Lenawee Medical Care Facility

Based on observation, interview, and record review, the facility failed to respect the right to privacy for one (R1) of three reviewed.

Findings include:

Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, vascular dementia, and major depressive disorder.

The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/25 revealed R1 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

Review of the facility's investigation revealed Witness G showed Human Resources Assistant (HRA) D videos that Certified Nursing Assistant (CNA) E recorded while in resident rooms and sent to CNA F.

The investigation revealed The second video [Witness G] showed [HRA D] was of the same staff member [CNA E] recording one of our residents in Windsor Ridge while her back was to the camera and resident was on the phone with someone. At the end of the video, the staff member turns the camera on herself, and I [HRA D] was able to verify the second video was also recorded by [CNA E]. On 9/22/25 at 10:52 AM, the above-mentioned video was observed with Corporate Compliance & Quality Assurance Manager (CCQAM) C.

The video was recorded from behind a resident as she sat in her wheelchair in front of her television, while talking on the telephone in her room. At the end, the video turns to CNA E's face. CCQAM C reported the resident in the video was R1 who was not aware that she had been recorded. On 9/22/25 at 9:18 AM, R1 was observed in a wheelchair in her room.

R1 was not aware of any instances of being recorded.

When asked how she would feel about being recorded, R1 stated it would depend on what it would be. In a telephone interview on 9/22/25 at 10:47 AM, CNA F reported they received one video via social media messenger from CNA E. CNA F reported CNA E recorded a video while in a resident's room and the back of a resident's head was seen in the video. CNA F reported herself and Witness G shared a social media account and that is how Witness G acquired the video. In a telephone interview on 9/22/25 at 11:14 AM, CNA E reported they recorded a video in R1's room as a way of their own complaining and documentation of false allegations that were happening against us at that time. CNA E reported R1 turned her call light on, she responded, and R1 shooed her away because she was on the telephone. CNA E reported she then took a video and sent it to CNA F In an interview on 9/22/25 at 10:26 AM, HRA D reported CNA E was terminated from employment due to violating the facility's policy of no photography or video recordings on the property, not treating R1 with respect, and violating R1's right to privacy.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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