Other·May 7, 2026

22 CCR § 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. 22 CCR § 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: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 42 CFR § 483.10 - Resident Rights. (a) Residents 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. (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. (2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. 42 CFR § 483.10 - Resident Rights. (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. (1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. On 3/24/2026, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging two Certified Nursing Assistants (CNA 1 and 2) took videos of Resident 1 and Resident 2. On 4/1/2026, the CDPH conducted an unannounced visit to the facility to investigate the FRI. The facility failed to: 1. Ensure CNA 2 did not violate Resident 1 and Resident 2's privacy after recording and photographing the residents on her personal cellular phone without the residents' knowledge or consent. 2. Ensure CNA 2 did not share the recordings and photographs of Resident 1 and Resident 2 with CNA 1. 3. Implement their policy and procedure (P&P) titled "Confidentiality of Information and Personal Privacy," which indicated the facility will protect and safeguard residents' confidentiality and personal privacy. As a result, Resident 1 and Resident 2's rights to privacy and confidentiality were violated and the residents were at risk for unauthorized disclosure of protected health information, loss of dignity, and emotional distress. Resident 1, was a 28-year-old male, originally admitted to the facility on 8/6/2025 and readmitted on 8/24/2025. Resident 1's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), depression (a common but serious, treatable mental illness characterized by persistent sadness, loss of interest in activities, and low energy), muscle weakness, dorsalgia (pain in the back, typically affecting the mid-back, neck, or lower back regions) and polyneuropathy (a neurological condition resulting from widespread damage to peripheral nerves, often causing numbness, tingling, pain, and muscle weakness, typically starting in the feet or hands). A review of Resident 1's History and Physical (H&P), dated 10/5/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/13/2026, indicated Resident 1's cognitive skills for daily decision making (the ability to think and process information) were intact. The MDS indicated Resident 1 was dependent on staff (helper does all the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Resident 2, was a 59-year-old male, admitted to the facility on 8/23/2024 with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), dysphagia (difficulty swallowing), acute kidney failure (a sudden, often reversible, loss of kidney function occurring within hours or days), and muscle weakness. A review of Resident 2's H&P, dated 6/19/2025, indicated Resident 2 was able to make needs known but could not make medical decisions. A review of Resident 2's MDS, dated 2/28/2026, indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 was dependent on staff for ADLs. During a telephone interview on 4/1/2026 at 12:57 p.m., CNA 2 stated on 2/17/2026, she recorded a video of Resident 1 and Resident 2, because Resident 2 started an altercation with Resident 1. CNA 2 stated she felt the need to record the altercation for "evidence". CNA 2 stated she also recorded the incident to show CNA 1. CNA 2 stated recording residents was not part of the facility's policy, and she should not have recorded and taken photographs of Resident 1 and Resident 2. During a telephone interview on 4/1/2026 at 1:04 p.m., CNA 1 stated she received a video of Resident 1 and Resident 2 from CNA 2 via her personal cellular phone. CNA 1 stated the recording was made for "safety purposes" due to a situation involving Resident 1 and Resident 2. CNA 1 stated her family member accessed her phone and sent the video and pictures of Resident 1 and Resident 2 to the facility. CNA 1 stated she notified the facility on 3/23/2026 that her phone had been taken but did not disclose at that time that the phone contained videos or photographs of Resident 1 and Resident 2 as she was unaware that her family member accessed or distributed the contents of the phone. During an interview on 4/1/2026 at 1:20 p.m., Licensed Vocational Nurse (LVN) 2 stated staff were required to follow all Health Insurance Portability and Accountability Act of 1996 (HIPAA- a United States Federal Law designated to protect sensitive patient health information from being disclosed without consent) regulations to ensure the protection of residents' privacy and confidentiality. LVN 2 stated any photographs of residents were only permitted with the residents' consent, must be for medical purposes and were part of the residents' medical chart. LVN 2 stated recording residents without their knowledge or consent was not an acceptable practice and was not consistent with facility policy or regulatory requirements. LVN 2 stated such actions were considered a violation of residents' rights, confidentiality, and HIPPA. LVN 2 stated, in situations involving combative or aggressive behaviors, staff were expected to follow facility protocols, including de-escalation techniques, ensuring resident and staff safety, and notifying the nurse immediately, rather than recording the incident on a personal device. During an interview on 4/1/2026 at 1:37 p.m., the Director of Staff Development (DSD) stated he received a text message from an unknown phone number which contained approximately two videos and an undetermined number of photographs of Resident 1 and Resident 2. The DSD stated he immediately notified the Administrator (ADM). The facility attempted to contact the sender of the videos and photographs. The DSD stated a female individual answered the call but refused to identify herself. The DSD stated he and the ADM requested that the individual delete the videos and photographs, to which she responded, "okay, bye," before ending the call. The DSD stated the phone number was not recognized by the facility. The DSD stated the text message contained the names of CNA 1 and CNA 2. The DSD stated the staff should not record or possess any videos or photographs of residents on their personal devices. The practice was not permitted and was a violation of residents' privacy and confidentiality rights. During an interview on 4/1/2026 at 2:56 p.m., the ADM stated the videos and photographs of Resident 1 and Resident 2 appeared to have been recorded by facility staff without the residents' knowledge or consent. The ADM stated recording residents on a personal device was strictly prohibited and a violation of facility's policy, residents' rights, and HIPAA. The ADM stated residents had the right to privacy, dignity, and confidentiality, and any recording required prior consent and must be for authorized medical or facility purposes only. The ADM stated staff were expected to follow established protocols, such as the "Stop and Watch" process, to report changes in resident condition or behaviors, rather than recording residents. The ADM stated failure to follow these protocols was not consistent with the facility's expectations or regulatory requirements. The ADM stated this incident reflected a breakdown in staff adherence to facility policies. A review of the facility's undated P&P titled, "Confidentiality of Information and Personal Privacy," indicated "Our facility will protect and safeguard resident confidentiality and personal privacy. Release of resident information, including video, audio, or computer stored information, will be handled in accordance with resident rights and privacy policies." A review of the facility's P&P titled, "Residents Rights", dated 2/2021, 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. Employees shall treat all residents with kindness, respect, and dignity." A review of the facility's P&P titled, "Dignity", dated 2/2021, indicated "Residents are treated with dignity and respect at all times. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Staff are expected to treat cognitively impaired residents with dignity and sensitivity." The facility failed to: 1. Ensure CNA 2 did not violate Resident 1 and Resident 2's privacy after recording and photographing the residents on her personal cellular phone without their knowledge or consent. 2. Ensure CNA 2 did not share the recordings and photographs of Resident 1 and Resident 2 with CNA 1. 3. Implement their policy and procedure (P&P) titled "Confidentiality of Information and Personal Privacy" which indicated the facility would protect and safeguard resident confidentiality and personal privacy. As a result, Resident 1 and Resident 2's rights to privacy and confidentiality were violated and the residents were at risk for unauthorized disclosure of protected health information, loss of dignity, and emotional distress. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.