Health inspection·August 1, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #39) of 1 sampled resident reviewed for physical restraints was free from a physical restraint. Residents Affected - Few Findings included: A facility policy titled, Use of Restraints, revised 04/2017, revealed, Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for disciple or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation: 1. Physical Restraints are defined as an manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Per the policy, 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. An admission Record revealed the facility admitted Resident #39 on 03/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, dementia, repeated falls, difficulty in walking, and dependence on wheelchair. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2024, revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. s The MDS indicated the resident was dependent on staff to come from a sitting to stand position and for chair/bed-to-chair transfers. Per the MDS, the resident used a trunk restraint daily. Resident #39's care plan included a focus area initiated 11/14/2022, that indicated the resident used a physical restraint, lap buddy, related to confusion and falls. Interventions directed staff to ensure the resident was positioned correctly with proper body alignment while restrained (initiated 11/14/2022). Resident #39's Order Summary Report with active orders as of 08/01/2024. included an order dated 04/17/2022, for a lap buddy while up in the wheelchair for safety due to frequent falls. Page 1 of 3 055028 055028 08/01/2024 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0604 Level of Harm - Minimal harm or potential for actual harm During an observation on 07/29/2024 at 10:47 AM, Resident #39 was a wheelchair in activities, with a padded lap pad in place. During an observation on 07/29/2024 at 2:07 PM, Resident #39 was in their wheelchair with a padded lap pad in place, being wheeled by staff to activities. Residents Affected - Few During an interview on 07/31/2024 at 3:02 PM, the Director of Nursing (DON) stated the lap buddy used by Resident #39 had been in place since 03/2022 due to the resident having sustained frequent falls out of their wheelchair. Per the DON, the medical symptom for the use of the physical restraint was falls. The DON confirmed a lesser restrictive device had not been attempted and there was no ongoing monitoring of physical restraint. During a follow-up interview on 08/01/2024 at 11:44 AM, the DON confirmed falls were not a medical symptom for the use of the physical restraint. During an interview on 08/01/2024 at 11:51 AM, the Administrator stated the facility needed to try to use the least restrictive device first and have a true medical symptom for the use of the restraint. During an interview on 08/01/2024 at 1:00 PM, Certified Nursing Assistant (CNA) #1 stated Resident #39 had the lap buddy ever since she worked in the facility for the past two years. CNA #1 stated the only time the lap buddy was removed was during showers and when the resident was placed in their bed. During an interview on 08/01/2024 at 1:02 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #39 had the lap buddy ever since she worked at the facility for the past two years. LVN #2 stated to her knowledge the lap buddy had never been removed. During an interview on 08/01/2024 at 1:09 PM, the Physical Therapist stated he knew Resident #39 had the lap buddy, but to his knowledge therapy was not consulted about the use of it. 055028 Page 2 of 3 055028 08/01/2024 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview, document review, and facility policy review, the facility failed to ensure the facility assessment was reviewed and updated annually. This deficient practice had the potential to affect all 55 residents who currently resided in the facility. Findings included: A facility policy titled, Facility Assessment, revised 10/2018, revealed, Policy Statement A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation: 1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The policy revealed, 9. The facility assessment is reviewed and updated annually, and as needed. The Facility Assessment, revealed the last date of assessment or updated was listed as 09/27/2022. During an interview on 07/31/2024 at 1:12 PM, the Director of Nursing (DON) and Nurse Consultant (NC) stated they had been working on updating the facility assessment since 2023. The NC stated they had been working on updating the resident population and saw that the acuity of the residents who resided in the facility had changed significantly. The DON stated the facility needed a facility assessment to know how to care for the residents. During an interview on 08/01/2024 at 12:05 PM, the DON stated it was her expectation that the facility assessment be reviewed annually by the facility management team. During an interview on 08/01/2024 at 12:13 PM, the Administrator stated it was his expectation that the facility assessment be reviewed at a minimum annually by the facility team and he was aware that it was being worked on. 055028 Page 3 of 3