Health inspection·October 28, 2025

Code of Federal Regulations, Title 42, Section 483.10 Resident rights. (a) Residents’ rights. The resident has right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Code of Federal Regulations, Title 42, Section 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 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). Code of Federal Regulations, Title 42, Section 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 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. Code of Federal Regulations, Title 42, Section 483.12(c) (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72315. Nursing Services – 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. California Code of Regulations, Title 22, Section 72319. Nursing Service - Restraints and Postural Supports. (a)Written policies and procedures concerning the use of restraints and postural support 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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: (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 9/23/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility Reported Incident regarding an allegation of staff to resident abuse. The facility failed to ensure: 1. Resident 1 was free from unnecessary restraints (a method or device that restricts a patient's freedom of movement or normal access to their body). 2. Certified Nursing Assistant (CNA) 2 did not wrap a linen sheet around Resident 1’s legs and tied it to Resident 1’s bedframe to restrict Resident 1’s movement on 9/11/2025. 3. Report an allegation of staff to resident abuse to CDPH and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours from the time Resident 1 was found with a linen sheet wrapped around Resident 1’s legs and tied to his bedframe. These failures resulted in Resident 1’s movement being restricted and had the potential for Resident 1 to experience indignity and humiliation, develop an injury, impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body), skin breakdown (damage to the skin that can lead to open wounds and infections), pain and to result in a delay of an onsite inspection by CDPH and had the potential for Resident 1 to experience ongoing abuse. A review of Resident 1’s Admission Record, indicated the facility admitted a seventy-nine-year-old-male on 7/25/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool) dated 8/8/2025, indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 was dependent on help for eating, oral hygiene, toileting hygiene, showering, bathing himself, upper body dressing, lower body dressing, personal hygiene, putting on footwear, and taking off footwear. A review of Resident 1’s Nurses Notes dated 9/12/2025 at 7:45 PM, indicated that around 11:35 PM on 9/11/2025 CNA 1 called the attention of Registered Nurse (RN) 1 to Resident 1’s room. The Nurses Notes indicated that upon entering Resident 1’s room, the resident was noted on his bed with his legs crossed and a sheet wrapped in his lower legs to keep them from sliding off the bed. The Nurses Notes indicated Resident 1 had a history of sliding his legs all over the bed, keeping his legs crossed, and dangling his legs over the bed. A review of the document titled “Report of Suspected Dependent Adult/Elder Abuse” dated 9/12/2025, indicated the facility reported neglect (a form of abuse in which there is a failure of a caregiver to meet a person's basic physical and emotional needs, leading to actual or potential harm). The document indicated Resident 1 was the victim and CNA 2 was the suspected abuser. The document indicated Resident 1 was noted with a sheet applied as an intervention to prevent Resident 1’s legs from falling off the bed. The document indicated an investigation by the facility had been initiated. The document indicated the incident occurred on 9/11/2025 at 11:30 PM. A review of a fax confirmation from the facility to CDPH dated 9/12/2025 at 8:30 PM, indicated the facility notified CDPH of Resident 1’s allegation of abuse over 2 hours and nearly 24 hours later. A review of an email from the facility to the Ombudsman dated 9/12/2025, indicated the facility notified the Ombudsman of Resident 1’s allegation of abuse. A review of Resident 1’s Nurses Notes dated 9/12/2025 at 10:42 PM, indicated on 9/11/2025 Resident 1 was noted in bed with his legs crossed. The Nurses Notes indicated Resident 1 had a sheet wrapped on his lower legs to keep them from sliding off the bed. A review of Resident 1’s Nurses Notes dated 9/13/2025 at 12:15 AM, indicated that at approximately 11:35 PM on 9/11/2025 a CNA (unidentified) called RN 2 to Resident 1’s room. The Nurses Notes indicated that upon RN 2’s entrance to Resident 1’s room, Resident 1 was noted to be lying in bed with his legs crossed. The Nurses Notes indicated a sheet had been wrapped around Resident 1’s lower legs in an apparent attempt to keep them from sliding off the bed. The Nurses Notes indicated that the supervising nurse was notified immediately, and the sheet was promptly removed. A review of the facility’s undated document titled “Investigation”, indicated RN 1, RN 2, RN 3, CNA 1, and CNA 2 were interviewed. The document indicated RN 1 saw Resident 1 with his legs crossed and a sheet wrapped around his lower leg area. The document indicated RN 2 noticed sheets were wrapped around Resident 1’s legs. The document indicated RN 3 was called to come into Resident 1’s room around 11:15 PM on 9/11/2025. The document indicated CNA 1 found Resident 1 with a sheet wrapped around the resident’s legs. The document indicated CNA 2 put a sheet around Resident 1’s legs to keep the resident safe so the resident would not fall and get hurt. The document indicated that CNA 2 mentioned Resident 1 kept trying to get out of bed. The document indicated CNA 2 was suspended pending an investigation of the incident. The document indicated CNA 2 later resigned from his position as a CNA at the facility. A review of the facility document titled “Verification of Incident Investigation/Administrative Summary” dated 9/17/2025, indicated that while providing routine care to Resident 1, a CNA (unidentified) loosely wrapped a sheet around the resident’s feet and then snuggly tucked the ends into each side of the bed in an effort to prevent the resident from shifting and/or potentially sliding out of bed. The “Verification of Incident Investigation/Administrative Summary” indicated another staff member noticed Resident 1 had a sheet wrapped around his feet and immediately proceeded to unwrap the resident’s feet. The “Verification of Incident Investigation/Administrative Summary” indicated the action (Resident 1’s feet being wrapped with a sheet) was identified as a suspicion of involuntary (an action that is not made by choice) restraint. The “Verification of Incident Investigation/Administrative Summary” indicated staff (unidentified) confirmed observing Resident 1 with a sheet wrapped around his legs which was determined to have admittedly been applied by CNA 2. The “Verification of Incident Investigation/Administrative Summary” indicated CNA 2 stated Resident 1 frequently swung his legs from side to side. The “Verification of Incident Investigation/Administrative Summary” indicated CNA 2 reported concerns that Resident 1 could injure himself by hitting his legs on the bed or falling. The “Verification of Incident Investigation/Administrative Summary” indicated CNA 2 acknowledged that wrapping Resident 1’s legs with a sheet was not how he was trained to address these types of issues. The “Verification of Incident Investigation/Administrative Summary” indicated the facility’s investigation substantiated that CNA 2 used an unauthorized method to prevent Resident 1 from sliding off the bed without a physician’s order and in violation of the facility’s policy. The “Verification of Incident Investigation/Administrative Summary” indicated that while CNA 2 stated his intent was attempting to protect Resident 1 from injury/harm, the intervention was inappropriate and not in alignment with professional standards for addressing this type of issue. Two attempts were made to contact RN 1 however; RN 1 could not be reached for an interview. During a telephone interview on 9/23/2025 at 11:10 AM, RN 2 stated that around 11:20 PM on 9/11/2025, a CNA (unidentified) told her to check on Resident 1. RN 2 stated when she (RN2) checked on Resident 1, she saw Resident 1’s legs tied. RN 2 stated Resident 1 had a white sheet wrapped around his ankles. RN 2 stated the two ends of the sheet were tied around the bed frame. RN 2 stated Resident 1 could not move his legs. RN 2 stated the sheet looked like it was tied tight around Resident 1’s ankles. RN 2 stated she was not sure how long Resident 1’s legs were tied to the bed. RN 2 stated Resident 1’s legs were restrained to his bed. RN 2 stated Resident 1 did not have any physician orders for restraints. RN 2 stated whoever tied Resident 1’s legs to the bed tried to take a short cut. RN 2 stated Resident 1 normally liked to move his legs around the bed. RN 2 stated tying and restraining Resident 1’s legs to the bed was a form of abuse. RN 2 stated “we should never tie the resident with a sheet”. RN 2 stated that because Resident 1’s legs were tied to the bed the resident could have potentially had skin injuries, pain, emotional distress, and the circulation to his ankles and feet cut off. During a telephone interview on 9/23/2025 at 12:24 PM, CNA 1 stated on 9/11/25 at around 11:10 PM to11:20 PM he checked on Resident 1 and saw that both of Resident 1’s feet were tied with a sheet to the left and right side of the bed frame. CNA 1 stated Resident 1’s feet were tied together with a flat sheet. CNA 1 stated the sheet was tied tight around Resident 1’s feet so the resident could not move his feet. CNA 1 stated he immediately notified RN 1. CNA 1 stated he was not sure who tied Resident 1. CNA 1 stated whoever tied Resident 1 probably did it so the resident could not move his legs. CNA 1 stated “we don’t do that; we don’t tie the residents”. CNA 1 stated tying Resident 1’s legs was a restraint. CNA 1 stated Resident 1 could have hurt themselves when restrained. During a telephone interview on 9/23/2025 at 12:43 PM, RN 3 stated on 9/11/2025 at around 11:15 PM he was asked by RN 1 to come and see Resident 1 to be another witness. RN 3 stated he saw Resident 1’s legs wrapped in a long bedsheet which was tied to each end of the resident’s bed. RN 3 stated the bed sheet was tied around Resident 1’s legs. RN 3 stated Resident 1 could not move his legs. RN 3 stated Resident 1 was placed in a restraint. RN 3 stated Resident 1 being restrained was a type of abuse because the resident could not move freely. RN 3 stated there was potential for Resident 1 to have his skin broken and his circulation cut off because of the restraints. During an interview on 9/23/2025 at 1:42 PM, the Director of Staff Development (DSD) stated wrapping a sheet around Resident 1’s legs and then tying the sheet to the bed was considered a restraint because it limited and restricted the resident’s movement. The DSD stated wrappi