Health inspection·March 20, 2026

F604 §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 . . . 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 . . . 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. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR § 72527 Patient’s 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: (10) To be free from mental and physical abuse. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 1/28/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident involving a resident who had been subjected to a physical restraint (as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident’s body; cannot be removed easily by the resident; and restricts the resident’s freedom of movement or normal access to his/her body). The facility failed to protect Resident 1’s right to be free from physical restraint when on 1/14/2026 at 3 a.m., Licensed Vocational Nurse 1 (LVN 1) found Resident 1’s hands were firmly tied together at the wrists with a scarf, with no way of getting out, no wiggle room, and with no ability to move or release her hands while Resident 1 was in bed in her room. Resident 1 who had severe cognitive impairment (a profound, often irreversible loss of mental capacity involving a major inability to think, remember, learn, communicate, or make decisions, requiring daily assistance with basic tasks like eating, dressing, or safety) and was dependent on staff (helper does all of the effort) for care. The facility failed to: 1. Ensure that a licensed nurse completed an assessment prior to the application of a physical restraint restricting Resident 1’s freedom of movement, in accordance with the facility’s policy and procedure (P&P) titled, “Restraints,” last reviewed on 7/28/2025, indicating, “… a physical restraint shall be used only after the interdisciplinary team (IDT – a collaborative group of healthcare professionals who work together to create, implement, and evaluate a personalized, comprehensive care plan for residents) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device.” 2. Ensure Certified Nursing Assistant 1 (CNA 1), who was assigned to Resident 1, was immediately removed from duty after being suspected of tying Resident 1’s hands and being observed sleeping during the assigned shift. On 1/14/2026 at 3 a.m., CNA 1 remained on the schedule and continued providing care to Resident 1 until clocking out at 7:16 a.m. on 1/14/2026. This failure allowed the potential for continued or further abuse. The facility failed to follow its P&P titled, “Abuse Prevention and Prohibition Program,” last reviewed on 7/28/2025, indicating, “Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator (ADM).” 3. Follow the facility’s P&P titled, “Restraints,” dated 11/1/2017, indicating, “Residents shall be provided an environment that is restraint-free…. The facility honors the resident’s right to be free from any restraints that are imposed for reasons other than that of treatment of the resident’s medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience.” 4. Follow the facility’s P&P titled, “Abuse Prevention and Prohibition Program,” last reviewed on 7/28/2025, indicating, “Each resident has the right to be free from abuse, neglect, mistreatment…. The Facility has zero-tolerance for abuse…. Staff must not permit anyone to engage in … physical abuse, neglect, mistreatment…. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff….” As a result of these failures, on 1/14/2026, CNA 1 subjected Resident 1 to a physical restraint while under the care of the facility. On 1/14/2026 at around 2:50 a.m., LVN 1 entered Resident 1’s room and observed Resident 1 lying in bed making quick, irregular shaking or twisting body movements to show LVN 1 that her hands were bound with a scarf. Such abuse created a risk of injury and further psychological (mental or emotional) effects including feelings of hopelessness, helplessness, and humiliation in Resident 1, and would create a risk of injury and psychological (mental or emotional) effects including feelings of hopelessness, helplessness, and humiliation in a reasonable person in Resident 1’s position. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, an 82-year old female, on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), generalized muscle weakness, and abnormalities of gait (manner of walking) and mobility (ability to move). A review of Resident 1’s Physician History and Physical (H&P- a process used by doctors to understand residents’ health which combines medical history and a physical examination), dated 9/5/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, indicated Resident 1 had a fall risk score of 21, which classified Resident 1 as being at high risk for falls. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 12/8/2025, indicated Resident 1 rarely understood others and was rarely understood. The MDS further indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. A review of CNA 1’s Timecard, dated 1/13/2026, indicated CNA 1 clocked in to work on 1/13/2026 at 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. A review of Resident 1’s Progress Note, dated 1/15/2026 timed at 8:45 a.m., indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless and yelling on and off. The Progress Note indicated LVN 1 asked CNA 1 to check on Resident 1. The Progress Note further indicated CNA 1 exited Resident 1’s room and stated Resident 1 was okay and that she (Resident 1) always behaved this way. Approximately 10 minutes later, Resident 1 was again yelling. The Progress Note indicated LVN 1 entered Resident 1’s room and observed Resident 1’s blanket on the floor. LVN 1 picked up the blanket and was about to place it on Resident 1, who was lying in bed, when LVN 1 observed Resident 1’s wrists tied together in front of her with what appeared to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and immediately assessed Resident 1 with no visible injury noted. During a concurrent interview and record review on 1/28/2026 at 9 a.m. with the ADM, CNA 1’s Timecard dated 1/13/2026 was reviewed. The ADM stated CNA 1 clocked in on 1/13/2026 at 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During an interview on 1/28/2026 at 11:25 a.m. with CNA 1, CNA 1 stated she worked the 11 p.m. to 7 a.m. shift (work schedule) on 1/13/2026 and was the assigned CNA for Resident 1. CNA 1 stated she continued caring for Resident 1 until the end of her (CNA 1) shift. CNA 1 stated she was not removed from Resident 1’s care assignment. During an interview on 1/28/2026 at 1:02 p.m., with the Risk Management Nurse (RMN), the RMN stated she observed a photograph of Resident 1 with her (Resident 1) hands tied together in the front of her (Resident 1) body, with the wrists positioned on top of each other in a cross-like position. She (RMN) could not determine from the photograph whether the scarf was tight. The RMN stated that tying a resident’s hands could prevent the resident from getting up and would also prevent the resident from using the call light. Resident 1 was at risk for falls risk and if attempting to get up while her hands were tied, Resident 1 could injure herself because she would not be able to use her hands to protect herself during a fall. The RMN stated this situation could also prevent Resident 1 from drinking water. CNA 1 completed her shift and continued to care for Resident 1 on 1/14/2026. LVN 1 should have immediately removed CNA 1 from the assignment and CNA 1 should have left the facility premises. During an interview on 1/28/2026 at 2:49 p.m., with LVN 1, LVN 1 stated she worked the 11 p.m. to 7 a.m. shift on 1/13/2026. LVN 1 stated on 1/13/2026 at around 1:30 a.m. to 2 a.m. she (LVN 1) heard Resident 1 making sounds that resembled chanting in another language. She (LVN 1) did not speak the language and could not understand what Resident 1 was saying. LVN 1 stated she asked CNA 1, who was assigned to Resident 1 and spoke the same language, what Resident 1 was saying. CNA 1 responded that Resident 1 always behaved that way. A few minutes later (did not specify exact time) Resident 1’s chanting became louder and more frequent. LVN 1 stated she asked CNA 1 to check on Resident 1. CNA 1 entered Resident 1’s room, spoke with Resident 1, and then exited Resident 1’s room. Resident 1’s chanting continued to worsen and became louder. At approximately 2:50 a.m., on 1/14/2026, LVN 1 entered Resident 1’s room and observed Resident 1 lying in bed with her blanket on the floor. LVN 1 stated she thought Resident 1 might be cold. LVN 1 stated she bent down to pick up the blanket and shook it out. At that time, LVN 1 observed that Resident 1’s hands were bound. Resident 1’s wrists were firmly tied together in front of her body with a scarf, leaving no ability for Resident 1 to free herself and no room for movement. Resident 1’s wrists were “hog tied” tied together with the scarf in a figure eight pattern at least three times. LVN 1 stated that prior to removing the scarf, she took a photograph of Resident 1’s tied hands to show her supervisors. She (LVN 1) untied Resident 1 at around 3 a.m. When she initially entered Resident 1’s room, Resident 1 appeared relieved and became “wiggly” as she was moving around, attempting to show LVN 1 that her (Resident 1) hands were bound. LVN 1 stated that after untying Resident 1 she (LVN 1) l looked for CNA 1 and observed CNA 1 at the Nursing Station desk asleep and snoring. CNA 1 woke up at unknown time to continued working her shift. CNA 1 completed the remainder of her shift and continued caring for Resident 1. Resident 1 was subjected to a physical restraint, as her wrists were firmly tied together with a scarf. During an interview on 1/28/2026 at 3:32 p.m., with the RMN, the RMN stated the incident constituted abuse because Resident 1 was unable to move due to being tied. There was no way to determine how long Resident 1 had been tied. The RMN stated allowing CNA 1 to continue working after the allegation of abuse placed Resident 1 and other residents at risk for further abuse. During an interview on 2/2/2026 at 3:19 p.m., with the Director of Nursing (DON), the DON stated that on 1/14/2026 LVN 1 showed her a photograph of Resident 1 whose wrists were bound side-by-side with what the DON described as a greenish scarf. She (DON) could not determine how tight the scarf was, but it appeared secure, and that Resident 1 would not have been able to pull her arms apart. The scarf would inhibit Resident 1 from grabbing the bed rails and believed it may have been done to prevent Resident 1 from pulling herself up and getting out of bed. Resident 1 would not have been able to use the call light, drink water or scratch her face due to the manner in which her wrists were bound. The DON stated that with Resident 1’s hands tied, Resident 1 would have been at increased risk for falling because she would not have been able to use her hands to maintain balance. She (DON) believed CNA 1 tied Resident 1’s hands to prevent Resident 1 from getting out of bed. There was no assessment conducted for the use of a scarf as a restraint. The scarf functioned as a restraint and stated it was used for the convenience of CNA 1 so Resident 1 would not get out of bed. The incident constituted physical abuse and the use of a physical restraint, as Resident 1 had the potential to sustain injury due to restricted mobility with her wrists tied. The restraint could also affect Resident 1’s sleep. The DON stated that psychosocially the incident could negatively impact Resident 1’s mental status because Resident 1 may have been confused about why she was unable to move. Resident 1’s increased chanting was indicative of agitation (a condition in which a person is unable to relax and be still) that could have been related to being restrained. The scarf was used as a restraint on Resident 1 and there was no facility policy permitting the use of a scarf as a restraint. The DON stated that when restraints are used, the facility must conduct a comprehensive assessment to ensure the resident can remove the restraint, documentation must be completed and signed off, and informed consent must be obtained. The DON confirmed there was no assessment or consent for the use of a scarf as a restraint for Resident 1. During an interview on 2/2/2026 at 4:44 p.m., with the ADM, the ADM stated he serves as the facility’s abuse coordinator. The ADM stated tying Resident 1 with a scarf constituted a form of restraint and fell under abuse. The incident would be considered physical abuse. He (ADM) believed CNA 1 tied Resident 1 for convenience because Resident 1 was restless at the time. CNA 1 should have been removed immediately from the work schedule once LVN 1 found Resident 1 was bound because there was a potential risk CNA 1 could harm other residents and could interfere with the investigation. A review of the facility’s P&P titled, “Abuse Prevention and Prohibition Program,” last reviewed on 7/28/2025, indicated, “Each resident has the right to be free from abuse, neglect, mistreatment…. The facility has zero-tolerance for abuse, neglect, mistreatment…. Staff must not permit anyone to engage in … physical abuse, neglect, mistreatment….