complaint·May 19, 2025

[CONTINUED FROM LIC 9099] Per R1’s Face Sheet, they had lived at the facility since February 2024. Per R1’s LIC602 Physician’s Report, corroborated by their Preplacement Appraisal and latest Individual Service Plan: R1’s primary diagnosis and reason for being at the facility was hemiplegia and hemiparesis following a stroke. R1 experienced residual left sided weakness and had history of knee replacement. R1 required hands-on staff assistance with transferring in/out of bed, and with rotating/repositioning in bed, among other activities of daily living. During his 05/19/2025 visit, LPA observed: R1 had a hospital bed in their bedroom, but the pair of half-length bed rails were not affixed to R1’s bed. The rails were instead set aside on the floor. Staff interviews showed: R1 rented their hospital bed (which came with the rails) from a third-party durable medical equipment (DME) company. (Therefore, both the bed and the rails in question were R1’s personal property, and not Licensee’s property.) About one month earlier, facility manager Staff #1 removed R1’s bed rails from R1’s bed, because the rails conflicted with Licensee’s internal facility/company policy. LPA subsequently obtained a copy of Licensee’s internal facility/company policy, which stated in part: “The use of bed rails is discouraged [at the facility]. Half bed rails are only utilized to assist in mobility and not as a restraint and are only used with specific physician’s order mandating the use and will require the permission of the Regional Director of Health Services.” California Code of Regulations, Title 22, Section 87608 titled “Postural Supports,” states in part: “(a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.” Regulation does not require a physician’s order for half-length bed rails. CCLD also reviewed the Admissions Agreement contract between R1 and Licensee, finding no mention of the facility’s stance/policy on bed rails. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Interviews further showed: For most of R1’s residency at the facility (over a year), R1 had bed rails on their hospital bed, without issue. R1 and their responsible person (RP) both affirmed to CCLD their strong preference for R1 to have the half-rails affixed to their bed, because they help R1 feel more secure and are a potential grab-point for R1’s hand during assisted transfer/rotation maneuvers. Neither person considered the half-rails to be a restraint. Both persons were unaware of Licensee’s reasoning for removal of the bed rails. R1 subsequently communicated their desire for their rails to be reattached to facility direct care staff (as confirmed by both R1 and direct care staff). Licensee therefore had constructive knowledge to timely remedy. Based on records and interviews, a preponderance of evidence exists to show Licensee did not allow Resident #1 (R1) to keep their bed rails on their own bed. The allegation is therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Kim Bonn and Health Services Director Katie Ferguson, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.