Health inspection·February 17, 2026

§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(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. § 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. § 72319. Nursing Service--Restraints and Postural Supports. (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. (c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties means soft cloth which does not cause abrasion, and which does not restrict blood circulation. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. (i) The requirements for the use of physical restraints are: (1) Treatment restraints may be used for the protection of the patient during treatment and diagnostic procedures such as, but not limited to, intravenous therapy or catheterization procedures. Treatment restraints shall be applied for no longer than the time required to complete the treatment. (2) Physical restraints for behavior control shall only be used on the signed order of a physician, or unless the provisions of section 1180.4(e) of the Health and Safety Code apply to the patient, a psychologist, or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. (C) Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (E) Conditions under which restraints are used, the application of restraints, and the mechanism used for monitoring and controlling their use. On 12/29/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was tied with a linen on both sides around her abdomen. On 1/9/2026, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1). Ensure Resident 1 was not tied to the bed with a linen (blanket). 2). Ensure Resident 1's doctor ordered the use of a physical restraint (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) for the resident. 3). Implement its policy and procedure (P&P) titled, "Restraints," which indicated, the facility will honor the resident's right to be free from any restraints imposed for reasons other than that of treatment of the resident's medical symptoms. These failures violated Resident 1's right to be free from physical restraints and had a potential to cause injury to the resident. Resident 1 was a 78-year-old female, originally admitted to the facility on 6/12/2024 and readmitted on 4/25/2025. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and hyperlipidemia ([high cholesterol], bipolar disorder (a mental condition marked by alternating periods of elation and depression), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (are a group of mental disorders characterized by significant feelings of anxiety and fear, a worry about future events, and fear is a reaction to current events), low back pain and chronic pain syndrome (a complex condition characterized by persistent pain that lasts beyond the expected healing time, often accompanied by emotional and psychological symptoms). A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 10/15/2025, indicated Resident 1 had severe cognitive impairment (problems with the ability to think, remember, and solve problems). Resident 1 required partial/moderate assistance (helper does less than half the effort) for Activities of Daily Living (ADLs) such as showering/bathing self. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as rolling left to right, from sitting to lying flat on bed, sit to stand, chair/bed-to-chair transfer and toilet transfer. A review of Resident 1's eInteract Change in Condition (COC) Evaluation dated 12/28/2025 at 4:30 p.m., indicated on 12/30/2025 at approximately 4:30 p.m., the Physical Therapist (PT) notified the Charge Nurse (unidentified) that Resident 1 was observed with a linen over her abdomen tied to both sides of the bed. The COC indicated the linen was removed immediately. A review of Resident 1's Order Summary Report for 4/25/2025 to 12/29/2025 did not indicate any order for the use of a physical restraint. A review of facility's five-day investigation report, dated 1/5/2026, indicated the Certified Nursing Assistant (CNA) acknowledged a linen was placed on Resident 1 to the bed, to protect and ensure that Resident 1 did not fall while attending to another resident. During an interview on 1/9/2026 at 1:49 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff should not tie a linen on a resident to the bed even if the resident was considered a fall risk because it restricted the resident's movement. LVN 1 stated tying the resident with a linen was a form of abuse. During an interview on 1/9/2026 at 2:05 p.m., with PT 1, PT 1 stated a physical restraint required a doctors' order. Pt 1 stated on 12/28/2025, Resident 1 was tied across the body to both sides of the bed, and that was considered a type of physical restraint. PT 1 stated the facility should not use a blanket to tie the resident as a form of restraint. During an interview on 1/9/2026 at 2:38 p.m., with CNA 2, CNA 2 stated on 12/28/2025, a linen was placed across Resident 1's breast and ankles and tied to the bed because CNA2 wanted to ensure Resident 1 will not fall, while she attended (care) to another resident. CNA 2 stated tying Resident 1 to the bed with a linen should not have been done because it was a form of restraint. Tying Resident 1 to the bed could affect the resident's dignity. The staff should have called other staff to help while attending to Resident 1 and other residents. During an interview on 1/9/2026 at 4:53 p.m., with the Director of Nursing (DON), the DON stated CNA 2 did not follow the facility's P&P (unspecified) when CNA 2 restrained Resident 1 to the bed, with linen. The DON stated, "the CNA's action affected the residents rights, in stopping the resident from doing whatever she wanted to do even though the staff's intent was to prevent Resident 1 from hurting self." During an interview on 1/12/2026 at 1:32 p.m., with Registered Nurse (RN) 1, RN 1 stated he told CNA 2 that tying Resident 1 to the bed was a form of restraint and could have impacted the resident's circulation, dignity and freedom to move freely and was a violation of the company's safety protocol. RN 1 stated the restraint could also have caused Resident 1 to be agitated (upset) and injured. A review of facility's P&P titled, "Resident Rights," dated 1/2012, indicated, employees will treat all residents with kindness, respect, and dignity and honor residents' rights. A review of facility's P&P titled, "Restraints," dated 1/25/2024, indicated, the facility will honor the resident's right to be free from any restraints that was imposed for reasons other than that of treatment of the resident's medical symptoms. The facility failed to: 1). Ensure Resident 1 was not tied to the bed with a linen. 2). Ensure Resident 1's doctor ordered the use of a physical restraint for the resident. 3). Implement its P&P titled, "Restraints," which indicated, the facility will honor the resident's right to be free from any restraints imposed for reasons other than that of treatment of the resident's medical symptoms. These failures violated Resident 1's right to be free from physical restraints and had a potential to cause injury to the resident. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.