Health inspection·March 5, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). Residents Affected - Few This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. In order to assist Resident 1 to safely perform grooming, toilet use, and personal hygiene, staff were to conduct the following interventions, [For] toilet use .[Resident 1] requires assistance to .clean self, transfer onto toilet, transfer off toilet, to use toilet .Encourage [Resident 1] to discuss feelings about self-care deficit .Encourage [Resident 1] to participate to the fullest extent possible with each interaction . A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/20/25, indicated the following: -Section C: A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident's) score of 4, which indicated severe cognitive (relating to processes of thinking and reasoning) impairment. -Section F: Resident 1 notified staff it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. -Section GG: Facility staff assessed Resident 1 was able to perform toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding, etc.), lower body dressing (the ability to dress and undress below the waist), and toilet transfer (the ability to get on and off the toilet or commode) with partial/moderate assistance (when the helper does less than half of the effort to carry out the activity). -Section H: Facility staff assessed Resident 1 was always continent (had the ability to control Page 1 of 2 056215 056215 03/05/2025 Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490

F 0604 bladder function and retain urine until the appropriate time) of urine. Level of Harm - Actual harm A review of Resident 1's Skilled Weekly Review dated 2/24/25 at 6:50 p.m. indicated, .toileting transfer/clothing management min [minimum] assist [when a person needs very little help], peri [perineal] care CG [caregiver]/ min assist .Lb [lower body] dressing mod [moderate] assist [when a person needs help with half of the effort to complete a task] and feeding (I [independent]). Residents Affected - Few A review of Resident 1's Progress Notes, dated 2/27/25, at 7:19 P.M., indicated, According to [Resident 1] he was held down by a female and male CNA while they changed his pants . A review of Resident 1's Progress Notes, dated 2/28/25, at 9:02 A.M., indicated, [Resident 1] reported that two CNAs had physically abused him on 2/26 to the DOR [Director of Rehab] . A review of Resident 1's Interdisciplinary Team (a group of professionals from different disciplines who work collaboratively to provide care to a resident) note dated 2/28/25 at 9:28 p.m. indicated, Resident made allegation to staff member that he was 'forced' to wear a brief during a bed bath that occurred on 2/26/25 .[Resident 1] would like to independently perform peri care in the bathroom with the door closed . A review of Resident 1's behavior note dated 3/3/25 at 2:51 p.m. indicated, Nursing staff has reported behaviors of the following: Throwing personal belongings= 0 [on] all shifts .Making sexual advances= 0 [on] all shifts .Verbal aggression= D [Day shift]= 0 NOC [nocturnal shift]= 0 . During a concurrent observation and interview in Resident 1's room on 3/5/25, at 10:13 A.M., Resident 1 stated, 2 CNAs [CNA A and CNA B], one on each side. They held me down. The larger one put her weight on me . They wanted to put a diaper on me. I told them no . but they put it on me anyway . this is demeaning . I was pissed. While Resident 1 recounted the event, he became teary eyed. During an interview on 3/5/25, at 12:03 P.M., Licensed Nurse (LN) stated CNA A told him Resident 1 refused a brief (an adult diaper) change. The LN stated he, remembered [Resident 1] didn't want females caring for him. During an interview on 3/5/25, at 1:45 P.M., the DOR stated Resident 1 told her, . they held me down, pulled down my pants and put diapers on me. The DOR stated Resident 1 was upset and used the word manhandled in his description of the event. During an interview on 3/5/25, at 1:56 P.M., CNA A stated Resident 1 was not cooperating with his brief change stating he did not want it. The CNA also stated, [Resident 1] started to become aggressive and told us to get out . we each held a hand and put on the brief with our free hands. During an interview on 3/5/25, at 2:35 P.M., the Operations Manager (OM) confirmed the incident occurred and confirmed holding a resident down was a form of abuse. During a record review of facility policy titled Abuse: Prevention of and Prohibition Against, dated 1/2024, indicated, It is the policy of this facility that each resident has the right to be free from abuse . Residents also have the right to be free from . physical abuse .Abuse is willful infliction of . intimidation, or punishment . with resulting . mental anguish. 056215 Page 2 of 2