Other·April 23, 2026

Title 42 Code of Regulations: §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 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). §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 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. Title 22 California Code of Regulations: § 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. §72527(a)(24) (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. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time. On 3/31/2026 the California Department of Public Health (CDPH) made an unannounced visit to conduct an annual recertification survey. The facility failed to ensure Resident 3 was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: -Ensure licensed nurses (in general) assessed Resident 3 and documented specific behavioral symptoms for the use of Haloperidol (Haldol, a type of medication used to treat the symptoms of schizophrenia [a mental illness that affects thoughts, mood, and behavior]) 10 milligrams (mg, unit of measurement). This failure had the potential for Resident 3 to become over-medicated, restrict mobility, and experience adverse side effects (unexpected or harmful consequences of medication) of Haldol such as dizziness, sedation (a decrease in awareness), blurred vision, and constipation (infrequent bowel movements). A review of Resident 3's Admission Record indicated the facility admitted a 75 year old female on 9/19/2023 with diagnoses that included mood affective disorder (a mental health condition involving long-term emotional disturbances), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety (a mental health condition characterized by feelings of fear, dread and uneasiness that interfere with daily activities). A review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2026, indicated the resident had severely impaired cognition (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) from facility staff with eating and oral hygiene. The MDS indicated Resident 3 was dependent on facility staff for help with toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 was taking antipsychotic medication (medication used to treat schizophrenia). A review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 3/26/2026, indicated informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits, and alternatives offered) was received from the resident's surrogate decision maker (a person authorized to make healthcare decisions for someone else who has become incapacitated) for Haldol 10 mg at bedtime for schizophrenia manifested by auditory hallucinations (hearing voices or noises that don't exist in reality). A review of Resident 3's Order Summary Report (physician order) dated 4/1/2026 indicated for Resident 3 to take Haldol 10 mg at bedtime for responding to internal stimuli (unspecified) related to schizoaffective disorder. A review of Resident 3's Medication Administration Record (MAR) dated 3/27/2026 to 3/31/2026 indicated Resident 3 received Haldol 10 mg daily at bedtime for manifestations of responding to internal stimuli (unspecified) related to schizoaffective disorder. The MAR indicated Resident 3 had three instances of responding to internal stimuli (unspecified) on the evening shift on 3/31/2026. During an observation on 3/31/2026 at 9:47 AM in Resident 3's room, Resident 3 was observed lying in bed. Resident 3's call light was observed within the resident's reach. Resident 3's bed was observed in a low position with the right side of the bed against the wall and a floor mat to the left side of the bed. Resident 3 could not be interviewed. During a concurrent interview and record review on 4/2/2026 at 11:03 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. LVN 1 stated Resident 3 had schizophrenia. LVN 1 stated Resident 3 was taking Haldol for responding to internal stimuli. LVN 1 stated there were physician orders to monitor Resident 3 for behaviors of responding to internal stimuli. LVN 1 stated she (LVN 1) was not sure what responding to internal stimuli meant. LVN 1 stated it would have been easier to monitor Resident 3 for more specific behavior like yelling or talking to herself (Resident 3). During a concurrent interview and record review on 4/2/2026 at 12:58 PM with Registered Nurse 1 (RN 1), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. RN 1 stated Resident 3 was on Haldol for schizophrenia and responding to internal stimuli. RN 1 stated responding to internal stimuli referred to how Resident 3 was responding internally to environmental factors. RN 1 stated that the nurses (in general) were supposed to monitor how Resident 3 responded internally to environmental factors, such as noise levels. RN 1 stated the nurses (in general) were supposed to adjust Resident 3's environment based on how the resident responded internally to environmental factors. RN 1 stated the nurses (in general) were not monitoring for specific behavior. RN 1 stated responding to internal stimuli was not a specific behavior. During a concurrent interview and record review on 4/2/2026 at 1:09 PM with RN 2, Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. RN 2 stated Resident 3 had physician orders for Haldol 10 mg for schizophrenia manifested by responding to internal stimuli. RN 2 stated responding to internal stimuli referred to Resident 3 having auditory or visual hallucinations. RN 2 stated responding to internal stimuli was a broad manifestation which could cover all of Resident 3's behavioral symptoms. RN 2 stated that if the physician order for Haldol had a manifestation that was more specific, it would be easier to monitor Resident 3 for that specific behavior. RN 2 stated there was a potential that the licensed nurses would interpret the manifestation of responding to internal stimuli differently which could lead to the resident's behaviors not being monitored accurately. During a concurrent interview and record review on 4/3/2026 at 8:31 AM with the Director of Nursing (DON), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. The DON stated Resident 3 had physician orders for Haldol 10 mg for schizophrenia manifested by responding to internal stimuli. The DON stated the manifestation for responding to internal stimuli was not specific enough to be monitored. The DON stated there was a potential for the licensed nurses to have different interpretations of "responding to internal stimuli". The DON stated she (the DON), had difficulty explaining what responding to internal stimuli meant. The DON stated the behavior manifestation for Resident 3's Haldol order should have been a more specific behavior such as an auditory hallucination. The DON stated there was a potential for Resident 3 to become overmedicated and experience side effects of Haldol if the resident's behaviors were not interpreted or monitored accurately. A review of the facility's Policy and Procedure (P&P) titled "Antipsychotic Medication Use" dated 1/15/2026, indicated "Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications." The facility failed to ensure Resident 3 was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: -Ensure Resident 3's physician order dated 4/1/2026 for Haloperidol 10 mg at bedtime specified resident specific behavior manifestations. This failure had the potential for Resident 3 to become over-medicated, restrict mobility, and experience adverse side effects of Haldol such as dizziness, sedation blurred vision, and constipation The above violations had direct or immediate relationship to the health, safety, or security of Resident 3.