**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149175. Based on interview and record review the facility failed to ensure residents privacy was maintained for two residents (R16 and R22) out of 20 residents reviewed for residents' rights. Findings include: Review of a facility reported incident sent to the state agency dated 12/20/24, reported a staff member sent videos to a coworker using Instagram (social media) using private messaging. R16 Review of electronic medical records (EMR) documented R16 was initially admitted into the facility on 5/3/15 with a pertinent diagnosis of Alzheimer's disease (common cause of Dementia and memory loss). Review of Brief interview for Mental Status (BIMS) dated 10/7/24, R16 scored 3 out of 15 (severe cognitive impairment). Review of Minimum Data Set (MDS) dated [DATE], documented R16 required substantial/maximal assist with most Activities of Daily Living (ADLS). An interview was conducted on 1/12/25 at 11:25 AM with R16, resident had no recollection of the event. Review of Video 2.mov (no date) revealed Resident Assistant (RA) A standing in front of R16 eating a cookie. A caption at the bottom of the screen noted, Eating a cookie and dripping all the crumbs on the devil's floor because she beats me on a regular. R22 Review of EMR documented R22 was initially admitted into the facility on 6/5/17 with a pertinent diagnosis of dementia (a group of symptoms affecting memor). Review of Brief interview for Mental Status (BIMS) dated 11/14/24, R22 scored 1out of 15 (severe cognitive impairment). Review of Minimum Data Set (MDS) dated [DATE], documented R22 required substantial/maximal assist with most Activities of Daily Living (ADLS). An interview was conducted on 1/12/25 at 12:15 PM, R22 was not able to respond appropriately related to impaired cognition. Review of Video 2.mov (no date) RA A's video revealed an empty plastic drinking cup on the floor, RA A then holding a cat, followed by another empty plastic drinking cup on the floor. Finally, R22 sitting in a wheelchair. A caption at the bottom of the screen noted, Came back and (R22) took my Dr. Pepper (soda) drank all of it and then put it on the floor. An interview was conducted with Social Worker (SW) B on 1/14/25 at 10:03 AM, it was reported the video recordings of the residents were inappropriate and was an invasion of the resident's privacy. An interview with Nursing Home Administrator (NHA) on 1/14/25 at 11:30 AM, reported that RA A had made videos using Snapchat (social media) with private messaging and had sent the videos of the two residents (R16 and R22) without any consent. It was further reported that the videos of the residents were an invasion of their privacy. Finally, it was reported by the NHA that RA A was terminated related to the videos of the residents. Review of the facility's policy Personal Communication Devices (Cell Phones) (no date), documented .6.Photographing residents with any and all devices is prohibited.7.Employees who use an electronic device as mentioned above which constitutes an interference with resident care or uses a device in a manner that is profane, indecent, or obscene or constitutes an invasion of privacy will be subject to disciplinary action including termination. Review of admission Booklet (no date), documented Privacy-A resident is entitled to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect, and full recognition of his or her dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an annual PASARR (Preadmission Screening (PAS) Annual Resident Review (AAS) screening, for one resident (R52) of one reviewed for PASARR, resulting in the potential for the lack of adequate mental health care and services. Findings include: Record review of R52's electronic medical record revealed admission into the facility on [DATE] with diagnoses that included hemiplegia (weakness). According to the Minimum Data Set R52 had a BIMS of 15/15, indicating intact cognition. Further review revealed R52 had a new onset of Bipolar Disorder dated 4/5/23. Record review revealed there was no annual PASARR for R52 for 2022 and 2023. On 12/20/23 at 9:10am Social Worker (SW) C was interviewed and reported that the annual PASARR should be completed every year. It was further reported by SW C: that a significant change PASARR should have been completed with new diagnosis of bipolar disorder in May 2023. Record review revealed the Significant Change PASARR was not completed until 12/19/23. The completed Significant Change occurred after survey inquiry. On 12/20/23 at approximately 10:00 AM, the Nursing Home Administrator (NHA) was interviewed and reported that a significant change PASARR should have been completed at the time of the new onset of bipolar disorder which occurred May 2023. The NHA also confirmed that annual PASSAR should be completed in a timely manner. Review of the facility's policy titled Resident Assessment - Coordination with PASARR Program dated August 23, 2023 documented the following: . 6. The social services director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 8. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.

Based on interview and record review the facility failed to ensure Dementia Management training was performed for one Certified Nurse Assistant (CNA) B out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs. Findings include: On 12/19/23 at 2:24 PM, review of five CNAs in-service training education content revealed the following: CNA B Date of hire (DOH)- 8/31/22. Review of a facility provided transcript dated 11/1/22 through 12/19/23 for CNA B, failed to identify dementia management training. On 12/20/23 at 8:42 AM in an interview with Assistant Director of Nursing (ADON)/Staff Development A revealed there was no record of dementia training for CNA B and said the training was due on 9/30/23. When queried about the significance of CNA trainings, ADON A stated, It is important to have trainings for the CNAs to meet their requirements and to provide education for what they do daily to meet resident needs. On 12/20/23 at 9:30 AM in an interview with the Director of Nursing (DON) agreed that CNAs are expected to have yearly training that includes dementia management.