Desert Canyon Post Acute, Llc

During a review of Resident 2's Order Summary Report dated 11/13/2025, the Order Summary Report did not indicate a physician's order for the use of pillows tucked under the fitted sheet.

During a review of Resident 2's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 2 was a high risk for falls.

During a review of Resident 2's care plan (CP) on risk for falls or injury initiated on 11/6/2025, the CP indicated to keep needed items, water in reach, and promote a safe environment as a few of the interventions to minimize the risk of falls.During a concurrent observation and interview on 11/13/2025 at 9:07 a.m., inside Resident 2's room with CNA 1, observed Resident 2 lying in bed asleep. CNA 1 stated Resident 2 had pillows tucked under the fitted sheet on the right side of the bed with the bed against the wall on the left side. CNA 1 state they usually put the pillows under the fitted sheet to prevent falls or injury when Resident 2 gets out of bed unassisted. CNA 1 stated the pillows tucked under the fitted sheet is not a restraint as Resident 2 was still able to climb over the pillows. CNA 1 stated they had in-services regarding restraints but does not remember that the pillows under the fitted sheet cannot be used and is considered a restraint.During a concurrent interview and record review on 11/13/2025 at 12:33 p.m., reviewed Resident 2's Order Summary Report, care plans, and fall risk assessments with the ADON.

The ADON stated that Resident 2 was at a high risk for falls due to his cognition and dementia.

The ADON stated Resident 2 did not have a physician's order for the use of pillows tucked under the fitted sheet and it was not in the CP as one of the interventions to minimize risk of falls.

The ADON stated the facility does not allow the use of pillows tucked under the fitted sheet as it is considered a restraint.

The ADON stated application of the pillows tucked under the fitted sheet for Resident 2 is not honoring the resident's right to be restraint-free.

During an interview on 11/13/2025 at 4:15 p.m. with the DON, the DON stated the use pillows tucked under the fitted sheet is not a practice in the facility and should not be used at any time as it is considered a restraint and restricting the resident's freedom of movement.

The DON stated CNA 1 should have placed the pillows on top of the fitted sheet but not tucked as it restricts Resident 2's freedom of movement which can lead to a decline in physical functioning and increased dependence to staff.

During a review of the facility's policy and procedure (P&P) titled, Respect and Dignity - Physical Restraints, last reviewed on 10/21/2025, the P&P indicated:- Physical restraints: 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 normal access to one's body.- Removes easily: the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by staff considering the resident's physical condition and ability to accomplish objective.- The following practices shall be considered a physical restraint including but not limited to tucking in a sheet tightly so that the resident cannot get out of bed restricting resident's freedom of movement.- Physical restraint may increase the risk for a decline in physical functioning including an increased dependence in ADLs, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures; accidents such as falls, strangulation, or entrapment.- Psychosocial impact related to the use of any physical restraint may include feelings of imprisonment or restriction of freedom of movement.

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