 through 11/30/23, documented digoxin 125 mcg was not administered to Resident #5 on 11/21/23 and 11/29/23 because the vitals signs were outside of parameters to administer. The record also documented diltiazem HCl ER 240 mg was not administered to Resident #5 on 11/21/23, 11/24/23, and 11/29/23 because the vitals signs were outside of parameters to administer. The record did not document vital sign parameters for either medication. A medication administration record, dated 12/01/23 through 12/31/23, documented digoxin 125 mcg was not administered to Resident #5 on 12/01/23, 12/04/23, 12/06/23, 12/07/23, 12/10/23, 12/11/23, 12/12/23, 12/13/23, 12/14/23, 12/15/23, 12/16/23, 12/17/23, and 12/18/23 because the vital signs were outside of parameters to administer. The record also documented diltiazem HCl ER 240 mg was not administered to Resident #5 on 12/01/23, 12/04/23, 12/06/23, 12/07/23, 12/10/23, 12/11/23, 12/12/23, 12/14/23, 12/15/23, 12/16/23, 12/17/23, and 12/18/23 because the vital signs were outside of parameters to administer. The record did not document vital sign parameters for either medication. On 12/18/23 at 9:00 a.m., CMA #1 was observed administering medications to Resident #5. CMA #1 measured the resident blood pressure and pulse. They then stated the resident's vital signs were too low to administer the resident's prescribed digoxin and diltiazam. They then administered the resident's other medications and moved on to the next resident. On 12/19/23 at 8:08 a.m., the ADON stated they did not see any vital sign parameters in the orders for Resident #5's digoxin or diltiazem orders. They stated they believed the CMA's may have recalled parameters for those medications for previous residents and were going by memory. At 8:51 a.m., CMA #2 stated they had not administered Resident #5's medication yet that day. They reviewed the digoxin and diltiazem orders and stated they did not see vital sign parameters for the medications. They stated they knew from CMA training and experience that if a pulse was below 60 beats per minute they would hold those medications. At 9:04 a.m. the DON stated the two medication should each have vital sign parameters for holding. They stated they were unaware they did not. They stated their expectation is that a CMA would inform a nurse anytime they were [NAME] to hold a medication especially without parameters. At 11:56 a.m., the ADON stated there was no order for digoxin levels for Resident #5 and there was no documentation in their medical record that digoxin levels had been obtained from Resident #5 since admission. At 12:03 p.m., the DON stated digoxin needed to be in a certain level in the blood stream to be effective. They stated they currently did not have a process to ensure someone on digoxin also had an order for the appropriate lab work. They stated there were no other current residents prescribed digoxin at that time.

Based on observation and interview, the facility failed to ensure that catheter bags were covered for one (#1) of one resident reviewed for urinary catheters. The DON reported three residents in the facility had urinary catheters. Findings: Resident #1 had diagnoses including neuromuscular dysfunction of bladder and hypertension. An annual assessment, dated 11/14/23, documented the resident had severe cognitive impairment and was always incontinent. On 12/14/23 at 12:20 p.m., Resident #1 was observed attending a Christmas activity in the common area of the facility. A catheter bag was observed to be hanging under the resident's chair; the bag was not covered. On 12/14/23 at 12:37 p.m., Resident #1 was observed in the dining room. A catheter bag was observed to be hanging under the resident's chair; the bag was not covered. On 12/18/23 at 10:04 a.m., the ADON stated catheter bags should be covered. On 12/19/23 at 9:04 a.m., the DON stated catheter bags should be covered with a dignity bag.

Based on record review and interview the facility failed to revise a care plan for one (#31) of 14 sampled residents reviewed for care plans. A CMS-671, dated 12/15/23, documented 35 residents resided in the facility. Findings: The facility's Resident Care Plan policy, revised date 03/27/17, read in part, .The comprehensive care plan will be reviewed and updated by the IDT after each quarterly and annual assessment thereafter . Resident #31 had diagnoses which included age-related physical debility and depression. A physician order, dated 07/10/23, documented the resident was to be weighed monthly. An admission assessment, dated 07/17/23, documented in the behavioral section the resident rejected care one to three days during the assessment period. A review of the resident's medical record found two weights had been recorded since admission. On 07/10/23 the residents weight was recorded as 175.0 pounds and on 09/27/23 the weight was recorded as 140.0 pounds. A review of the resident's current comprehensive care plan, revised date 10/20/23, did not find a focus or goal dedicated to rejection of care. The care plan had a focus and goals regarding nutrition with the related interventions to offer health shakes if the resident eats less that 50% of meals and to weight the resident monthly and record the weights in the medical record. A nutrition/dietary note, dated 11/07/23, documented the resident refused to have their weight measured. A physician order, dated 11/30/23, documented the resident was to received a house supplement [health shake] with each meal. A nutrition/dietary note, dated 12/05/23, documented the resident refused to have their weight measured. On 12/14/23 at 11:01 a.m., a resident representative stated the resident was only drinking health shakes and refusing to eat offered meals and they believed that was causing weight loss. On 12/18/23 at 10:52 a.m., the ADON stated when rejection of care had triggered on the admission assessment, dated 07/17/23, a focus, goal, and interventions should have been created in the resident's comprehensive care plan. They stated the rejection of meals, measurement of weights, and the correct order for health shakes should have been added to the care plan.

Based on observation, interview, and record review, it was determined the facility failed to implement their abuse policy to prevent abuse, report allegations of abuse and protect residents from the liklihood of further abuse for one (#1) of three sampled residents who were reviewed for abuse. Resident #1 had been video recorded with a cell phone, by a staff member, while partially undressed and being toileted. The video was then posted to a social media site. The DON identified 62 residents who resided in the facility. Findings: An undated abuse, neglect, and misappropriation of client/resident property policy documented, .ABUSE: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .The facility trains staff initially when employed and periodically throughout the year and as needed .Training shall include the need for reporting all incidents .Any employee that is told of an allegation or observes abuse .shall report immediately to the individual who is in charge of the facility and the Administrator . A staff inservice record, dated 01/22/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, HIPPA, and social media. A staff inservice record, dated 03/18/16, documented the facility conducted a staff inservice which included resident rights and HIPPA. A staff inservice record, dated 04/01/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, social media, and HIPPA. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/14/16, documented the resident had short and long term memory loss, was severely impaired cognitively for daily decision making, and required extensive assistance with most ADLs. A staff inservice record, dated 10/04/16, documented the facility conducted a staff inservice which included cell phone usage. A staff inservice record, dated 10/18/16, documented the facility conducted a staff inservice which included cell phone usage. A state reported incident, dated 10/29/16 at 11:36 a.m., documented CNA #1 had reported to LPN #1 that CNA #2 had posted a video of resident #1 on a social media site. The report documented CNA #2 had been terminated. A written statement by CNA #1, dated 10/29/16, documented she had seen a video on a social media site of resident #1 on (MONTH) 26th or 27th. She stated CNA #2 had posted the video of the resident. The video showed the resident sitting on the toilet and he was talking or singing. CNA #1 stated the resident's face and privates had been colored out. A written statement by CNA #4, dated 10/29/16, documented she had viewed the social media posting of resident #1 on her cell phone while at home on her day off. She stated the video showed the resident sitting on the toilet in the shower room. She stated the resident's face had been altered but was still recognizable. She stated the posting contained the caption, another day in paradise with a laughing emoji. A written statement by CNA #6, dated 10/29/16, documented she had viewed a social media posting of resident #1 on her cell phone. She stated the resident was sitting on the toilet and his face and private area had been blurred. A written statement by CNA #7, dated 10/29/16, documented a video of resident #1 had been posted around the middle of the week. She stated the video showed the resident being toileted with his face and private area covered. A statement signed by the administrator and DON, dated 10/29/16 at 5:55 p.m., documented the police department had been notified regarding the video of resident #1 that had been posted to a social media site and an investigation had been initiated. A statement signed by the administrator and DON, dated 10/29/16 at 8:00 p.m., documented resident #1's wife had been notified that a video had been taken of her husband and had been posted to social media. The statement documented the wife was informed an investigation had been initiated, the OSDH and nurse aide registry would be notified, and the police department had been notified. A facsimile report, dated 10/29/16 at 9:28 p.m., documented the facility had submitted an initial investigative report to OSDH and the nurse aide registry. A written statement by CNA #8, dated 10/31/16, documented she had opened the video posted to the social media site on her cell phone but did not view the entire video because it was difficult to understand. Employee warning documents dated 10/31/16, documented CNA #1, CNA #4, CNA #6, CNA #7, and CNA #8 had received a written warning related to the delayed reporting of the posted video to social media. A staff inservice record, dated 11/01/16, documented the facility, in conjunction with a local law enforcement officer, conducted a staff inservice which included HIPPA; social media posting; state statutes; law enforcement codes; promptness of reporting immediately to charge nurse or administration of HIPPA, resident rights, abuse, neglect, or misappropriation of funds violations; and the prohibited use of cell phones inside the facility. A staff inservice record, dated 11/15/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, the prohibited use of cell phones, social media, HIPPA, and immediate reporting. On 11/21/16 at 11:45 a.m., CNA #1 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would report it to the charge nurse or DON. The CNA was asked when she would report it. She stated she would report it when it happened. The CNA was asked why she had not reported the video posting of resident #1 for three days. She stated she and CNA #2 had had problems in the past and she thought one of the other staff who had seen the video would report it. On 11/21/16 at 12:00 p.m., CNA #4 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would inform someone immediately. CNA #4 was asked why she had not reported the video posting of resident #1. She stated she had viewed the video while at home on her day off. She stated she did not know what to do at the time. CNA #4 stated once she learned the charge nurse had been notified by CNA #1, she knew she needed to report it as well. On 11/21/16 at 12:45 p.m., the administrator was asked what she had done once she became aware of the video posting of resident #1. She stated when she received the report of what had happened, she immediately began her investigation. She stated cell phones were prohibited from the building beginning 10/29/16. She stated staff and residents had been interviewed, reports were filed with OSDH, the nurse aide registry, and the police department. She stated CNA #2 had been terminated on 10/29/16. The administrator stated she held inservices in conjunction with the police department detailing state statutes and the seriousness of posting any material to social media sites. The administrator stated she had attended an inservice regarding new CMS guidance related to social media and resident abuse on Thursday 11/17/16 and had written new policies regarding social media and abuse. On 11/21/16 at 1:13 p.m., resident #2's wife was contacted by telephone. She stated she had been informed by the administrator on 10/29/16 that the resident had been videoed while being toileted by CNA #1 and CNA#1 had posted the video on social media. The resident's wife was asked if she thought the resident would remember the incident. She stated absolutely not, that he did not know what went on from one minute to the next. She was asked how he may have felt had he known. She stated he had been a very private person and she thought he would have felt disrespected. The resident's wife stated she cared for him at home as long as she could. She stated he became too difficult to manage at home and so he was placed in long term care. The resident's wife was asked how this made her feel. She stated she expected him to be treated with respect and this hurt.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's privacy was not violated for one (#1) of three sampled residents who were reviewed for privacy. Resident #1 had been video recorded with a cell phone, by a staff member, while partially undressed and being toileted. The video was then posted to a social media site. This resulted in the resident's privacy being violated. The DON identified 62 residents who resided in the facility. Findings: A resident's civil rights and resident's legal rights policy, updated 07/23/12, documented, .Every resident shall receive respect and privacy in the resident's medical care program .Every resident shall have the right to receive courteous and respectful care and treatment .Every resident shall be free from mental and physical abuse . Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/14/16, documented the resident had short and long term memory loss, was severely impaired cognitively for daily decision making, and required extensive assistance with most ADLs. A staff inservice record, dated 10/04/16, documented the facility conducted a staff inservice which included cell phone usage. A staff inservice record, dated 10/18/16, documented the facility conducted a staff inservice which included cell phone usage. A state reported incident, dated 10/29/16 at 11:36 a.m., documented CNA #1 had reported to LPN #1 that CNA #2 had posted a video of resident #1 on a social media site. The report documented CNA #2 had been terminated. A written statement by CNA #1, dated 10/29/16, documented she had seen a video on a social media site of resident #1 on (MONTH) 26th or 27th. She stated CNA #2 had posted the video of the resident. The video showed the resident sitting on the toilet and he was talking or singing. CNA #1 stated the resident's face and privates had been colored out. A written statement by CNA #4, dated 10/29/16, documented she had viewed the social media posting of resident #1 on her cell phone while at home on her day off. She stated the video showed the resident sitting on the toilet in the shower room. She stated the resident's face had been altered but was still recognizable. She stated the posting contained the caption, another day in paradise with a laughing emoji. A written statement by CNA #6, dated 10/29/16, documented she had viewed a social media posting of resident #1 on her cell phone. She stated the resident was sitting on the toilet and his face and private area had been blurred. A written statement by CNA #7, dated 10/29/16, documented a video of resident #1 had been posted around the middle of the week. She stated the video showed the resident being toileted with his face and private area covered. A statement signed by the administrator and DON, dated 10/29/16 at 5:55 p.m., documented the police department had been notified regarding the video of resident #1 that had been posted to a social media site and an investigation had been initiated. A statement signed by the administrator and DON, dated 10/29/16 at 8:00 p.m., documented resident #1's wife had been notified that a video had been taken of her husband and had been posted to social media. The statement documented the wife was informed an investigation had been initiated, the OSDH and nurse aide registry would be notified, and the police department had been notified. A facsimile report, dated 10/29/16 at 9:28 p.m., documented the facility had submitted an initial investigative report to OSDH and the nurse aide registry. A written statement by CNA #8, dated 10/31/16, documented she had opened the video posted to the social media site on her cell phone but did not view the entire video because it was difficult to understand. Employee warning documents, dated 10/31/16, documented CNA #1, CNA #4, CNA #6, CNA #7, and CNA #8 had received a written warning related to the delayed reporting of the posted video to social media. A staff inservice record, dated 11/01/16, documented the facility, in conjunction with a local law enforcement officer, conducted a staff inservice which included HIPPA; social media posting; state statutes; law enforcement codes; promptness of reporting immediately to charge nurse or administration of HIPPA, resident rights, abuse, neglect, or misappropriation of funds violations; and the prohibited use of cell phones inside the facility. A staff inservice record, dated 11/15/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, the prohibited use of cell phones, social media, HIPPA, and immediate reporting. On 11/21/16 at 11:45 a.m., CNA #1 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would report it to the charge nurse or DON. The CNA was asked when she would report it. She stated she would report it when it happened. The CNA was asked why she had not reported the video posting of resident #1 for three days. She stated she and CNA #2 had had problems in the past and she thought one of the other staff who had seen the video would report it. On 11/21/16 at 12:00 p.m., CNA #4 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would inform someone immediately. CNA #4 was asked why she had not reported the video posting of resident #1. She stated she had viewed the video while at home on her day off. She stated she did not know what to do at the time. CNA #4 stated once she learned the charge nurse had been notified by CNA #1, she knew she needed to report it as well. On 11/21/16 at 12:45 p.m., the administrator was asked what she had done once she became aware of the video posting of resident #1. She stated when she received the report of what had happened, she immediately began her investigation. She stated cell phones were prohibited from the building beginning 10/29/16. She stated staff and residents had been interviewed, reports were filed with OSDH, the nurse aide registry, and the police department. She stated CNA #2 had been terminated on 10/29/16. The administrator stated she held inservices in conjunction with the police department detailing state statutes and the seriousness of posting any material to social media sites. The administrator stated she had attended an inservice regarding new CMS guidance related to social media and resident abuse on Thursday 11/17/16 and had written new policies regarding social media and abuse. On 11/21/16 at 1:13 p.m., resident #2's wife was contacted by telephone. She stated she had been informed by the administrator on 10/29/16 that the resident had been videoed while being toileted by CNA #1 and CNA#1 had posted the video on social media. The resident's wife was asked if she thought the resident would remember the incident. She stated absolutely not, that he did not know what went on from one minute to the next. She was asked how he may have felt had he known. She stated he had been a very private person and she thought he would have felt disrespected. The resident's wife stated she had cared for him at home as long as she could. She stated he became too difficult to manage at home and so he was placed in long term care. The resident's wife was asked how this made her feel. She stated she expected him to be treated with respect and this hurt.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident was free from mental abuse for one (#1) of three sampled residents who were reviewed for abuse, neglect, and exploitation. Resident #1 had been video recorded with a cell phone, by a staff member, while partially undressed and being toileted. The video was then posted to a social media site. This had the potential to affect the 62 residents who resided in the facility. Findings: An undated abuse policy documented, .Any employee that is told of an allegation or observes abuse, neglect, or misappropriation of property, by an employee, visitor, family member or other person .shall report immediately to the individual who is in charge of the facility and the Administrator . A staff inservice record, dated 01/22/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, HIPPA, and social media. A staff inservice record, dated 03/18/16, documented the facility conducted a staff inservice which included resident rights and HIPPA. A staff inservice record, dated 04/01/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, social media, and HIPPA. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/14/16, documented the resident had short and long term memory loss, was severely impaired cognitively for daily decision making, and required extensive assistance with most ADLs. A staff inservice record, dated 10/04/16, documented the facility conducted a staff inservice which included cell phone usage. A staff inservice record, dated 10/18/16, documented the facility conducted a staff inservice which included cell phone usage. A state reported incident, dated 10/29/16 at 11:36 a.m., documented CNA #1 had reported to LPN #1 that CNA #2 had posted a video of resident #1 on a social media site. The report documented CNA #2 had been terminated. A written statement by CNA #1, dated 10/29/16, documented she had seen a video on a social media site of resident #1 on (MONTH) 26th or 27th. She stated CNA #2 had posted the video of the resident. The video showed the resident sitting on the toilet and he was talking or singing. CNA #1 stated the resident's face and privates had been colored out. A written statement by CNA #4, dated 10/29/16, documented she had viewed the social media posting of resident #1 on her cell phone while at home on her day off. She stated the video showed the resident sitting on the toilet in the shower room. She stated the resident's face had been altered but was still recognizable. She stated the posting contained the caption, another day in paradise with a laughing emoji. A written statement by CNA #6, dated 10/29/16, documented she had viewed a social media posting of resident #1 on her cell phone. She stated the resident was sitting on the toilet and his face and private area had been blurred. A written statement by CNA #7, dated 10/29/16, documented a video of resident #1 had been posted around the middle of the week. She stated the video showed the resident being toileted with his face and private area covered. A statement signed by the administrator and DON, dated 10/29/16 at 5:55 p.m., documented the police department had been notified regarding the video of resident #1 that had been posted to a social media site and an investigation had been initiated. A statement signed by the administrator and DON, dated 10/29/16 at 8:00 p.m., documented resident #1's wife had been notified that a video had been taken of her husband and had been posted to social media. The statement documented the wife was informed an investigation had been initiated, the OSDH and nurse aide registry would be notified, and the police department had been notified. A facsimile report, dated 10/29/16 at 9:28 p.m., documented the facility had submitted an initial investigative report to OSDH and the nurse aide registry. A written statement by CNA #8, dated 10/31/16, documented she had opened the video posted to the social media site on her cell phone but did not view the entire video because it was difficult to understand. Employee warning documents, dated 10/31/16, documented CNA #1, CNA #4, CNA #6, CNA #7, and CNA #8 had received a written warning related to the delayed reporting of the posted video to social media. A staff inservice record, dated 11/01/16, documented the facility, in conjunction with a local law enforcement officer, conducted a staff inservice which included HIPPA; social media posting; state statutes; law enforcement codes; promptness of reporting immediately to charge nurse or administration of HIPPA, resident rights, abuse, neglect, or misappropriation of funds violations; and the prohibited use of cell phones inside the facility. A staff inservice record, dated 11/15/16, documented the facility conducted a staff inservice which included abuse, neglect, misappropriation of property, the prohibited use of cell phones, social media, HIPPA, and immediate reporting. On 11/21/16 at 11:45 a.m., CNA #1 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would report it to the charge nurse or DON. The CNA was asked when she would report it. She stated she would report it when it happened. The CNA was asked why she had not reported the video posting of resident #1 for three days. She stated she and CNA #2 had had problems in the past and she thought one of the other staff who had seen the video would report it. On 11/21/16 at 12:00 p.m., CNA #4 was asked what she would do if she suspected or witnessed the abuse or neglect of a resident. She stated she would inform someone immediately. CNA #4 was asked why she had not reported the video posting of resident #1. She stated she had viewed the video while at home on her day off. She stated she did not know what to do at the time. CNA #4 stated once she learned the charge nurse had been notified by CNA #1, she knew she needed to report it as well. On 11/21/16 at 12:45 p.m., the administrator was asked what she had done once she became aware of the video posting of resident #1. She stated when she received the report of what had happened, she immediately began her investigation. She stated cell phones were prohibited from the building beginning 10/29/16. She stated staff and residents had been interviewed, reports were filed with OSDH, the nurse aide registry, and the police department. She stated CNA #2 had been terminated on 10/29/16. The administrator stated she held inservices in conjunction with the police department detailing state statutes and the seriousness of posting any material to social media sites. The administrator stated she had attended an inservice regarding new CMS guidance related to social media and resident abuse on Thursday 11/17/16 and had written new policies regarding social media and abuse. On 11/21/16 at 1:13 p.m., resident #2's wife was contacted by telephone. She stated she had been informed by the administrator on 10/29/16 that the resident had been videoed while being toileted by CNA #1 and CNA#1 had posted the video on social media. The resident's wife was asked if she thought the resident would remember the incident. She stated absolutely not, that he did not know what went on from one minute to the next. She was asked how he may have felt had he known. She stated he had been a very private person and she thought he would have felt disrespected. The resident's wife stated she cared for him at home as long as she could. She stated he became too difficult to manage at home and so he was placed in long term care. The resident's wife was asked how this made her feel. She stated she expected him to be treated with respect and this hurt.