Health inspection·July 23, 2025

CFR §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (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 Freedom from Abuse, Neglect, and Exploitation 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. (a) The facility must— (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. CCR 22, § 72319 - Nursing Service-Restraints and Postural Supports (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. (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. (g) Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient. (h) Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. (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. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (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. On 5/30/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) alleging that on 5/30/2025 at 2:30 a.m., Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1 restrained Resident 1 by wrapping a bed sheet around his legs to keep Resident 1 from getting out of bed. On 5/30/2025 at 3:30 p.m., the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, CDPH determined the facility failed to: 1. Assess Resident 1 for possible causes of behaviors and implement interventions before the application of physical restraints. 2. Notify Resident 1’s physician of Resident 1’s continued agitation and trying to get out of bed unassisted and obtain a Physician Order for the use of Physical restraints before applying the restraints. 3. Develop a care plan to address the need for the implementation of physical restraints. 4. Attempt to use less restrictive interventions before application of physical restraints on Resident 1. 5. Ensure RN, CNA 1, and facility staff were competent in using physical restraints and managing fall risks and challenging behaviors. These deficient practices resulted in violation of Resident 1’s right to be free from restraints. On 5/30/2025 approximately 2:30 a.m. until 10:00 a.m., RN 1 and CNA 1 restrained Resident 1 (using a bed sheet wrapped and tied around Resident 1’s legs to restrict his movements) due to a risk of recurrent falls and combative behavior. This practice placed Resident 1 at risks of skin breakdown, injury from attempts to free himself, feelings of helplessness, fear, and humiliation leading to physical, long term emotional, mental decline, and reduced self-worth.  During a review of Resident 1’s Admission Record, the Admission Record indicated the facility admitted Resident 1 a 71-year-old male, on 5/18/2025, with diagnoses including, cognitive communication deficit (difficulty carrying a conversation), abnormal posture, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic pain syndrome (persistent pain that lasts weeks to years).  During a review of Resident 1’s Minimum Data Set (MDS-, a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 1’s cognition (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1needed substantial staff assistance) with dressing, personal hygiene, oral hygiene, and Resident 1 was dependent on staff with toileting hygiene, and showering. During a record review of the facility’s Interview Record of CNA 1 at 5/30/2025 at 8:57 a.m., the record indicated CNA 1 stated on 5/30/2025, Resident 1 was very agitated and was kicking during care, and was not redirectable.   During a phone interview on 5/30/2025 at 4:45 p.m., CNA 1 stated Registered Nurse (RN) 1 tied Resident 1 on the calf and leg area to the bed frame with a bed sheet to prevent Resident 1 from falling. CNA 1 stated RN 1 and CNA 1 forgot to untie Resident 1 thus to remove the restraints. During a record review of the facility’s Interview Record of RN 1 at 5/30/2025 at 5:10 p.m., the record indicated RN 1 stated he (RN 1) made a clinical judgement to secure Resident 1 to the bed to prevent the resident from harming himself as well as the staff. RN1 stated Resident 1 was agitated kicking staff unable to control and manage his behavior so RN 1 and CNA 1 secured his legs to prevent further harm and for the resident’s safety.   During a phone interview on 5/30/2025 at 5:30 p.m., RN 1 stated on 5/30/2025 from 2:30 a.m. until 10:00 a.m., he wrapped sheets around Resident 1’s legs and tied it to the bed frame to prevent him from getting out of bed, to prevent him from hitting and kicking staff. RN 1 stated the physician was not notified nor Resident 1’s responsible party. RN 1 stated there were no orders for the restraints and he forgot to untie the resident to remove the restraint. RN 1 stated it was poor judgement on his part. During a review of Resident 1’s Change in Condition Evaluation, dated 5/30/2025 at 11:05 a.m., the Change in Condition evaluation indicated at approximately 10 a.m., Resident 1 was noted lying in bed with bed sheets wrapped around his ankles. During an interview on 5/30/20025 at 3:55 p.m., CNA 2 stated she and the Certified Occupational Therapist Assistant (COTA) found sheets wrapped around Resident 1’s calf and leg area, and she immediately called Licensed Vocational Nurse (LVN) 2 to remove the sheets that were tied around Resident 1’s legs. CNA 2 stated she reported it because the facility does not allow restraints, and "we do not tie residents to prevent them from falling." During an interview on 6/4/205 at 2:38 p.m., LVN 2 stated later in the day after morning medication pass, CNA 2 alerted LVN 2 that Resident 1 was restrained. LVN 2 stated sheets were wrapped around Resident ‘s legs around the calf area "like a roll". The legs were closed together. During an interview and record review with the Administrator (ADMIN) on 6/6/2025 at 2:54 p.m., the ADMIN stated RN 1 stated he (RN 1) made a clinical judgement to secure Resident 1 to the bed to prevent him from harming himself as well as the staff. The ADMIN stated RN 1 reported Resident 1 was agitated, kicking staff unable to control and manage his behavior so RN 1 and CNA 1 secured his legs to prevent further harm and for the resident’s safety.   During a concurrent interview and record review on 6/6/2025 at 3:10 p.m., with the Director of Nursing (DON), Resident 1’s medical record was reviewed. The DON stated the bedsheet wrapped around Resident 1’s legs considered to be a restraint because it limits the resident’s movement. The DON stated Resident 1 was not assessed for possible causes of behaviors prior to the application of restraints. The DON stated the physician did not order and was not aware of the restraint. The DON stated there is no care plan for restraint application for this resident. The DON stated the less restrictive interventions that could have been used instead of restraint application included activities, redirection, increase monitoring, or 1:1 supervision. During a review of facility policies and procedure (P&P), titled, "Resident Rights", revised 12/2021, the P&P indicated federal and state laws guarantee certain basic rights to all residents of the facility including the right to be free from physical or chemical restraints not required to treat the residents’ symptom. During a review of the facility’s P&P titled, "Use of Restraints", revised 4/2017, the P&P indicated: 1. Restraints shall only be used for the safety and well-being of the residents(s) and only after other alternatives have been tried unsuccessfully. 2. Restraints shall only be used to treat the resident's medical symptom(s) and never for staff convenience or for the prevention of falls. 3. 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 of the need for restraints will be documented. 4. Physical Restraints" are defined as any 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. 5. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. 6. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including Tucking sheets so tightly that a bed-bound resident cannot move. 7. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to detem1ine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. The facility failed to: 1. Assess Resident 1 for possible causes of behaviors and implement interventions before the application of physical restraints. 2. Notify Resident 1’s physician of Resident 1’s continued agitation and trying to get out of bed unassisted and obtain a Physician Order for the use of Physical restraints before applying the restraints. 3. Develop a care plan to address the need for the implementation of physical restraints. 4. Attempt to use less restrictive interventions before application of physical restraints on Resident 1. 5. Ensure RN, CNA 1, and facility staff were competent in using physical restraints and managing fall risks and challenging behaviors. These deficient practices resulted in violation of Resident 1’s right to be free from restraints. On 5/30/2025 approximately 2:30 a.m. until 10:00 a.m., RN 1 and CNA 1 restrained Resident 1 (using a bed sheet wrapped and tied around Resident 1’s legs to restrict his movements) due to a risk of recurrent falls and combative behavior. This practice placed Resident 1 at risks of skin breakdown, injury from attempts to free himself, feelings of helplessness, fear, and humiliation leading to physical, long term emotional, mental decline, and reduced self-worth.    These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.