Other·June 2, 2026

§483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §72523(a) 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. On 4/20/2026, the California Department of Health (CDPH) received a complaint alleging the suspect (a contracted activity provider) was committing elder abuse by taking pictures and videos of multiple residents (Residents 6, 10, 11, 12, 13, and 14) and posting them on social media platforms without a consent from the residents' families. When the families and the nursing facility asked the contracted activity provider to remove the residents' videos and pictures they refused. On 4/21/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, the CDPH determined Residents 6, 10, 11, 12, 13 and 14 were videotaped without the residents' and/or their representatives' consent and the residents' were included in an activity program conducted by a contracted activity provider using disparaging (criticizing, belittling, or undervaluing someone, often in a way that shows a lack of respect or aims to diminish their reputation) remarks directed at the residents. The facility staff did not monitor the activity provided by the contracted activity provider to ensure the residents privacy was protected and the activity was appropriate for the resident population. The facility failed to: 1. Ensure an outside activity provider, who was contracted by the facility to provide activities to residents, was monitored by the facility to ensure the outside activity provider did not videotape residents without the residents' and/or their representative's consent. 2. Ensure the outside activity provider did not use disparaging remarks directed at the residents during their activity program. 3. Ensure the outside activity provider did not post unauthorized recordings of Residents 6, 10, 11, 12, 13 and 14 during their activity program on multiple social media outlets. 4. Ensure the facility followed its Policy and Procedure (P/P), titled, "Confidentiality of Information and Personal Privacy" revised 1/2026 that indicated the facility shall strive to protect and safeguard the residents' confidentiality and personal privacy during visits, family and resident group meetings and activities. 5. Ensure the facility followed its P/P, titled, "Dignity" revised 1/2026, that indicated the facility residents shall be cared for in a manner that promotes and enhances their well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. All residents of the facility shall be treated with dignity and respect at all times. 6. Ensure the facility followed its P/P, titled, "Email, Internet and Social Media Use" revised 1/2026, that indicated the social media platforms will be used only within the legal, ethical and professional boundaries established by the state and federal privacy laws, professional standards of practice, and facility policy. As a result, Residents 6, 10, 11, 12, 13 and 14, who had different levels of cognitive impairment (a condition when a person has trouble with mental tasks such as memory, learning, concentration or decision making), unknowingly and without permission were videotaped during an activity program while the contracted activity provider teased and mocked the residents and later posted identifiable images of the residents on multiple social media outlets. These deficient practices had the potential for residents' loss of privacy and dignity, embarrassment and loss of trust in staff. Resident 6's Admission Record (Face sheet), indicated Resident 6, a 77-year-old female, was initially admitted to the facility on 12/28/2018 and readmitted on 1/13/2026. Resident 6 had diagnoses that included metabolic encephalopathy (a disease that affects the brain leading to confusion), and dementia (a progressive state of decline in mental abilities). A review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool) dated 4/14/2026, indicated Resident 6 was forgetful and was not able to make consistent and reasonable decisions. Resident 6 required a one-person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 6's Skilled Nursing Facility Progress Note dated 1/23/2026, indicated Resident 6 was able to make medical decisions with her brother's assistance. Resident 10's Admission Record (Face sheet), indicated Resident 10, a 53-year-old male, was initially admitted to the facility on 5/31/2024 and readmitted on 4/7/2026. Resident 10 had diagnoses including metabolic encephalopathy, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and depression (a mood disorder characterized by persistent sadness that interferes with daily life, work and relationships). A review of Resident 10's MDS dated 4/5/2026, indicated Resident 10 was unable to make reasonable and consistent decisions. Resident 10 required a one-person assist to complete his ADLs. Resident 11's Admission Record (Face sheet), indicated Resident 11, a 75-year-old female, was initially admitted to 11/14/2001 and readmitted on 3/20/2026. Resident 11 had diagnoses including metabolic encephalopathy and dementia. A review of Resident 11's MDS dated 3/26/2026, indicated Resident 11 was unable to make decisions that were reasonable and consistent. Resident 11 required a two-person assist to complete her ADLs. Resident 12's Admission Record (Face sheet), indicated Resident 12, a 66-year-old female, was initially admitted to the facility on 11/20/2025 and readmitted om 11/20/2025. Resident 12 had diagnoses including psychosis, and dementia. A review of Resident 12's MDS dated 3/18/2026, indicated Resident 12 was forgetful and not able to make consistent and reasonable decisions. Resident 12 required a one person assist to complete her ADLs. A review of Resident 12's Physician's Progress Note dated 4/7/2026, indicated Resident 12 had no capacity for medical decision making due to dementia. Resident 13's Admission Record (Face sheet), indicated Resident 13, a 69-year-old male, was initially admitted to the facility on 11/7/2024 and readmitted 12/8/2025. Resident 13 had diagnoses including anoxic brain damage (when oxygen is cut off completely to the brain), and psychosis. A review of Resident 13's MDS dated 3/17/2026, indicated Resident 13 was forgetful and was not able to make consistent and reasonable decisions. Resident 13 required a one person assist to complete his ADLs. A review of Resident 13's H&P dated 12/9/2025 indicated Resident 13 did not have the capacity to understand and make decisions. Resident 14's Admission Record (Face sheet) indicated Resident 14, a 68-year-old male, was initially admitted to the facility on 12/2/2024 and readmitted on 1/3/2026. Resident 14 had diagnoses including encephalopathy and psychosis. A review of Resident 14's MDS dated 4/12/2026, indicated Resident 14 was able to make decisions that were reasonable and consistent. A review of Resident 14's H&P dated 1/4/2026, indicated Resident 14 had the capacity to understand and make decisions. A review of an Instagram ([IG] commonly known as a Reel is a short engaging video clip shared through a social media platform designed for quick viewing similar to TikTok) Video dated 3/15/2025, indicated Resident 10 was sitting in his wheelchair in the presence of the contracted activity provider and eight other unidentified residents. The contracted activity provider was engaged in a conversation with two residents (a female and a male) and was heard saying "listen couple, listen hot stuff, you are interrupting my show, it's rude, if you want to take her out, take her outside." The video indicated the male resident told the female resident "Shake that pussy!" The contracted activity provider laughed and was heard saying "he mentioned shake that pussy instead of shake that tushy." Continued review of the IG video showed no indication that staff at the facility intervened during the inappropriate conversation between residents and/or the contracted activity provider. A review of an IG Video dated 3/16/2026, indicated Resident 10 was sitting in his wheelchair in the presence of eight unidentified residents, when the contracted activity provider was heard rapping "hey shake that tushy, eat a cookie, yeah shake it doll, shake it at the mall, shake it doll in the bathroom stall." A review of an IG Video dated 3/17/2026, indicated Resident 10 and Resident 11 were sitting in their wheelchairs in the presence of 14 unidentified residents when the contracted activity provider was heard rapping "do the finger dance, can't get up that's fine, put your fingers up real high, move it from side to side, yeah (called out a resident's name, unidentified ) looking real fly, shake them fingers don't be shy, you got arthritis common just try." The contracted activity provider then pointed to an unidentified male resident and said "Oh, my God he's got no finger? Perfect, I love that he's making do." A review an IG Video dated 3/24/2025, indicated there were six unidentified residents attending the activity program and the contracted activity provider was heard rapping, "Gramps in his wheelchair cruising, but the bandage on his head is oozing, call the nurse over here to clean him up, all my walkers in the front row stand up, got a drink in your hand drop that cup, put your hands on the bar you know what's up, for those people who can't get out of bed, put your fingers up you ain't dead." A review of an IG Video dated 4/29/2026, indicated Resident 6 was sitting in her wheelchair, in the presence of seven unidentified residents, when the contracted activity provider was heard rapping "crockpot, make some chicken stew, throw it all into the crockpot, then it's all cooked boo, hot, hot." After completing the rap song, the contracted activity provider was heard saying, "I am so distracted by (called out a resident's name, unidentified). A review of an IG Video dated 5/25/2025, indicated the contracted activity provider in the presence of Resident 6 and five unidentified residents was heard rapping "I stalk my boyfriend it's not a big deal, call me a creep I am just keeping it real, I am just kidding no way, I only stalk during the day." Resident 6 was seen walking to and then holding hands with the contracted activity provider as they danced. A review of a TikTok Video (a short form of video created, edited and shared through a social media platform designed for a quick entertainment featuring dances, comedy, educational hacks and lip-syncs) dated 7/30/2025, indicated Resident 12 danced while the contracted activity provider was heard rapping, "don't need a cane to make you sway, turn this bingo hall into a cabaret, hot like soup like an early bird, making them purr without saying a word, who's having their fourth marriage, where's the bride, don't take your diaper off just move it to the side." Resident 10, Resident 11, Resident 13 and Resident 14 were seen in the TikTok video sitting in their wheelchairs along with 12 unidentified residents. A review of a TikTok Video dated 8/11/2025, showed Resident 12 dancing with the contracted activity provider who was heard rapping, "we are all gonna die I am giving you a pass, yeah pass that gas, I ain't judging, you can't remember the date or time, you are like a VHS tape on rewind, so what doll you're losing your mind, let's show these youngins' how we bust and grind, put your hands in the air if you got that gray hair even if it's down in there who cares, embrace your age if you dare, do a wheelie in that wheelchair, we are all gonna die let's dance maybe our last chance." Resident 10, Resident 11, Resident 13 and Resident 14 were seen on the TikTok video sitting in their wheelchairs and Resident 6, was standing by the side of the dining room, waving her hand. The TikTok video indicated there were 3 facility staff present (Activity Assistant [AA] 1, 2, and 3) in the dining room during the activity. A review of a TikTok Video dated 8/13/2025, indicated a contracted activity provider was heard rapping, "she loves the elderly and children because they don't judge and are innocent, their teeth fall out some grow back in and both wear diapers they like to pee in, both get food in their chin- chin, don't touch their happy meal or pill bin, they eat healthy lunch, both are blended because they can only munch." Resident 10 and Resident 11 were seen in the TikTok video sitting in their wheelchairs, while Resident 6 was dancing beside the contracted activity provider. During an interview and concurrent record review on 4/21/2026 at 2:03 p.m., Restorative Nurse Assistant (RNA) 1 stated Resident 6, Resident 10, Resident 11, Resident 12, Resident 13 and Resident 14 were amongst the identified residents in the TikTok and IG Videos. RNA 1 stated there were three activity assistants (AA 1, 2 and 3) in the video on 8/11/2025. RNA 1 stated videotaping of the residents without consent is not allowed in the facility. During a concurrent interview and observation of the videos on 4/21/2026 at 3:18 p.m., the Activity Director (AD) stated she hired the contracted performers for the residents' activities, but she only discussed the rate of pay with them during a telephone conversation and nothing else. The AD viewed the videos, and stated videotaping of residents should not have happened without consent of the residents and/or their responsible party (RP). The facility's activity staff should have stopped the videotaping and protected the residents' privacy. During an interview on 4/22/2026 at 9:58 a.m., Resident 12 stated the performer (contracted activity provider) and her were dancing in the dining room in front of other residents and staff on different dates during birthday celebrations (dates unknown) and somebody videotaped her and the contracted activity provider dancing. Resident 12 stated she did not feel right about being videotaped because she did not give permission, but she did not stop the videotaping because she saw the residents and the staff were very happy. During an interview on 4/22/2026 at 10:56 a.m., the Director of Staff Development (DSD) stated the activity staff and any other staff present during the contracted activity provider performance should have monitored the residents' and the contracted activity provider to ensure there was no unauthorized videotaping of the residents. The DSD stated this should not have happened because there were AAs present during resident activities at all times. During an interview on 4/22/2026 at 12:06 p.m., the Director of Nursing (DON) stated videotaping of the residents should not have happened at any time because the residents were under the supervision of the facility's activity staff. Facility staff present during the performance should have protected the residents and stopped unauthorized photos and videos from being taken. During an interview on 4/22/2026 at 12:52 p.m., the Administrator (ADM) stated the facility should have monitored the contracted activity provider to prevent unauthorized videotaping of the residents and compromise of the residents' privacy and dignity. A review of the facility's P/P titled "Confidentiality of Information and Personal Privacy" revised 1/2026, indicated the facility shall strive to protect and safeguard the residents' confidentiality and personal privacy during visits, family and resident group meetings and activ