Health inspection·July 2, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint numbers CA00966013 and CA00966213. A Class "B" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Title 22 California Code of Regulations: § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (11) To be assured confidential treatment of financial and health records and to approve or refuse their release, except as authorized by law. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. (13) Not to be required to perform services for the facility that are not included for therapeutic purposes in the patient's plan of care. On 6/5/2025, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related resident's privacy not protected. The facility failed to ensure the Certified Nursing Assistant (CNA) 1 did not violate the resident's rights to be treated with respect and dignity and did not subject the resident to humiliation (the feeling of being ashamed or losing respect for yourself) for Resident 1 by failing to ensure: 1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 Responsible Party 1's (RP 1) consent. 2. CNA 1 did not post a video of Resident 1 on social media. As a result, Resident 1's right was violated, not treated with respect and dignity and the potential to subject Resident 1 to humiliation (the act of being made to feel ashamed, embarrassed, or worthless, often publicly). A review of Resident 1's admission records indicated, Resident 1, a 94-year-old male was admitted to the facility on 5/15/2025 with diagnosis including human metapneumovirus pneumonia (HMPV - a type of virus that mostly affects the nose, throat, and lungs. Like the common cold, it can cause symptoms like coughing, wheezing, and a runny nose), dysphagia (difficulty swallowing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, it indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired (having a condition or problem that significantly limits a person's physical or mental ability to perform basic work activities or daily functions). The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 had a total of 12 severity score (moderate depression symptoms) during his mood interview and had mood disturbance such as little interest or pleasure in doing things and feeling down, depressed, or hopeless several days in a week. During a review of an anonymous complaint submitted to the District Office, received on 6/5/2025 at 11:45 a.m., a complaint received regarding CNA 1 who posted a video of Resident 1 on social media with two photos attached to the complaint intake. During an interview with CNA 1 on 6/5/2025 at 2:30 p.m., CNA 1 stated, she (CNA 1) did not take a photo of Resident 1, and she did not share any photos of him on her social media. CNA 1 stated it is not okay to share residents' personal information as it is against the rules. CNA 1 further stated, she worked from 7 a.m. to 11 p.m. (double shift) on 6/4/2025 and will also work double shift today (6/5/2025). During an interview with DON on 6/5/2025 at 2:47 p.m., DON reviewed photos that was attached to the complaint sent to the District Office, and DON stated and confirmed, Photo #1 was of CNA 1 and Photo #2 was of Resident 1. DON stated, there has been a breach on Resident 1's privacy. The DON identified and stated the pictures were that of Resident 1. The DON confirmed and stated that CNA 1 did not follow the facility's policies and procedures regarding: 1. "Videotaping, Photographing, and Other Imaging of Residents" dated 1/2025 which indicated "Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family." 2. "Resident Rights" dated 1/2025, which indicated, "Unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues." 3. "Protected Health Information (PHI - any information about a person's health or healthcare that can be used to identify them), Management and Protection of" dated 1/2025, which indicated Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws." During a follow-up interview with CNA 1 on 6/5/2025 at 2:50 p.m., CNA 1 stated, "Yesterday (6/4/2025), she (CNA 1) was with Resident 1, and he (Resident 1) was making jokes, she (CNA 1) then posted a story on Instagram with him (Resident 1), and I (CNA 1) shouldn't have done that. CNA 1 stated, she did not tell (Resident 1) that everyone would see it (video clip). CNA 1 further stated, she (CNA 1) was texting her friends on Instagram while she was in his (Resident 1's) room in which she Facetime called and posted on her (CNA 1)'s Instagram story. CNA 1 stated having video called (FaceTime) with friends and posting Resident 1's picture on her (CNA1's) personal social media. During an interview with Resident 1 on 6/5/2025 at 3:03 p.m., Resident 1 stated, he did not know that someone took a video of him, and it was posted on social media. Resident 1 stated, "Why would she pick on me like that?". Resident 1 stated he had been trying to keep his stay in the facility low key (a term used by someone who wants to hide or not draw further attention) and no other people knew he was in the facility or why he was there, only him and his RP 1. During a telephone interview on 6/6/2025 at 7:30 a.m., Resident 1's Responsible Party (RP 1) stated on 6/5/2025 at 4:30 p.m. the facility called RP 1 to inform RP 1 of an "incident" in which CNA 1 posted pictures of herself (CNA 1) and Resident 1 in the background on CNA 1's personal social media account. RP1 reported feeling stunned by the incident and did not understand why CNA 1 was in Resident 1's room and why facility staff were allowed to take pictures of residents. RP1 stated HIPAA rights were supposed to protect residents from incidents such as these. RP1 visited Resident 1 on 6/5/2025 after the facility called and stated Resident 1 reported being interviewed the night prior by a staff member. RP 1 was not sure what the extent of damage was as RP1 was not informed how many people saw the picture or what the purpose of posting the picture was. RP1 denied being informed that the picture posted was a direct picture of Resident 1. RP 1 stated it was one thing to post a picture of someone in the background and another to post a direct shot of the person. During the same interview on 6/6/2025 at 7:30 a.m., RP 1 further stated Resident 1 was a very private person and did not ever have social media and would not want to be displayed in such a vulnerable condition to the public. The RP 1 stated Resident 1's rights to privacy, dignity, and respect were violated by the facility and was concerned as to who had access to Resident 1's unauthorized images. RP 1 stated "The rule of thumb is once you put it up on social media it is there forever., it is in the cloud, it is out there forever even if you take it down." RP1 stated Resident 1 was not able to understand or give consent to having a picture taken or posted on social media. RP 1 stated Resident 1 was a very private person and did not have social media or allowed pictures to be taken by family/friends. RP1 stated Resident 1 did not wish to be seen in his current condition. RP 1 stated Resident 1 was an accomplished person and to be made a mockery of and shown in current condition was harmful and degrading to all, Resident 1 is a well accomplished person. RP1 stated Resident 1's dignity was violated and stated any reasonable person would feel violated that can negatively affect their self-esteem. During an interview with Social Services Assistant 1 (SSA 1) and Social Services Assistant 2 (SSA 2) on 6/6/2025 at 11:32 a.m., SSA 1 and SSA 2 stated, it is not allowed to take photos and videos of residents without proper consents. SSA 2 stated, it is a violation of residents' privacy and disrespectful to take photos and videos of residents without a proper form of consents. During an interview with SSD on 6/6/2025 at 12:06 p.m., SSD stated, it is very important and on top of their priority to protect residents' privacy. SSD stated, residents should not be photographed and video recorded without their consents. SSD stated the ADM showed her a short video clip of CNA 1 and Resident 1, in which she was told that it was posted on CNA 1's Instagram story. During an interview with DSD on 6/6/2025 at 12:35 p.m., on 6/5/2025 towards the end of morning shift (7 am - 3:30 p.m.), the DSD stated she was made aware of the incident that CNA 1 took photo and video of Resident 1 and shared it on her social media. DSD stated they have to investigate what happened and CNA 1 went home after that morning shift. DSD reviewed CNA 1's staffing assignment which indicated CNA 1 worked double shift (morning shift to evening shift [3 p.m. - 11 p.m.) on 6/5/2025. DSD stated, she was not aware that CNA 1 continued working on 6/5/2025 after knowing that CNA 1 posted a video of Resident 1 on her social media. During a review of the video clip sent by the ADM on 6/6/2025 at 3:27 p.m., the video clip showed CNA 1 waving with Resident 1 inside Resident 1's room. During a review of Resident 1's Medical Record for consents and email received from the Medical Records Director (MRD) on 6/16/2025 at 5:25pm, as of 6/7/2025, there was no written consent signed by Resident 1 and/or RP 1 regarding release of images or recordings. During a review of the facility's P&P titled, "Videotaping, Photographing, and Other Imaging of Residents", dated 1/2025, the P&P indicated, "Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities ... Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family. Transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such." During a review of the facility's P&P titled, "Resident Rights", dated 1/2025, the P&P indicated "The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer." During a review of the facility's P&P titled, "Telephone, Employee Use of", dated 1/2025, the P&P indicated, "Cellular phones may be used for personal calls and text messaging ONLY when the employee is on authorized meal and break periods. Employee cell phones will remain off and/or silent during all other work hours." During a review of the facility's P&P titled, "Protected Health Information (PHI), Management and Protection of", dated 1/2025, the P&P indicated, "Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws ... It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure." The facility failed to ensure the CNA 1 did not violate the resident's rights to be treated with respect and dignity and did not subject the resident to humiliation for Resident 1 by failing to ensure: 1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 RP 1's consent. 2. CNA 1 did not post a video of Resident 1 on social media. As a result, Resident 1's right was violated, not treated with respect and dignity and the potential to subject Resident 1 to humiliation. The above violation had a direct relationship to the health, safety, and security of Resident 1.