Health inspection·March 12, 2025

F603 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) Code of Federal Regulations, Title 42, §483.12(a)(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

F604 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (7) To be encouraged and assisted throughout the period of stay to exercise rights as a patient and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination or reprisal. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 2/13/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct an abbreviated survey to investigate one complaint (CA00945085) and one Facility Reported Incident (CA00944726) regarding involuntary seclusion of residents. The CDPH determined the facility failed to protect the rights of two residents (Resident 5 and Resident 6) to be free from unreasonable confinement when Certified Nursing Assistant (CNA 7) tied the room door shut with a garbage bag to prevent Resident 5 from leaving the room shared with his roommate (Resident 6). This failure had the potential to negatively impact Resident 5's and Resident 6's sense of dignity and well-being. A review of Resident 5's "ADMISSION RECORD" indicated Resident 5 was admitted to the facility in 2024 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (a nervous disorder characterized by a state of excessive easiness and apprehension that interferes with daily living), and a history of falling. A review of Resident 6's "ADMISSION RECORD" indicated that Resident 6 was admitted to the facility in 2021 with diagnoses which included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should, causing fluid to back up into the lungs), and chronic kidney disease (progressive damage and loss of function of the kidneys). During a phone interview on 2/13/25, at 3:42 p.m., with LN 4, LN 4 stated she was the charge nurse on duty on the day of the incident. LN 4 confirmed that CNA 7 tied Resident 5's room door shut with a garbage bag, and that Resident 6 was also in the room. LN 4 further stated CNA 7 tied the room door shut because Resident 5 was trying to leave the room. LN 4 stated CNA 7 just tied the room door shut one time. LN 4 further stated she did not know how long the room door was tied because she was busy charting. LN 4 stated CNA 7 had said that she watched Resident 5 until Resident 5 went to sleep, then she untied the door, but she forgot to remove the garbage bag from the door. LN 4 stated she was aware that it was unacceptable to tie a resident's room door shut. During a phone interview on 2/13/25, at 4:15 p.m., with CNA 7, CNA 7 confirmed that she tied the door to Resident 5's room shut with a garbage bag. CNA 7 further confirmed that Resident 6 was also in the room when the door was tied shut. CNA 7 stated she tied the door with the garbage bag to keep Resident 5 from leaving the room and going outside because he was agitated. CNA 7 stated she only tied the resident's room door shut one time, just that night, to keep the resident safe. CNA 7 stated she had informed the charge nurse that she tied the resident's room door shut. CNA 7 further stated she was aware that tying a resident's room door shut was unacceptable. During an interview on 2/13/25, at 12:21 p.m., with the Director of Nursing (DON), the DON confirmed that she saw the photo and text message sent by a CNA showing Resident 5 and Resident 6's room door tied shut with a garbage bag. The DON further confirmed that Resident 5 and Resident 6 were in the room that had the door tied shut with the garbage bag. The DON stated that an investigation concluded that one of the CNAs on duty acknowledged that she tied the Resident 5 and Resident 6's room door shut with a garbage bag after another CNA identified her as the one who tied the door shut. The DON further stated the Licensed Nurse (LN) on duty stated that she was aware that the CNA tied the residents' room door shut. The DON stated that tying the residents' room door shut was unacceptable. During an interview on 2/13/25, at 2:45 p.m., with the Administrator (ADM), the ADM stated that she became aware of the incident on 2/5/25 when the Assistant Director of Nursing (ADON) showed her a text message from one of the CNAs with a photo of the resident room door tied shut with a garbage bag. The ADM further stated that this was the only instance of a resident room being tied shut that she was aware of. The ADM stated that she did not know how long the room door was tied shut. The ADM further stated that the incident occurred on the night shift which began on 2/4/25 at 10:30 p.m. and ended on 2/5/25 at 7 a.m. The ADM explained that this was involuntary seclusion, and this was not an acceptable practice. The ADM stated the incident affected Resident 5's and Resident 6's sense of dignity. During a review of a facility policy and procedure (P&P) titled, "Use of Restraints," revised 4/17, the P&P indicated, "...Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience...13. Seclusion...shall not be employed..." During a review of a facility P&P titled, "Abuse Prohibition Policy and Procedure," dated 2/23/21, the P&P indicated, "...HealthCare Centers prohibit abuse, mistreatment...for all residents. This includes, but is not limited to...involuntary seclusion...Involuntary seclusion is defined as separation of a patient from other patients or from her/his room or confinement to her/his room (with or without roommates) against the patient's will...6.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion...is to tell the abuser to stop immediately and report the incident to his/her supervisor..." During a review of a facility P&P titled, "Resident Rights," revised 12/21, the P&P indicated, "...Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; a. a dignified existence...d. to be free from...involuntary seclusion..." During a review of a facility P&P titled, "Dignity," revised 2/21, the P&P indicated, "...Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem...1. Residents are treated with dignity and respect at all times...13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior..." Therefore, the department determined the facility failed to protect the rights of Resident 5 and Resident 6 to be free from unreasonable confinement when CNA 7 tied their room door shut with a garbage bag to prevent Resident 5 from leaving the room. This failure had the potential to negatively impact Resident 5's and Resident 6's sense of dignity and well-being. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a resident.