Complaint Investigation Report

The investigation revealed the following: Allegation: Staff are inappropriately restraining a resident resulting in injuries. Record review of R1’s Admission Agreement dated 03/06/26 confirms that R1 was admitted to the facility on 03/06/26. Review of the Physician’s Report dated 03/06/26 indicates that R1 is ambulatory. The department reviewed R1’s Appraisal/Needs and Services Plan dated 03/09/26 and did not observe any documented need for postural supports or restraining devices. Record review of a physician’s order dated 04/06/26 reflects an order authorizing full side rails and a self releasing seat belt for R1.

On 05/06/26, the department conducted interviews with S1–S3. Of those interviewed, 3 out of 3 staff denied the allegation and stated they do not restrain residents without a physician’s order. However, during the interview, S1 disclosed that a wheelchair seat belt had been placed on R1 without a physician’s order from the time of admission until approximately one month ago. S1 stated the seat belt was used depending on R1’s behavior and sundowning episodes and was discontinued once staff were informed that no physician’s order existed. An interview with S2 revealed that a self releasing seat belt is used on R1 at times, depending on behavior. S2 stated there is a physician’s order authorizing a self releasing seat belt and full side rails for R1.

On 05/06/26, the department conducted interviews with R1 and R5–R6 and attempted to interview R2–R4 but was unable to due to cognitive impairment. Of those interviewed, 3 out of 3 residents could not corroborate the allegation.

On 05/06/26, the department conducted interviews with W1-W2. Attempts were made to contact W3-W4 for interviews; however, they did not respond. Of those interviewed, 1 out of 2 witnesses corroborated the allegation.

Based on record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Ricky Bernal, and a copy of this report and the Appeal Rights were provided.