Complaint·August 22, 2025

On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable to respond to questions about complaint allegations due to their neurocognitive disorders. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1 and S2. Both admitted they were using multiple diapers on R1, due to R1’s urination, which soils his/her bed and the resident him/herself. S1 stated if residents R1 or R2 get wet at night, they will use 3-4 diapers. S2 stated only R1 has multiple diapers at night. Both staff interviewed acknowledged there wasn’t a difference between R1 soiling him/herself at night or during waking hours. On July 15 & 24 and August 13, 2025 LPA interviewed ADM. ADM admitted staff place double diapers on R1 at night. ADM stated Only R1 has 2 diapers, because he/she has heavy urination. LPA asked ADM if there is a discrepancy with R1 when he/she soils him/herself in the morning, evening or night. ADM acknowledged that there wasn’t a difference. ADM stated R1 has two diapers at night because at night is easier to take it off and change him/her when he/she has 2 diapers. ADM stated she did instruct her staff to put 2 diapers on R1 at night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025, R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not outline a specific bowel and bladder management plan for resident R1. Based on interviews and documents review the preponderance of evidence has been met therefore the above allegations is found to be SUBSTANTIATED . Staff restrained resident On July 10, 2025, the Department received a complaint alleging Staff restrained resident. It has been alleged that R1 was observed lying in bed with both of his/her legs tied together with a bed sheet. Page 2 Out of 4. On July 11, 2025, LPA interviewed Witness W1 and W2. Both witness interviewed stated on July 7, 2025, around 9am both W1 and W2 entered the facility and met with the facility administrator. W1 and W2 headed towards R1’s bedroom and observed resident R1 had his/her feet tied together with a bedsheet. W1 stated he/she asked ADM why R1 feet were tied. Both witnesses stated the ADM had told them, R1 was tied because R1 was being combative when he/she was being changed. On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable communicate or respond to interview questions due to their neurocognitive disorder. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1. S1 stated on July 7, 2025, the ADM and S2 called him/her for assistance. S1 stated he/she went to R1’s room and helped by holding R1’s hands and holding them close to R1’s chest, while ADM cleaned R1. S1 stated R1 was tied in a manner that was not tight, but closed off enough to keep R1 from kicking his/her feet. S1 stated ADM initiated tying R1’s feet. S1 stated after R1 was tied, two hospice care givers arrived at the care home. S1 stated the hospice care givers arrived either a few minutes or half an hour after R1’s diaper was changed. On July 15 & 24 and August 13, 2025, LPA Monter interviewed staff S2. S2 stated that morning, R1 was yelling and found R1 had a large bowel movement (BM). S2 stated staff attempted to change R1 but he/she was combative. S2 stated that R1 was mostly kicking and moving his/her arms. S2 stated he/she and the ADM were the ones who did the tying. S2 stated R1 was tied with the bedsheet around R1’s ankles area. S2 stated after R1 was changed, 5-10 minutes later, two staff from redwood hospice came and saw that R1 was tied. S2 stated they forgot to remove the tied bed sheet. On July 15 & 24 and August 13, 2025, LPA Monter interviewed ADM. ADM stated on July 7, 2025 , around 7:30-8:30am R1 woke up, yelling. ADM stated she saw R1’s had a defecated so much that it leaked out of the diaper. ADM asked S2 for assistance, but R1 was kicking and swinging his/her arms. ADM stated because R1 was being combative, and she decided to tie R1, to get R1 clean and to minimize R1’s from hitting and swinging his arms or hurting himself or the staff. ADM stated R1 was tied slightly above the ankle area. ADM described the tying as not tight, but closed off enough to keep R1 from kicking while he/she is being changed. ADM stated R1 was tied around 8-9am. ADM stated after they assisted R1, the care givers from redwood hospice arrived 15-20 minutes after, and that’s when they saw R1 tied. Page 3 Out of 4. Staff S1, S2 and ADM stated that was the only time resident R1 was tied. S1, S2 and ADM acknowledged that R1 has had this combative behavior since move in. S1, S2 and ADM acknowledged that there wasn’t a discrepancy when R1 soiled him/herself in the morning, evening or night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025 , R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not detail how the facility will change resident R1 when he/she is being combative. Based on interviews conducted, Witness observed resident R1’s feet were tied on July 7, 2025. Interviews conducted with facility staff confirmed that on July 7, 2025, R1’s feet were tied, and his/her personal rights were violated. Staff interviewed, stated they tied R1 because of his/her combative behavior when he/she is being changed. Facility staff confirmed R1 has had this combative behavior since move in and R1’s ANS does not detail how the facility will change R1 when he/she is being combative. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED . Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator Eliza Daquioag. A copy of the report was provided. Appeal rights were provided. Page 4 Out of 4. END OF REPORT.