Health inspection·March 19, 2026

§ 483.10 (e) Respect and Dignity The resident has a right to be treated with respect and dignity, including: § 483.10 (e) (1) §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 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. §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. Code of Federal Regulations, Title 42, Section 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: (24) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. On 2/3/26, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. As a result of the investigation, the CDPH determined the facility failed to ensure Resident 1 was free from physical restraints. Resident 1’s bed was placed against the wall on the left side and a Geri Char was placed on the right side of Resident 1’s bed. The facility did not have a physician’s order for the use of Geri Chair for Resident 1.   This failure limited Resident 1’s mobility, violated Resident 1's right and had the potential to cause physical and/or psychological harm to Resident 1.   A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 75-year-old male, on 11/25/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and contracture of the right upper arm and right knee. A review of Resident 1’s untitled Care Plan (CP) initiated on 11/25/25 indicated Resident 1 was at risk for falls related to confusion and history of falls due to attempting to get out of bed unassisted. The CP interventions included 1:1 supervision for Resident 1, to maintain 1:1 observation “at all times” and not to leave Resident 1 unattended.  A review of Resident 1’s Order Summary Report (OSR) dated 11/25/25 indicated 1:1 supervision for Resident 1 for safety. The OSR did not indicate an order for the use of Geri Chair for Resident 1.   A review of Resident 1’s Minimum Data Set dated 12/1/25, indicated Resident 1’s cognition was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance from staff for eating, oral hygiene, toilet hygiene, personal hygiene, shower and bathing, upper and lower body dressing and putting on/taking off footwear.   A review of Resident 1’s Fall Risk Evaluation dated 12/23/25 indicated Resident 1 was at high risk for falls with a score of 19. The form indicated a total score of 10 or more, indicated Resident 10 was at high risk for potential falls.     During an observation inside Resident 1’s room on 2/3/26 at 4:54 AM, Resident 1’s bed was placed against the wall on the left side and a Geri Chair was placed directly against Resident 1’s bed on the right side, wedged against the bed frame creating a physical barrier. Resident 1 was lying in the center of the bed in a curled-up position, wrapped with blanket from head to toe.   During an interview inside Resident 1’s room with Sitter 1 (S1) on 2/3/26 at 4:55 AM, S1 stated the Director of Nursing (DON) gave permission for staff to place the Geri Chair next to Resident 1’s bed.   During an observation and interview inside Resident 1’s room with License Vocational Nurse 1 (LVN1) on 2/3/26 at 4:56 AM, LVN1 stated LVN 1 was aware the Geri Chair was placed against Resident 1’s bed. LVN 1 stated the Geri Chair was used as a restraint to prevent Resident 1 from rising up off the bed since Resident 1 “tends to wiggle out of the bed.” LVN 1 stated the Geri Chair had been there since the day shift of 2/1/26 and both the facility Administrator (Admin) and the DON were aware.   During an interview with Registered Nurse Supervisor 1 (RNS 1) on 2/3/26 at 7:51 AM, RNS 1 stated it was dangerous to have a Geri Chair placed against Resident 1’s bed because it was an entrapment and a restraint. RNS 1 stated when Resident 1 attempted to get up from the bed, Resident 1 would be at a higher risk of falling and suffering injuries by becoming entrapped between the bed and the Geri Chair. RNS 1 stated other alternatives should have been used instead of using the Geri Chair as a restraint. RNS 1 stated having the Geri Chair at bedside could increase agitation, confusion, and feelings of anxiety in Resident 1. RNS 1 stated using the Geri Chair as a device to restrain a resident for staff convenience was not acceptable.   During an interview with the facility’s DON on 2/3/26 at 8:29 AM, the DON stated the Geri Chair should not have been placed blocking Resident 1 in bed because it was considered a form of restraint and could cause harm to Resident 1.   During an interview with the facility’s Admin on 2/3/26 at 9:54 AM, the Admin stated using a Geri chair to keep residents in bed was unacceptable and considered a type of restraint.   A review of the facility’s Policy and Procedure (P&P) titled, “Use of Restraints,” revised 4/2017 indicated restraints shall only be used to treat the resident’s medical symptoms and never for discipline or staff convenience or for the prevention of falls.   A review of the facility’s P&P titled, “Safety and Supervision of Residents,” revised 7/2017 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.   A review of the facility’s P&P titled, “Quality of Life-Dignity,” revised 2/2020 indicated, “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, feeling of self-worth and self-esteem”. The facility failed to ensure Resident 1 was free from physical restraints. Resident 1’s bed was placed against the wall on the left side and a Geri Char was placed on the right side of Resident 1’s bed. The facility did not have a physician’s order for the use of Geri Chair for Resident 1.   This failure limited Resident 1’s mobility, violated Resident 1's right and had the potential to cause physical and/or psychological harm to Resident 1. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.