Health inspection·August 8, 2023

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 observation, interview, and record review, the facility failed to maintain the privacy of one of 86 residents (Resident 1) who resided within the facility when a staff member recorded a video of Resident 1 (while inside the facility's dining room) and posted the video on a personal social media platform without Resident 1's approval or consent. Residents Affected - Few This failure resulted in a violation of Resident 1's right to privacy and confidentiality as well as a breach of the Health Insurance Portability and Accountability Act law (HIPPA -a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge). Findings: During a review of Resident 1's admission Record (contains Resident 1's medical and demographic information), undated, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning); Schizoaffective disorder, depressive type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression); Anxiety disorder (mental illnesses that causes constant and overwhelming anxiety and fear); restlessness and agitation. During an interview on May 31, 2023, at 3:26 PM, with the Case Manager 1 (CM 1), CM 1 stated on May 22, 2023, she received a call from a former employee (Licensed Vocational Nurse 1 - LVN 1) who wanted to notify her that there was a video of Resident 1 recorded from within the facility's dining room and posted on the social media platform [name of social media]. CM 1 stated LVN 1 sent her the video and she (CM 1) was able to identify Resident 1, and Certified Nursing Assistant 1 in the video because she could see their faces. CM 1 stated the video recording showed Resident 1 and CNA 1 while in the facility's dining room and the video showed Resident 1 flipping someone off across the room. CM 1 then stated she could see from the video that it was from the social media platform [name of social media] and that it was posted to the social media account of Certified Nursing Assistant 2 (CNA 2). CM 1 stated she forwarded the video to the facility's Administrator (ADMIN). During an interview on June 27, 2023, at 10:50 AM, with ADMIN, the ADMIN stated CM 1 brought to his attention that employee CNA 2 had posted a video of Resident 1 to her (CNA 2's) social media account and that the video was taken from within the facility. The ADMIN further stated when he reviewed the video he could see Resident 1 and CNA 1 in the video who were both flipping off someone while in the facility's dining room. The ADMIN stated the video was approximately 5 seconds long, was sent to him via a text, and you could see that the video was posted to the social media account of CNA 2. (continued on next page) 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 TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056365 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yucaipa Hills Post Acute 13542 2nd St. Yucaipa, CA 92399 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)