Every finding on record at Elk Grove Post Acute

Based on observation, interview, and record review, the facility failed to maintain safe operating condition for kitchen equipment for a census of 129 residents, when a damaged thermometer was used for the automatic dishwashing machine. This failure decreased kitchen staff's potential to know if dishware was sanitized for resident use.Findings:During a concurrent observation and interview on 5/11/26 at 1:03 p.m. with Dietary Aide (DA) 1 and the Regional District Manager (RDM), DA 1 ran dishware through the automatic dishwasher. The machine's thermometer reached 110 degrees Fahrenheit ( F - a temperature measurement system) throughout three cleaning cycles and during nonuse. RDM stated the water temperature for both wash and rinse cycles needed to be at a minimum of 120 F to properly sanitize dishware. RDM obtained a new dishwasher thermometer which registered 137.7 F during the rinse cycle. RDM stated the thermometer on the dishwasher was broken and kitchen staff would not know if dishware was washed at the designated temperature to properly sanitize them for resident use.A review of the facility's undated log titled, Dish Machine Log - Low temperature (Chemical Sanitizer), Chemical Sanitizing (Low Temp): Wash: 120-140 F, Rinse: 120-140 F.A review of the facility's policy and procedures (P&P) titled, Warewashing, revised December 2024, indicated, All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for . low temperature machines.A review of the facility's P&P titled, Safety, revised September 2017, indicated, The kitchen and associated equipment will be properly maintained and that all Dining Services staff follow safe operating practices. All . kitchen equipment issues will be promptly reported to facility staff and recorded according to facility protocol.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained for a census of 129 residents, when garbage dumpsters were left uncovered for three consecutive days. This failure decreased the facility's potential to maintain sanitary conditions in the garbage storage area and reduce the risk of pest infestation. Findings: During an observation on 5/11/26 at 7:38 a.m. in the backyard of the facility, garbage dumpsters were observed. One recycle dumpster was over filled to close the lid and some empty boxes were found on the ground next to it. Two garbage dumpsters were left opened and a few empty boxes and buckets were found around on the ground. No staff was observed using the dumpsters. During a concurrent observation and interview on 5/12/26 at 10:40 a.m. with Maintenance Supervisor (MS), garbage dumpsters were observed. One recycling dumpster was over filled to close the lid and two garbage dumpsters were left opened. MS confirmed recycling and garbage dumpsters were left opened. During a concurrent observation and interview on 5/13/26 at 11:15 a.m. with MS and Infection Preventionist (IP), garbage dumpsters were observed. MS and IP confirmed recycling and garbage dumpsters were left opened. IP stated all dumpsters lids should remain closed when not in use. During an interview on 5/14/26 at 11:30 a.m. with the Administrator (ADM), ADM confirmed recycling and garbage dumpsters were left uncovered for three consecutive days. ADM expected staff to close the dumpsters' lids immediately after using to prevent pests infestation and spreading infection in the facility. A review of the facility's policy and procedure titled, Dispose of Garbage and refuse, revised on 2/2025, indicated, . The Director of Maintenance to ensure that the area surrounding the exterior of the dumpsters is maintained in a manner free of rubbish or other debris . All trash will be properly disposed of in external receptacles (dumpsters) with lids covered when not in use .

Based on observation, interview, and record review, the facility failed to maintain proper kitchen and food safety measures for a census of 129 residents, when:1. Kitchen floors were wet for three days;2. Frozen waffles were stored unsealed in the reach-in refrigerator;3. Food boxes were stored directly on the floor and on top of upside-down milk crates in the walk-in freezer with food stored on rusty metal shelving;4. Four steam table pans were stored wet; one steam table pan was found with a clumpy beige residue on the outside; and5. Four spice bottles were stored with open lids.These failures decreased the facility's potential to ensure kitchen safety and safely store and serve food.Findings:1. During a concurrent observation and interview on 5/11/26 at 8:09 a.m. with Dietary Manger (DM) at the entrance hall of the kitchen, the kitchen area was inspected. DM confirmed there was a water trail leading from the main kitchen area and stated the floors should not be wet. DM expected kitchen crew to promptly mop up water spills. DM further stated the wet area was a fall hazard due to the large amount of water.During an observation on 5/12/26 at 8:41 a.m., a trail of water was noted on the kitchen floor in front of the hot steam table. At 2:08 p.m., a worker was seen pushing a cart loaded with dishes through a water trail in front of the dishwasher.During an observation on 5/13/26 at 10:29 a.m. in the kitchen, a standup Caution- Wet Floor sign was observed at the dirty dishes counter. The floor from the counter to the entrance door (approximately 40 feet) was wet and not been mopped. Wet shoe prints indicated someone had walked through the water.A review of the facility's policy and procedures (P&P) titled, Safety, revised September 2017, indicated, The kitchen . will be properly maintained and that all Dining Services staff follow safe operating practices . Floor mats and wet floor signs will be used, as appropriate.2. During a concurrent observation and interview on 5/11/26 at 8:25 a.m. with DM, the reach-in refrigerator was inspected. A large bag of frozen waffles was found unsealed. DM stated the waffles should have been sealed to keep the food protected.3. During a concurrent observation and interview on 5/11/26 at 8:35 a.m. with DM, the walk-in freezer was inspected. 11 boxes of food were stored directly on the freezer floor. Six boxes were also stored on four upside-down milk crates and a metal shelving unit had a reddish-brown material that resembled rust on the bottom shelf and corner pole. DM stated the boxes should have been stored on appropriate shelving, as stacking on the floor, plastic crates, and rusty shelving could contaminate the food.During an interview on 5/13/26 at 2:12 p.m. with Registered Dietician (RD), RD expected kitchen staff to store food properly. RD stated boxes stacked on top of each other in the walk-in freezer could topple and injure an employee in addition to being contaminated from sitting on the freezer floor.A review of the facility's P&P titled, Food Storage: Cold Foods, revised February 2023, indicated, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code . All food items will be stored six inches above the floor . All foods will be stored wrapped or in covered containers, labeled and dated, and stored in a manner to prevent cross contamination.4. During a concurrent observation and interview on 5/11/26 at 8:46 a.m. with DM, four quarter-sized steam table pans were found stored wet, and one half-sized steam table pan was found with a soft, clumpy beige residue. DM stated kitchenware run through the dishwasher should have been thoroughly dried and cleaned before storing. During an interview on 5/13/26 at 2:22 p.m. with RD, RD stated kitchen staff should have followed protocol for storing cooking pans safely to ensure sanitary food service to residents.A review of the facility's P&P titled, Warewashing, revised December 2024, indicated, All dishware, service ware, and utensils will be cleaned and sanitized after each use . The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware . All dishware will be air dried and properly stored.5. During a concurrent observation and interview on 5/11/26 at 9:15 a.m. with DM, four spice bottles were found stored with open lids. DM stated the cooks should have closed the lids after use because the spices could become contaminated.A review of the facility's P&P titled, Food Storage: Dry Goods, revised February 2023, indicated, All packaged and canned food items will be kept clean, dry and properly sealed.

Based on observation, interview, and record review, the facility failed to remove from use discontinued medications for a census of 129 residents, when medications belonging to discharged residents were stored with active residents' medications.This failure increased the facility's potential to administer discontinued medications.Findings:During a concurrent observation and interview on 5/14/26 at 8:32 a.m. with Licensed Nurse (LN) 8 inside the medication room at nurses' station one, LN 8 confirmed a vial of regular insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was found inside the refrigerator. LN 8 stated the insulin vial belonged to a resident who was discharged from the facility.During a concurrent observation and interview on 5/14/26 at 11:55 a.m. with LN 4, the southeast medication cart was inspected. LN 4 confirmed a bottle of dexamethasone (medication used to treat inflammation and allergic reactions) oral solution and a pack of ipratropium bromide-albuterol sulfate (combination of medication used to manage breathing difficulties and airflow blockages in the lungs) inhalation solution were stored in the cart. LN 4 stated the medications belonged to residents who were discharged from the facility.During an interview on 5/14/26 at 2 p.m. with the Director of Nursing (DON), DON stated medications belonging to discharged residents should have been removed, disposed of or stored separately from those assigned to active residents to prevent medication administration errors.A review of the facility's policy titled, Medication Storage in the Facility, revised in 1/2025, indicated, Medication storage . are monitored on a routine basis . and corrective action taken if problems are identified . medications are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observation, interview, and record review, the facility failed to follow the recipe for nine residents of a census of 129, when [NAME] (C) 1 added unmeasured amounts of water and milk to pureed (smooth, lump-free, moist food with the consistency of pudding) meals.This failure decreased the facility's potential to serve food that was easy to swallow and retained its nutrients.Findings:A review of the facility's lunch menu titled, Week-at-a-Glance - Spring 2026, dated 5/13/26, indicated the menu consisted of barbeque pork ribs, baked or mashed potatoes, collard greens, cornbread, and Texas sheet cake.A review of the facility's recipe titled, BBQ Pork Rib: Puree, dated 2026, indicated a maximum of 14.4 ounces [(oz.- a unit of measure) 1.8 cups] of hot water was to be added to 12 servings of pork.A review of the facility's recipe titled, Cornbread: Puree, dated 2026, indicated the maximum amount of warm milk to be added for 12 servings of cornbread was 19.2 oz (2.4 cups).During a concurrent observation and interview on 5/13/26 at 10:29 a.m. with C 1 and Registered Dietician (RD), lunch preparation for pureed food was observed. C 1 stated she was preparing 12 servings of pureed meals. C 1 measured 12 servings of barbeque pork and put the meat in a blender, then added warm water in increments using two different sized eating spoons and a Styrofoam cup. C 1 then prepared the cornbread, adding four cups of warm milk in increments, alternating adding an unmeasured amount of milk six times. The cornbread mixture was thick and stiff. C 1 stated she should have followed the recipes for adding the correct water and milk amounts.During an interview on 5/13/26 at 11:14 a.m. with RD, RD stated C 1 added unmeasured amounts of water to the pork and added unmeasured amounts of milk to the cornbread and confirmed C 1 did not follow the recipe. RD also stated the bread's consistency was inadequate for residents with swallowing problems (potential for choking), and residents on pureed diets might not get essential nutrients if the food had excess liquids.A review of the facility's policy and procedures (P&P) titled, Therapeutic Diets, revised October 2022, indicated, Therapeutic diet is . ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition . to [modify] specific nutrients in the diet, or to provide food that a resident is able to eat .A review of the facility's P&P titled, Food: Quality and Palatability, revised February 2023, indicated, Food will be prepared by methods that conserve nutritive value . Food and liquids are prepared and served in a manner, form and texture to meet resident's needs.

Based on interview and record review, the facility failed to submit in a timely manner a Minimum Data Set (MDS, a federally mandated assessment tool) assessment for one of 30 sampled residents (Resident 17), when Resident 17's discharge MDS was completed after 14 days of discharge.This failure had the potential to delay the transmission of Resident 17's data to the Centers for Medicare and Medicaid Services (CMS).Findings:A review of an admission record indicated Resident 17 was admitted to the facility on [DATE] and discharged on the same date.During a concurrent interview and record review on 5/12/26 at 1 pm with the Assistant Director of Nursing (ADON), Resident 17's MDS assessments and progress notes, dated 11/24/25 were reviewed. ADON confirmed Resident 17's MDS entry and discharge assessments shared the same assessment reference date (ARD) but was completed and transmitted to CMS on 12/11/25, more than 14 days later.During an interview on 5/14/26 at 2 pm with the Director of Nursing (DON), DON expected the assigned staff to follow the required timeframes for MDS submission.A review of the facility's policy titled, Comprehensive Assessments, revised in 10/2023, indicated, Assessments for residents that has been admitted to the facility and was discharged return anticipated must be completed by the end of day 14.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was recorded accurately for one of 30 sampled residents (Resident 140), when Resident 140's resuscitation (the emergency act of reviving someone who is not breathing, or heart has stopped beating) instructions were inaccurately documented in the MDS.This failure decreased the facility's potential to maintain accurate assessments for Resident 140's end of life care, treatment, and preferences.Findings:A review of Resident 140's admission Record, dated [DATE], indicated Resident 140 was admitted to the facility in [DATE] with a diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).A review of Resident 140's Order Summary Report (OSR), dated [DATE], indicated on [DATE] a physician order to do not resuscitate (DNR - a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). During a concurrent interview and record review on [DATE] at 2:51 p.m. with MDS - Registered Nurse (MDS-RN), Resident 140's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) and MDS were reviewed. Resident 140's POLST, dated [DATE] indicated DNR, but the MDS dated [DATE] indicated full resuscitation. MDS-RN confirmed resuscitation instructions were documented incorrectly and stated inaccurate documentation might compromise Resident 140's rights and disregard family's wishes.During an interview on [DATE] at 11:45 a.m. with Administrator (ADM), ADM confirmed the resuscitation instructions for Resident 140 were documented inaccurately in MDS. ADM expected staff to maintain accurate documentation for Resident 140 to provide correct care and treatment when needed.A review of the facility's policy and procedure (P&P) titled, Electronic Transmission of the MDS, revised in [DATE], indicated, . The MDS coordinator is responsible for ensuring that appropriate edits are made to MDS data .A review of the facility's P&P titled, MDS Error Correction, revised in [DATE], indicated, . Errors to the MDS are corrected promptly and within guidelines established by the Resident Assessment Instrument User's Manual .

Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 37) was free from abuse, when Resident 117 hit Resident 37. This failure had the potential to negatively impact Resident 37's highest practicable physical, mental, and psychosocial well-being.Findings: A review of an admission record indicated Resident 37 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia (a decline in mental ability such as memory, reasoning, and problem solving that interferes with daily life), anxiety disorder (a mental health condition characterized by excessive persistent, and uncontrollable fear or worry), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and loss of interest in activities). A review of an admission record indicated Resident 117 was admitted to the facility with a diagnosis of dementia. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/12/26, indicated Resident 117 got into a physical altercation with Resident 37 on 5/12/26 at 8 p.m. During an interview on 5/13/26 at 2:36 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she observed on 5/12/26 at approximately 8 p.m. Resident 117 sitting in her wheelchair and blocking the entrance into Resident 37's room. CNA 1 attempted to redirect Resident 117 to move out of the doorway of Resident 37's room, but she did not. Then, Resident 37 woke up in her bed and told Resident 117 to put a shirt on as she was only covered with a towel at that time. CNA 1 further stated Resident 117 stood up from her wheelchair, walked to the edge of Resident 37's bed and hit Resident 37 twice on her lower right leg with a closed left fist. During an interview on 5/13/26 at 1:11 p.m. with Licensed Nurse (LN) 2, LN 2 stated CNA 1 reported to her that Resident 117 hit Resident 37. LN 2 further stated Resident 117 got out her wheelchair and went towards the end of the bed where Resident 37 was lying down and hit Resident 37 twice on her lower right leg with her left closed fist. During an interview on 5/13/26 at 12:54 p.m. with LN 1, LN 1 stated she received a report of physical altercation between Resident 37 and Resident 117 when Resident 117 hit Resident 37 at night. During an interview on 5/14/26 at 2:08 p.m. with Director of Nursing (DON), DON confirmed Resident 37 was hit twice by Resident 117 while lying in her bed and stated all residents should be free from any type of abuse. A review of the facility's policy and procedure titled, Abuse Prohibition Policy and Procedure, revised 2/21, indicated, Health care centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents . Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment .

Based on observation, interview, and record review, the facility failed to maintain professional standards of care for two out of 30 sampled residents (Resident 1 and Resident 139), when:1. Resident 139's blood pressure medication was not administered on time; and2. Resident 1 did not have an order for an indwelling urinary catheter (a tube placed in the bladder to drain urine which is collected in a bag).These failures decreased the facility's potential to follow physician orders for residents. Findings: 1. A review of Resident 139's admission Record, indicated he was admitted to the facility in April 2025 with multiple diagnoses including cerebral infarction (a type of stroke, loss of blood flow to a part of the brain) and dysphagia (difficulty swallowing). A review of Resident 139's Order Summary Report (OSR), dated 4/27/25, indicated an order for isosorbide mononitrate (a medication to treat high blood pressure) 10 milligrams (mg, unit of measurement) given through the gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) three times a day at 9 a.m., 1 p.m., and 5 p.m. During a concurrent observation, interview, and record review on 5/12/26 at 11 a.m. with Licensed Nurse (LN) 7, Resident 139's Medication Administration Record (MAR) and OSR were reviewed. LN 7 prepared Resident 139's medication by crushing, mixing with 30 milliliters (ml, unit of measurement) of water and administering through the g-tube. LN 7 confirmed the administration of Resident 139's blood pressure medication occurred later than the scheduled time at 9 a.m. During an interview on 5/14/26 at 2 p.m. with the Director of Nursing (DON), DON expected nurses to administer medications according to the physician's instructions, particularly those prescribed multiple times daily, to ensure residents' health needs were properly addressed. A review of the facility's policy titled, Medication Administration-General Guidelines, dated 10/2017, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . 2. A review of Resident 1's admission Record, indicated he was admitted to the facility on [DATE] with diagnoses including a urinary tract infection (UTI- an infection caused by bacteria in the urinary system, which includes the bladder, urethra, and kidneys) and severe chronic kidney disease (a persistent, severe loss of kidney function). A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 3/30/26, indicated Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) scored 15 out of 15 with intact cognition. During a concurrent observation and interview on 5/12/26 at 10:24 a.m. with Resident 1 in his room, Resident 1 had a urinary catheter hanging from the right side of his bed, draining clear medium yellow liquid. Resident 1 stated he had a urinary catheter for almost three months. A review of Resident 1's Care Plan Report, indicated he had an indwelling urinary catheter since 2/12/26. Care plan further indicated on 3/28/26 Resident 1 experienced an abdominal pain and his urinary catheter was not draining. A review of Resident 1's Progress Notes, dated 3/28/26, indicated Resident 1 was sent to the emergency department for abdominal pain and lack of urinary catheter drainage. The notes further indicated he returned from the hospital with a new urinary catheter and a diagnosis of UTI. During a concurrent interview and record review on 5/14/26 at 12:45 p.m. with LN 4, Resident 1's OSR dated 5/14/26 was reviewed. LN 4 confirmed there was no order for a catheter and stated an order was needed for nurses and certified nursing assistants (CNAs) to provide care and to monitor Resident 1's urine output and blood in urine. LN 4 further stated without an order, Resident 1 had a higher risk of getting another UTI and an increased possibility of leakage or catheter dislodgement if staff were unaware of its placement. During an interview on 5/14/26 at 12:49 p.m. with CNA 2, CNA 2 stated she cleaned Resident 1's urinary catheter daily and emptied and measured the urine. During a concurrent interview and record review on 5/14/26 at 1:01 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. ADON confirmed there was no order for the urinary catheter and stated nurses missed the order. ADON further stated without an order, no one would know when the catheter was inserted. A review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 3/22/22, indicated, Purpose: This will ensure that all physician orders are complete and accurate. A review of the facility's P&P titled, Urinary Catheter, dated 11/15/21, indicated, Purpose: To ensure there is a valid medical justification for use of an indwelling catheter and that the catheter is discontinued as soon as clinically warranted.

Based on observation, interview, and record review, the facility failed to follow the menu for two residents (Resident 6 and Resident 72 ) of a census of 129, when food items were omitted from lunch menus.This failure decreased the facility's potential to serve meals complete in nutrient value.Findings:A review of Resident 72's admission Record, indicated she was admitted to the facility in 2023 with a diagnosis of type two diabetes (a condition in which blood sugar is too high due to the pancreas' inability to make enough insulin) and dysphagia (difficulty swallowing).A review of Resident 72's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/24/26, indicated her Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) scored 10 out of 15 with moderate cognitive impairment. A review of Resident 72's Order Summary Report, dated 12/21/25, indicated Resident 72 was prescribed a carbohydrate controlled diet (a diet that involves counting carbohydrates and eating the same number each day) with soft and bite sized texture and thin consistency liquids.During a concurrent observation, interview, and record review on 5/11/26 at 12:45 p.m. with Resident 72 and Rehabilitative Nursing Assistant (RNA) 1 in the dining room, Resident 72 was served her lunch. Resident 72's meal ticket titled, Noon Meal, dated 5/11/26, indicated the lunch menu consisted of baked chicken and gravy, potato salad, buttered carrots, bread, Mandarin oranges, and beverage. Resident 72 stated she was not served Mandarin oranges as listed on her meal ticket, and she liked oranges and wanted them. RNA 1 stated Resident 72 should have been served Mandarin oranges.A review of Resident 6's admission Record, indicated he was admitted to the facility in April 2026 with diagnoses including type two diabetes and moderate protein-calorie malnutrition (a potentially life-threatening condition caused by an inadequate intake of protein and calories).A review of Resident 6's Order Summary Report, dated 4/14/26, indicated Resident 6 was prescribed a carbohydrate controlled, renal (kidney) diet, regular texture, thin consistency liquids with fluid restriction of 1500 milliliters (ml- a unit of measure).During a concurrent observation, interview, and record review on 5/13/26 at 12:18 p.m. with Dietary Aide (DA) 2 and Regional District Manager (RDM) in the kitchen, tray line was observed. Resident 6's meal ticket titled, Noon Meal, dated 5/13/26, indicated his lunch consisted of a pork chop with gravy, noodles, collard greens, bread, Texas sheet cake, and a beverage. Resident 6 was served his pork chop without gravy. DA 2 and RDM stated Resident 6 was supposed to get gravy on his pork chop.During an interview on 5/13/26 at 2:25 p.m. with Registered Dietician (RD), RD stated leaving out items of the menu could decrease a resident's intake of needed nutrients. A review of the facility's policy and procedures titled, Menus, revised October 2022, indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines . Menus will be served as written .

Based on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 30 sampled residents (Resident 100 and Resident 140), when:1. Resident 140's touch pad call light was not within reach; and2. Resident 100's regular call light was not within reach. These failures decreased the facility's potential to assist residents in a timely manner when needed.Findings: 1. A review of Resident 140's admission Record, dated 5/13/26, indicated Resident 140 was admitted to the facility in April 2014 with a diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a concurrent observation and interview on 5/11/26 at 10:23 a.m. with Certified Nursing Assistant (CNA) 3 and Resident 140, Resident 140's touch pad call light was observed clipped to her gown and placed next to left hip. Resident 140 stated she was unable to reach her call light due to complete weakness in left arm and very little movement in right hand. CNA 3 confirmed Resident 140's call light was not within reach and stated the touch pad call light should have been placed on Resident 140's chest near her right hand so she can touch it when needed.During an interview on 5/12/26 at 10:37 a.m. with the Director of Nursing (DON), DON confirmed Resident 140's call light was not within reach. DON expected staff to place call light near Resident 140's right hand to use when needed.2. A review of Resident 100's admission Record, dated 5/14/26, indicated Resident 100 was admitted to the facility in August 2019 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left side (total paralysis of the arm, leg, and trunk on the left side of the body).During a concurrent observation and interview on 5/12/26 at 12:06 p.m. with Unit Clerk (UC) and Resident 100, Resident 100 was yelling for help from her bed. Resident 100's call light was observed clipped and placed to the left side of her pillow. Resident 100 stated she was unable to reach her call light due to weakness in left arm. UC confirmed Resident 100's call light was not within reach to use when needed. During an interview on 5/14/26 at 11:30 a.m. with the Administrator (ADM), ADM confirmed Resident 100's call light was placed on left side and was not within reach. ADM expected staff to place Resident 100's call light near her right hand and stated call lights should be placed within residents' reach to meet their needs. A review of the facility's policy and procedure titled, Answering the Call Light, revised on 10/24/2024, indicated, . Ensure that the call light is accessible to the resident when in bed .

Based on interview and record review the facility failed to replace one of four sampled residents (Resident 1's) personal belongings in a timely manner when Resident 1's eyeglasses were lost.This failure had the potential to compromise Resident 1's vision.Findings:A review of Resident 1's face sheet (a summary of medical information) indicated he was admitted to the facility in late 2025 with diagnoses which included a brain disease that impaired memory. The facility listed Resident 1's family member as his responsible party (RP, person who is responsible for making health care and financial decisions).During a review of Resident 1's, Order Summary Report [OSR], dated 9/17/25, the ORS indicated Resident 1 did not have the capacity to make medical decisions.During an interview on 3/30/26 at 9:01 a.m. with Resident 1's Responsible Party (RP), the RP stated the facility had lost Resident 1's glasses and had not replaced the glasses or reimbursed for the cost to replace the glasses.During an interview on 3/30/26 at 11:51 a.m. with the Social Service Assistant (SSA), the SSA stated if a resident lost an item, a theft and loss form would be filled out, she would talk to family and if the item was not located then the facility would pay for the lost item. The SSA stated a copy of the theft and loss form would be kept in the social service offices.During a concurrent interview and record review on 3/30/26 at 2:59 p.m. with the SSA, the SSA stated she recalled Resident 1's RP had reported his glasses were missing and the facility had met with Resident 1's RP to discuss the lost glasses. The SSA stated the glasses were not located, so a theft and loss form was completed. The SSA did not know if Resident 1 had received his new glasses. During an interview on 3/30/26 at 5:02 p.m. with the SSA and Director of Nursing (DON), the SSA and DON stated they were unable to locate the theft and loss form for Resident 1's lost glasses. The SSA stated she did not know the exact date the glasses were lost sometime between September and December [2025]. The SSA showed the eye exam form from 1/22/26 and stated the resident declined new eyeglasses after the exam. The SSA confirmed Resident was unable to make medical decisions and the RP should have been notified after the exam. The SSA confirmed nothing further had been done to replace Resident 1's glasses. The SSA stated glasses were important to help the residents see.During interview on 3/30/26 at 5:30 p.m. with the DON, the DON stated she expected a theft and loss form to be completed when someone reported a lost item, the family updated and the issue resolved in a timely manner. The DON indicated that the facility should have contacted Resident 1's RP stating, I would expect staff to talk to the appropriate person.During a review of the facility's policy and procedure (P&P) titled, Investigating Incidents of Theft and loss, dated 4/17, the P&P indicated, All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated.Residents have the right to be free from theft and loss.Our facility will exercise reasonable care to protect the resident from property loss or theft, including.Promptly responding to and investigating complaints of theft or misappropriation of property.The administrator or his designee will notify the resident and/or the resident's representative. of the results of the investigation and corrective action taken within days of the completion of the investigation.

Based on observation, interview, and record review, the facility failed to protect resident right to be free from physical abuse for two of five sampled residents (Resident 1 and Resident 2) when Resident 2 struck Resident 1 and Resident 1 scratched Resident 2 during an altercation on 2/21/26.This failure resulted in physical injury to Resident 1 and Resident 2 and had the potential to result in psychosocial harm for both residents.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with hemiplegia and hemiparesis (oxygen and nutrients to part of the brain is blocked causing brain tissue death resulting in physical paralysis and physical weakness) and difficulty walking.A review of Resident 1's Minimal Data Set (MDS) (a standardized assessment tool used in nursing homes), dated 12/11/25, indicated Resident 1 had Brief Interview for Mental Status (BIMS) (short test used to check a person's memory and thinking) of 15/15 indicating intact cognition.Resident 2 was admitted to the facility 1/21/23 with diagnoses of cerebral infarction with hemiplegia and hemiparesis, dementia (a disease process of the brain causing inability to think clearly), communication deficit, difficulty walking, and a history of falls.A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS of 10/15 indicating moderate cognitive impairment.During an observation on 3/11/26 at 11:00 AM in the hallway, Resident 2 was observed with a healed, thin scar to the right side of his/her forehead.A review of Resident 2's Change of Condition (COC) Evaluation dated 2/21/26 at 6:12 p.m., indicated, resident involved in physical altercation with roommate 40a. Superficial scratches to right forehead and right neck. Resident 2 stated I don't know why she scratched me, I just asked her to move and no recollection of striking Resident 1.During an interview with Resident 4 on 3/11/26 at 11:34 AM, Resident 4 stated, [Resident 2] hit [Resident 1] [in the doorway to their room]. [Resident 1] clawed back at [Resident 2] and scratched her in the face.During an interview with Resident 1 on 3/11/26 at 12:55 PM, Resident 1 stated, I was in my wheelchair in the doorway, [Resident 2] pushed my chair to get me out of the way. I told [Resident 2] to wait, but my [Resident 2] continued to push me into the hallway. I was resisting. [Resident 2] hit me in the right eye. I responded and reached back and swatted her away and she was scratched.During an interview with Certified Nursing Assistant 2 (CNA 2) on 3/11/26 at 12:04 PM, CNA 2 stated, I. saw Resident 2 hitting Resident 1. Resident 2 was bleeding from forehead and neck from scratches. Resident 1 was in her wheelchair.A review of the Facility Report investigated by the Director of Nursing (DON) and reported by the Administrator (ADM) dated 2/26/26 indicated, Resident 2 tried forcing her way out [of the room] when resident 1 responded by scratching resident 2 on the face.A review of Resident 2's Care plan updated 2/21/26 indicated, Root Cause: Both residents in the same bedroom, OOB in wheelchair, when resident got impatient, unable to wait and wanted to pass the other resident, she pushed [his/her] way to get pass, that prompted the other resident to scratch her in the face.A review of Resident 1's COC Evaluation dated 2/21/26 at 5:35 PM indicated, Resident was involved in physical altercation with [Resident 2] . An initial assessment. revealed no injury to [Resident 1] but after 30-45mins has right eye-subconjunctival redness.During an interview with the ADM on 3/11/26 at 2:04 PM, ADM stated awareness of the resident-to-resident abuse that occurred on 2/21/26. ADM stated there was an altercation between Resident 1 and Resident 2. Resident 1 was struck and Resident 2 was scratched in the altercation.During an interview with the DON on 3/11/26 at 2:12 PM in the Infection Control nurse's office, DON stated there were no previous incidents of Resident to Resident abuse between both residents. Resident 1 was hit in the eye, the right one I think, and had redness on the side of the eye. Resident 2 was scratched on the right side of the face. Injuries did not affect their ADLs and have resolved. Resident 2 was re roomed. Both residents showed no psychosocial changes.A review of the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedure, revised 2/21, the P&P indicated, Health Centers prohibit abuse, The center will implement an abuse prohibition program through. prevention of occurrences., Physical abuse includes hitting., etc.These findings represent past noncompliance with this regulatory requirement. Observations, interviews, and records' reviewed confirmed Resident 1 and Resident 2's involvement in resident-to-resident physical abuse. Interviews and record review confirmed facility staff promptly intervened, and the residents were immediately separated, resident 2 was re-roomed in a different hall, and facility management was notified. Record review confirmed physical and psychosocial assessment and monitoring was performed and a thorough facility led investigation and root cause analysis were conducted, the residents' care plans were updated with corresponding interventions initiated, local law enforcement was notified and a law enforcement investigation was conducted, an SOC 341 was faxed to the Ombudsman and the California Department of Public Health, the residents' physicians and responsible parties were notified, and in service abuse training was conducted. Interviews confirmed the facility continues to conduct and investigate performance improvement. There was sufficient evidence that the facility corrected the violation as of 2/27/26 and no other occurrences of noncompliance were identified. At the time of the survey, the facility was in substantial compliance of this regulatory requirement therefore, the violation does not require a plan of correction.

Based on observation, interview and record review, the facility failed to ensure a home like environment for facility residents for a census of 130 when three out of five shower rooms were unclean and unsanitary.This failure resulted in lack of provision for a home like environment for facility residents when the shower rooms were unclean. A review of Resident 1's admission record indicated Resident 1 was admitted in January of 2025 with a diagnosis of Type two Diabetes Mellitus (a chronic condition where the body does not regulate sugar levels in the body, that can cause slowed wound healing). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/21/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tool that tests cognition) score of 15 out of 15 indicating Resident 1 was cognitively intact.During an interview on 2/6/26 at 10 a.m. with Resident 1, Resident 1 stated the facility shower rooms were dirty and unclean. Resident 1 further stated he felt uncomfortable at the facility and wanted to leave.During a concurrent observation and interview on 2/6/26 at 10:17 a.m. with Licensed Nurse (LN 1) in the South Station shower room (SS), LN 1 confirmed there was mold on the shower curtain, a used tan bandage on the floor of the shower, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower and the sharp container was full and razors were observed sticking out. LN 1 stated the cracked exposed shelves in the shower room were not homelike. LN 1 confirmed this was not a home like environment for residents and the shower rooms were unclean.During a concurrent observation and interview on 2/6/26 at 11:14 a.m. with Licensed Nurse (LN 2), LN 2 confirmed the northwest shower room was out of order. LN 2 further confirmed mold was observed in the northeast shower room. LN 2 confirmed cracked tiles, and peeled paint was present in the north station shower room. LN 2 confirmed the shower rooms in use were unclean and not homelike for facility residents. During a concurrent interview and record review on 2/6/26 at 11:34 a.m. with the Infection Prevention Nurse (IP), the IP confirmed the unclean shower rooms did not represent a homelike environment for facility residents and that facility residents could feel uncomfortable with care when using the shower rooms. During a concurrent interview and record review on 2/6/26 at 12:10 p.m. with Director of Nursing (DON), the DON confirmed the expectation for facility staff is to ensure that the shower rooms were cleaned after each use. The DON further confirmed that the shower rooms did not represent a home like environment for facility residents and that facility residents could feel uncomfortable when using the unclean facility shower rooms during care.During review of facility policy and procedure (P&P) titled, .Home-like Environment. dated February 2021, indicated, .Residents are provided with a safe clean, comfortable and homelike environment . Staff provides person-centered care that emphasizes the residents' comfort. characteristics of the facility that reflect a personalized, homelike setting. clean, sanitary, and orderly environment.

Based on observation, interview, and record review, the facility failed to ensure a clean environment for facility residents when three out of 4 shower rooms in use were left unclean for a census of 130.This failure had the potential to spread infections to facility residents.During a concurrent observation and interview on 2/6/26 at 10:17 a.m. with Licensed Nurse (LN 1) in the South Station Shower room (SS), LN 1 confirmed there was mold on the shower curtain, a used tan bandage on the floor of the shower, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower, and the sharp container was full and had razors sticking out. LN 1 further confirmed there were broken tiles in the shower room.During a concurrent observation and interview on 2/6/26 at 10:35 a.m., with LN 1 in the East Station Shower Room (ES), LN 1 confirmed that there was an overflowing trash bin with soiled items bagged and no cover and an overfilled sharps container with razors overflowing. LN 1 further confirmed there was a dirty yellow Person Protective Equipment (PPE) gown on the floor and another gown on a bedside table, an open air freshener can on the floor of the ES shower room.LN 1 stated that the ES was dirty and a resident or staff member could get hurt if they had touched the blades overflowing from the sharp's container. LN 1 further stated the SS and ES rooms could have spread infectious organisms to facility residents since she did not know which resident the PPE gowns belonged to. LN 1 confirmed this could be a safety risk and infection control risk for facility residents. LN 1 stated the shower rooms are utilized by most facility residents and had the potential to spread infections to different residents throughout the facility.During a concurrent observation and interview on 2/6/26 at 11:14 a.m. with Licensed Nurse (LN 2), LN 2 confirmed the northwest shower room was out of order. LN 2 further confirmed mold was observed in the northeast shower room. LN 2 confirmed cracked tiles, and peeled paint was present in the north station shower room. LN 2 confirmed the North East shower room was unclean, and the shower rooms should have been clean after each use to prevent the spread of infections.During a concurrent interview and record review on 2/6/26 at 11:34 a.m., with Infection Prevention Nurse (IP), IP stated the expectation is for the shower rooms to be cleaned after each resident use. IP nurse confirmed the presence of the dirty tan bandage on the floor of the SS shower room, a used bandage with dry blood on the shelf adjacent to the shower, cracked tiles in the shower, mold present on the shower tiles, dark mold on the shower curtain, and overflowing sharp container in the South Station shower room. The IP nurse confirmed the presence of a used PPE gown, a PPE gown in a plastic wrap, an opened air freshener can on the floor, overflowing trash bin with soiled items bagged and no cover, and overflowing sharp container with razors sticking out and on top of the sharp container with plastic trash items in the South East shower room. The IP confirmed mold was present in the North East shower room. The IP nurse stated that the shower rooms were dirty and that both shower rooms had the potential to spread infections to facility residents. IP confirmed that improper cleaning practices can lead to spread of infections and improper disposal of full sharp containers can lead to a resident or staff member being cut by a sharp item and contracting infectious organisms. IP confirmed she did not do daily checks on the shower rooms to ensure staff was cleaning the rooms properly.During an interview on 2/6/26 at 12:10 p.m. with Director of Nursing (DON), the DON confirmed the expectation for facility staff is to ensure that the shower rooms are cleaned after each resident use. The DON further acknowledged the overflowing sharp materials in the shower rooms could have spread infectious organisms to staff and facility residents. During a review of facility policy and procedure (P&P) titled, . Infection prevention and Control., dated December 2023, indicated, .The facility adopted infection prevention and control policies and procedures are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . policies and procedures are to: . monitor, prevent, detect . maintain a safe, sanitary, and comfortable environment for personnel, residents . Provide .infection. control based on current best practices.During a review of facility policy and procedure (P&P) titled, .Sharps Disposal., dated January 2012, indicated, . Contaminated sharps will be discarded into containers that are. Closable. Puncture resistant. Leakproof on sides and bottom. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the containers .

Based on interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two out of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2's room was cluttered with multiple medium sized brown boxes, an empty soda can, two white towels, overripe bananas, and multiple personal items of their roommate. This failure had the potential to result in an unsafe and unsanitary environment for Resident 1 and Resident 2 to receive care and services and risk for the residents not to achieve their highest practicable well-being.Findings: 1a. A review of Resident 1's clinical record indicated Resident 1 was initially admitted January of 2026 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebrovascular disease (a group of conditions that affects the blood flow and the blood vessels in the brain) affecting right dominant side, need for assistance with personal care, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 1's MDS Mood Status, dated [DATE], indicated Resident 1 experienced several days of Feeling down, depressed, or hopeless. A review of Resident 1's care plan, dated [DATE], indicated, [Resident 1] is at risk for falls/injury. Impaired mobility .Maintain a clutter-free environment in the resident's room . During a phone interview on [DATE] at 11:56 a.m. with Resident 1's daughter, Resident 1's daughter stated she visited her mother on [DATE] and her room was cluttered with multiple boxes and was very unsanitary. Resident 1's daughter further stated they requested her mother to be moved to a different room because the room was so cluttered and unsanitary. Resident 1's daughter sent multiple photos and a video of Resident 1's room she took on [DATE]. A review of the photos and a video of Resident 1's room taken on [DATE] showed the room had multiple brown boxes which were stacked in front of the residents' beds, on the way to the room's bathroom. There were multiple personal items placed on top of the boxes. There was an empty brown box placed on top of a wheelchair. There were two white towels, and an empty can of soda placed in front of the television, next to a power cord. There were multiple personal items placed in front of one bed and there were overripe bananas on top of it. A review of Resident 1's social services progress note, dated [DATE], indicated, [Resident 1] is expected to transfer rooms on Reason for transfer: Family request [DATE] . During an interview on [DATE] at 12:05 p.m. with Housekeeping Staff (HKS), the photos and video of Resident 1's room taken on [DATE] were viewed. HKS stated staff should tidy and clean the room because it was not safe for residents to have a cluttered room. HKS further stated the clutter in Resident 1's room could cause an accident. 1b. A review of Resident 2's clinical record indicated Resident 2 was admitted November of 2025 and had diagnoses that included congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), need for assistance with personal care, muscle weakness, and difficulty walking. A review of Resident 2's MDS cognitive Patterns, dated [DATE], indicated Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 had an intact cognition. A review of Resident 2's MDS Mood Status, dated [DATE], indicated Resident 2 experienced several days of Feeling down, depressed, or hopeless. A review of Resident 2's care plan, dated [DATE], indicated, [Resident 2] is at risk for falls/injury r/t [related to] Impaired mobility .Maintain a clutter-free environment in the resident's room . During an interview on [DATE] at 12:37 p.m. with Resident 2, Resident 2 stated she remembered her room was cluttered with a lot of boxes and was not clean sometime last week and they did not talk to her about what the boxes were for. Resident 2 also stated she did not like it when her room was cluttered with boxes and was not clean. Resident 2 further stated staff should have tidied and cleaned the room up so it would be safe for them in the room. During an interview on [DATE] at 12:53 p.m. with Licensed Nurse (LN) 1, the photos and video of Resident 1's room taken on [DATE] were viewed. LN 1 explained the resident in bed C was moving out of the facility and was packing her personal items, that was why there were a lot of boxes in the room. LN 1 stated the room should not have been left cluttered and unsanitary because of resident safety concerns and infection control issues. LN 1 also stated the room should be kept clutter free for the residents in bed A and bed B so they could move around and be free from any accident. LN 1 further stated it was not a homelike environment for the residents in bed A and bed B. During an interview on [DATE] at 1 p.m. with Certified Nurse Assistant (CNA) 1, the photos and video of Resident 1's room taken on [DATE] were viewed. CNA 1 stated residents in bed A and bed B have the right to a clean and nice environment just like their home. CNA 1 further stated if she saw the room cluttered and unsanitary, she would say something because personally, she does not want any clutter in her own space too. During an interview on [DATE] at 1:08 p.m. with LN 2, the photos and video of Resident 1's room taken on [DATE] were viewed. LN 2 stated it was okay for the resident in bed C to have her personal items but not to the point that it compromises other residents' personal space and things. LN 2 also stated it was not good, and it was not right for the other residents in the room to have a cluttered and unsanitary room. LN 2 further stated having a cluttered and unsanitary room could cause infection control issues and safety concerns- especially in emergency situations. During an interview on [DATE] at 2:51 p.m. with LN 3, LN 3 stated she worked last [DATE] and saw Resident 1 and Resident 2's room cluttered with boxes and personal items and was left unsanitary. LN 3 further stated it was not safe for the residents, it could be a fire hazard, and it was not a homelike environment for the residents in the room. During an interview on [DATE] at 3:15 p.m. with the Administrator, (ADM), the ADM stated Resident 1's family requested Resident 1 to be moved to another room because her room was cluttered and unsanitary. The ADM further stated that all residents have the right to have a safe, clean, and homelike environment. A review of the facility's policy and procedures titled, Homelike Environment, revised 2/2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment .

Based on interview and record review, the facility failed to protect the resident's rights for one of six sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 kissed Resident 1's forehead without consent.This failure reduced the facility's potential to treat Resident 1 with dignity and respect.Findings:During a review of Resident 1's admission Record (AR), indicated, Resident 1 was admitted 9/25 with a diagnosis of wedge compression fracture (front part of the spinal bone collapses due to pressure, forming a wedge shape.)During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/12/25 indicated Resident 1 has intact cognition.During a review of Interdisciplinary conference (IDT - meeting where professionals from different fields come together to share knowledge and solve complex problems) dated 1/28/26 indicated, .allegation of inappropriate conduct by staff towards him (Resident 1). Additionally, IDT met with Resident 1 and gave more details including, .that a staff member kissed his forehead and push his behind during care.During an interview with Resident 1 on 1/28/26 at 2:23 p.m. stated, I felt violated, trashed, helpless and disrespected. I've never had anyone do that to me. Resident 1 further stated, he did not consent to the kiss on his forehead and there was no warning.During a telephone conversation on 1/28/26 at 4:32 p.m., with CNA 1, CNA 1 admitted that he kissed Resident 1's forehead without asking Resident 1's consent. CNA 1 further stated, he was providing incontinent care and was removing food off his bed.During an interview on 1/29/26 at 4:15 p.m. with the Director of Nursing (DON), the DON confirmed that residents at their facility have the right to be free from any form of abuse by staff, visitors and any individuals.During a review of the facility's policy and procedure titled, Resident Rights, dated, October 2025, indicated, .federal and state law guarantee certain basic rights to all residents.to be free from abuse, neglect, misappropriation of property and exploitation.

Based on observation, interview and record review the facility failed to ensure safety of residents when they failed to provide adequate monitoring and supervision for Resident 1 identified as at risk for elopement for a census of 129 residents. This failure resulted in Resident 1 wandering out of the facility to a coffee shop unaccompanied by staff. A review of Resident 1's clinical record indicated Resident 1 was admitted in November 2025 with a diagnosis of end stage renal disease (a condition where waste and fluid buildup in the body because the kidneys cannot remove them properly). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 12/1/25 indicated Resident 1 had moderately impaired cognition (memory or thinking problems). During a review of Resident 1's progress note dated 12/10/26, the progress note indicated Resident 1 . discussed during IDT (interdisciplinary, group of professionals) due to being identified as a risk for elopement due to history.During a review of Resident 1's progress note dated 1/3/26, the note indicated, .Staff saw the resident at the (local coffee shop) . was brought back to facility. verbalized his persistent desires to go home today. still requesting for discharge.During a review of Resident 1's care plans, the care plan titled, ' . Resident is at risk of elopement R/T (related to) wanting to go home/leave the facility.' dated 11/26/2025, indicated, . Continue monitoring for elopement risk behaviors . Reassess elopement risk as needed.During a concurrent interview and record review on 1/20/26 at 2:44 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated she was the assigned p.m. shift nurse for Resident 1. LN 1 further stated during shift report around 3 p.m. a call was received from an off-duty staff member that notified the facility that Resident 1 was seen at (local coffee shop). LN 1 further stated once the code (facility page indicating resident is missing) was initiated, Resident 1 was brought back to the facility within 30 minutes. LN 1 confirmed that there was no documented time of when Resident 1 left the facility without notifying staff.During a concurrent interview and record review on 1/20/26 at 3 p.m. with Director of Nursing (DON), the DON stated that Resident 1 returned to the facility within 15 minutes of off duty staff notifying the facility of the resident's location. The DON confirmed Resident 1 did not have a Leave of Absence order and did not notify any staff when leaving the facility. The DON could not provide an exact time that Resident 1 left the facility and acknowledged facility staff did not know when the resident left the facility.During an interview on 1/20//26 at 4:30 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 1 was found at (local coffee shop) sitting on the bench. CNA 1 stated Resident 1 stated he walked there. CNA 1 further acknowledged the walk from the facility to the coffee shop was equivalent to approximately 15 minutes' walk.During a review of facility Policy and Procedure (P&P) titled, Wandering and Elopements ., dated March 2019, indicated, . The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment . If identified as at risk for wandering, elopement the resident's care plan will include strategies and interventions to maintain the resident's safety .

Based on interviews, and record review, the facility failed to protect the right to be free from physical/mental abuse for one of six sampled residents (Resident 1), when Resident 2 forcefully grabbed Resident 1 by his throat during an altercation on 12/26/25. This failure had the potential to cause significant physical and emotional injury to Resident 1. Findings:Resident 1 was admitted to the facility in January of 2023 with diagnoses that included generalized weakness and Alzheimer's disease (a disease that causes a decline in cognitive function that interferes with daily life).A review of Resident 1's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 11/26/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating Resident 1 had severe mental and cognitive impairments.Resident 2 was admitted to the facility in December of 2024 with diagnoses that included dementia (a loss of thinking, remembering, and reasoning skills).A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 4 indicating Resident 2 had severe mental and cognitive impairments.A review of Resident 1's Nurses Progress Note (PN), dated 12/26/25, indicated, CNA [Certified Nursing Assistant] reported that patient [Resident 1] is yelling and check him and ask why he's yelling if he needs to get change and said no, CNA went to another room and approximately 5 to 6 minutes she heard patient [Resident 1] yelling again. When checked noted [Resident 2's] hands on his [Resident 1] neck. Separated patient right away. According to [Resident 1] squeezing his hand and neck.During an interview on 1/13/26 at 11:53 a.m. with Resident 1, Resident 1 stated that someone had grabbed his neck and hands. Resident 1 then began to rub his wrists stating his hands had been hurting since the incident. Resident 1 indicated that he felt safe only when he was not near his old room.During an interview on 1/13/26 at 1:40 p.m. with the Director of Nursing (DON), the DON acknowledged that the facility was considered Resident 1's home, and he should not be subjected to physical abuse.During an interview on 1/13/26 at 1:50 p.m. with CNA 1, CNA 1 reported that on 12/26/25 at approximately 3 a.m., she went to check on Resident 1 because he had been yelling. Upon entering Resident 1's room, she observed Resident 2 with his hand forcefully gripping Resident 1's throat.During a review of the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedure, revised 2/21, the P&P indicated, HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents.The Center will implement an abuse prohibition program through the following.Preventions of occurrences.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from abuse when Resident 2 threw a water pitcher towards Resident 3.This failure had the potential to result in physical injury and psychosocial distress to Resident 3. Findings:A review of Resident 3's record indicated resident 3 was admitted in September of 2025 with a diagnosis of Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest in activities). A review of Resident 3's Minimum Data Set (MDS- an assessment tool) dated 9/26/25 indicated Resident 3 was cognitively intact.A review of Resident 2's record indicated Resident 2 was admitted in September of 2025 with a diagnosis of Paraplegia (a condition that affects the spinal cord affecting use of half the body or lower legs).A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact.A review of Resident 2's progress noted dated 2/21/25 indicated Resident 2 grabbed an empty plastic water cup and threw it at Resident 3.During an interview on 9/24/25 at 1:44 p.m. with Resident 3, Resident 3 stated he told his roommate (Resident 2) to quiet down. Resident 3 stated the mother to Resident 2 approached him and started threatening him saying he was going to die anyway. Resident 3 further stated Resident 2 threw water pitcher toward Resident 3 leading to water splashing onto Resident 3. Resident 3 further stated Resident 2 and the family member stated they were going to have other people come into the facility to hurt Resident 3. During a telephone interview on 9/24/25 at 2:02 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated he was the CNA assigned to Resident 3 and Resident 2 on the date of the altercation. CNA 1 further stated (Resident 2) was being loud and arguing with (Resident 3). CNA 1 stated he witnessed Resident 2 throw a plastic water pitcher at Resident 3's bed, I saw water hit [Resident 3] but not the pitcher. CNA 1 further stated Resident 2 tried to grab a handle off his chair and was going towards Resident 3's bed and that he had to grab it from Resident 2.During an interview on 9/24/25 at 3:55 p.m. with Director of Nursing (DON), the DON stated resident to resident abuse is not tolerated at the facility.During a review of facility Policy and Procedure (P&P) dated 2/23/21, the P&P indicated, . Abuse is defined as willful infliction of injury . Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients and their families or within hearing distance.

Based on interview and record review, the facility failed to implement measures to prevent an avoidable fall for one of four sampled residents (Resident 1) when she was transferred from her bed to a chair without the use of a mechanical lift. This failure resulted in Resident 1 sustaining a left distal femur (lower end of thigh bone) fracture. Findings: A review of Resident 1's admission record indicated she was admitted in August of 2014 with diagnoses including hemiplegia and hemiparesis (weakness and paralysis of the body) affecting the right dominant side and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). A review of Resident 1's clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 1/8/24, indicated Resident 1 had severe cognitive impairment (severe difficulty remembering things, making decisions, concentrating, or learning). The MDS indicated Resident 1 had impairment on one side of her body in both the upper and lower extremities which interfered with daily functions or placed the resident at risk of injury. The MDS further indicated Resident 1 was dependent for bed to chair transfers with the helper doing all the effort and the resident doing none of the effort and sitting to standing had not been attempted. A Fall Risk Assessment, dated 7/12/23, indicated Resident 1 was at high risk for falls. A Fall Risk Care Plan, initiated 2/3/21, indicated Resident 1 was at risk for falls related to balance problems, generalized weakness and hemiplegia/hemiparesis. A Change in Condition (COC) nursing evaluation, dated 2/21/24 and completed by Licensed Nurse 1 (LN 1), indicated at 7:30 a.m. two certified nursing assistants (CNAs) had attempted to transfer Resident 1 from her bed to a shower chair by having her stand and pivot. The COC note indicated Resident 1's legs gave out and the CNAs lowered her to the floor where she sat in a squatting position. The COC further indicated Resident 1 complained of pain to the left knee, the physician (MD) was notified and an order for a left knee x-ray was obtained. A Medication Administration Record (MAR), dated February 2024, indicated an MD order for acetaminophen (a mild pain reliever), 500 milligram (mg. a unit of measurement) tablet, 1 tablet every 4 hours as needed for pain. The MAR indicated Resident 1 had been given 1 tablet on 2/21/24 at 7:39 a.m. for a reported pain level of 6 out of 10 (0-10 pain scale, with 0 indicating no pain and 10 indicating worst pain possible). A MAR, dated February 2024, indicated a MD order for hydrocodone-acetaminophen 5-325 mg. (a moderate to severe pain reliever) tablet, one time for pain management. The MAR indicated Resident 1 had been given 1 tablet on 2/21/24 at 1:46 p.m. for a reported pain level of 9 out of 10. An x-ray, dated 2/21/24, indicated Resident 1 had a displaced distal femur fracture. In an interview, on 3/13/24 at 11:10 a.m., LN 1 stated she was notified by staff Resident 1 had fallen and when she entered her room Resident 1 was in a supine position on the floor next to her bed. LN 1 stated the CNAs told her Resident 1 had refused to use the lift and they had attempted to transfer her from her bed to the chair by standing and pivoting with her instead but her legs gave out and they assisted her to the floor. LN 1 stated Resident 1 complained of pain to her left knee and she gave her a PRN (as needed) 500 mg. tablet of acetaminophen. LN 1 stated she notified the MD after the fall and was given an order for an x-ray. LN 1 stated later in the day Resident 1 had increasing pain, she notified the MD and obtained a one-time order for hydrocodone-acetaminophen 5-325 mg. for the pain and was given an order to transfer the resident to a General Acute Care Hospital (GACH) emergency room for further evaluation. LN 1 stated Resident 1 was supposed to be transferred with a mechanical lift, the CNAs should have notified her of the refusal and agreed the fall was avoidable and resulted in the left femur fracture. In an interview, on 3/13/24 at 11:31 a.m., CNA 1 stated Resident 1 was supposed to be transferred with a mechanical lift but on 2/21/24 she had refused to use it. CNA 1 stated she and another CNA stood on each side of Resident 1 and had her stand and pivot from the bed to the chair instead. CNA 1 stated she normally did not transfer residents that used a mechanical lift by having them stand and pivot because they could not stand or bend their legs very well. CNA 1 stated when they stood Resident 1 up her legs gave out and they ended up lowering her to the floor in a squatting position and then to her knees. CNA 1 stated Resident 1 screamed out in pain. In an interview, on 3/13/24 at 12 p.m., the Director of Nursing (DON) stated the mechanical lift was the safest method to transfer Resident 1 from the bed to a chair and agreed the CNAs should have used it when transferring Resident 1. The DON also stated transferring a resident with hemiplegia and hemiparesis by having her stand and pivot was not safe. The DON stated it was an assisted fall to the floor which could have contributed to the fracture and confirmed Resident 1 had no fractures prior to the fall. The DON agreed the event was an avoidable accident. Review of a facility policy titled, Falls and Fall Risk, Managing, undated, stipulated, An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. Review of a facility policy titled, Fall Management, dated 5/26/21, stipulated, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined at risk will receive appropriate interventions to reduce risk and minimize injury.

Based on interview and record review, the facility failed to provide the required two-person staff participation to use the toilet for one of three sampled residents (Resident 1), when Resident 1 was left alone while on the toilet, fell , and hit her head. This failure resulted in Resident 1 spending five days in the hospital to receive treatment for an acquired subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel in the brain). Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE], with diagnoses which included a displaced right femur (thigh bone) fracture after a fall, Parkinson's disease (a degenerative brain condition which results in problems with balance and movement) with dyskinesia (involuntary and erratic movement of the face, arms, and legs), difficulty in walking, and a need for assistance with personal care. A review of a fall risk assessment, dated 11/24/23 at 10:11 p.m., indicated Resident 1 had a high risk for falls and was, .Unable to independently come to a standing position . [and] Requires hands-on assistance to move from place to place . A review of a care plan focused on Resident 1's high risk for falls, initiated on 11/24/23, indicated the staff were to implement the following interventions to prevent falls:, .Anticipate and meet the resident's needs .The resident needs prompt response to all requests for assistance .follow facility fall protocol . A review of a care plan focused on Resident 1's Activities of Daily Living (dressing, bathing, toileting), initiated on 11/24/23, indicated Resident 1 had a self-care performance deficit related to impaired balance, limited mobility, limited range of motion, and pain. This care plan also indicated staff were to implement the following interventions when providing assistance to Resident 1, .TOILET USE: The resident requires (2) staff participation to use toilet .TRANSFER: The resident has requires [sic] (2) staff participation with transfers . A review of a care plan focused on Resident 1's use of paroxetine HCl (a medication used to treat depression) initiated on 11/24/23, indicated staff were to, .Monitor side effects of anti-depressant agent .such as .dizziness . A review of Resident 1's Medication Administration Record (MAR), dated November 2023, indicated licensed nursing staff administered 20 mg (milligram, a unit of measure) of paroxetine HCl to Resident 1 by mouth once a day at 9 a.m. from 11/25/23 to 11/28/23. A review of Resident 1's MAR, dated November 2023, also indicated licensed nursing staff administered 40 mg of enoxaparin sodium injection solution (medication used to prevent blood clots from forming) into Resident 1's abdomen twice a day at approximately 9 a.m. and 9 p.m. from 11/25/23 to 11/28/23 to prevent a deep vein thrombosis (DVT, a blood clot). A review of Resident 1's physician's order note, dated 11/25/23 at 1:15 a.m. indicated, Enoxaparin Sodium Injection Solution .Severity: Moderate .Interaction: Coadministration of enoxaparin with antiplatelet agents . [such as] paroxetine HCl .may increase the risk of bleeding . A review of Resident 1's progress note dated 11/25/23 at 3:30 p.m. indicated, .Staff notified .that resident slid from edge of toilet seat to the ground .resident family member stated, ' .she slid to the floor when she was trying to get up from the toilet.' Upon entering resident bathroom resident found sitting up with her bottom on ground and back against toilet and wall with left arm holding onto bathroom rail. When asking [sic] resident what happened, resident stated, ' I slid on the floor when I was finished using the bathroom.' .resident stated, 'No I didn't hit my head.' .Resident transferred .to wheelchair with 2 person assist. A review of Resident 1's History and Physical (H&P), dated 11/27/23 at 12:34 p.m., the physician (Physician 1) indicated, .Patient complaints since admission: had fall by bedside yesterday with no noted injuries .Delirium [a disturbance of mind including symptoms such as confusion, disorientation and agitation] .daughter notes intermittent confusion during their visits. A review of Resident 1's progress note, dated 11/27/23 at 8:43 p.m. indicated, [Physician] notified of unwitnessed fall on 11/25 stated to follow facility fall protocol and inform [physician]. Order noted, carried out . A review of Resident 1's order summary report indicated Resident 1 received the following physician's order, Fall precautions, and delirium precautions. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/28/23, indicated Resident 1 had moderate memory problems. This MDS also indicated for toileting hygiene, [was] Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. A review of a Situation, Background, Assessment, and Review (SBAR) Communication Form dated 11/29/23 indicated, . [Resident 1] struck head on floor of bathroom, skin intact. Bump present on posterior scalp measuring 2 in. [inches, a unit of measurement] x 3.1 in. x 1.7 in. redness noted in center. Pain and warmth upon touch .Resident [1] had an unwitnessed fall in the bathroom attempting to self transfer [sic] from toilet to [wheelchair] .Resident was found in supine position with head in between the wall near the door and wheelchair, feet facing opposing door into next room, wheel chair [sic] is locked and facing the toilet. Resident states that she hit her head on the floor and feels increasing aching pain on the back of head that does not radiate [travel] anywhere. A review of Resident 1's order summary report indicated Resident 1 received the following physician's order, Resident has limited capacity to make medical decision (brought forward from [physician ' s name] H&P .). A review of Resident 1's computed tomography scan conducted at the hospital on 11/29/23 at 9:10 a.m. indicated, Impression .Subdural hemorrhage along the falx [a strong, crescent-shaped sheet which lies between the two hemispheres of the brain] measuring 4 mm [millimeters, a unit of measurement] in thickness .Left parietal scalp [the main side bone of the skull] hematoma [an injury which results in a collection of blood to pool under the skin] . A review of an Interdisciplinary Team (IDT, a team made up of various disciplines who work in collaboration to address a patient's needs) progress note, dated 11/30/23 at 2:22 p.m. indicated, IDT met to discuss [Resident 1's] fall on 11/29/23. Resident had a fall in the bathroom. [Resident] attempted to stand up unassisted lost her balance and fell .Resident was sent out to [emergency room ] for further eval .[Resident] has capacity to make medical decisions and has a BIM [Brief Interview for Mental Status, a screening tool used to assess a person ' s mental processing ability] score of 9 (moderate impairment) .Upon further investigation the CNA [Certified Nurse Assistant] instructed the [Resident] to push the call light when she is finished and then the CNA stepped out and left the door ajar. Rehab came in they found the [Resident] on the bathroom floor. [Resident] had not used the call light and attempted to stand up and transfer self-off of the toilet . During an interview on 12/27/23 at 4:52 p.m., with CNA 3, CNA 3 stated he would maintain a close distance to the resident's bathroom if a resident asked for assistance to the toilet and wanted privacy. The CNA 3 also stated he would knock on the bathroom door to follow-up with the resident if he had not heard from the resident after some time had passed. During an interview on 12/29/23 at 9:10 a.m., with CNA 1, CNA 1 confirmed she had been assigned to Resident 1 on the day Resident 1 fell in the bathroom and hit her head. CNA 1 stated she had assisted Resident 1 to the toilet and Resident 1 asked her to give her privacy. CNA 1 stated she closed the door to the restroom and while Resident 1 was in the restroom, CNA 1 left Resident 1's room when another CNA asked for assistance with another resident. CNA 1 stated she went to assist her coworker with care for another resident in the same hallway, a couple of rooms down from Resident 1. When CNA 1 returned to Resident 1's room, she found out Resident 1 had fallen and had been found by another CNA. A review of the facility's policy and procedure titled Falls- Clinical Protocol, revised March 2018, indicated, .The physician will identify medical conditions affecting fall risk .and the risk for significant complications for falls (for example .increased risk of bleeding in someone taking an anticoagulant) .Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .Frail elderly individuals are often at greater risk for serious adverse consequences of falls .Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. The facility conducted re-education and training to all nursing staff regarding fall management and supervision of care for dependent residents. The facility was found to be back in substantial compliance with 42 CFR, Part 483 for Skilled Nursing Facilities effective 12/17/23.

Based on interview and record review the facility failed to provide adequate supervision and assistance for one of four sampled residents (Resident 1) when Resident 1 who required two-person assistance for bed mobility as per the Minimum Data Set (MDS, an assessment tool) fell from the bed while being assisted by one staff instead of two during incontinent care. Additionally, the one staff who was assisting the Resident turned away from her to grab a garbage bag on the floor. This failure resulted in Resident 1 sustaining a laceration (a deep cut or tear) on her left forehead, a left midclavicular (the bone connecting the breastbone and shoulder) fracture, and a left rib fracture. Findings: A review of Resident 1's Admission Record, indicated, Resident 1 was admitted to the facility early 2008 with multiple diagnoses that included quadriplegia (paralysis of the legs and arms) and muscle weakness (generalized). A review of the Minimum Data Set (MDS, an assessment tool) dated 9/9/23, indicated Resident 1 had severe cognitive impairment. The MDS also indicated that Resident 1 required extensive assistance with staff for activities of daily living (ADLs) and two+ person physical assist for bed mobility (how resident moves to and from lying position, turns side to side). A review of Resident 1's Care Plan, initiated 9/28/20, indicated, The resident has ADL self-care deficit r/t [related to] Impaired mobility .Interventions .MOBILITY: The resident Is totally dependent on staff for mobility .MOBILITY: The resident requires 2 staff participation [sic] for mobility . A review of Resident 1's Documentation Survey Report v2, dated 10/2023, indicated, .Bed mobility: Roll left and right(two person Assist) . The document also indicated that Resident 1 was dependent and needed substantial/maximal assistance. A review of Resident 1's Progress Notes dated 11/3/23, indicated, .Found the resident on the floor head is bleeding .As per the CNA [Certified Nursing Assistant] she is doing patient care, she turns patient to her right side and fell . Check the head of the resident bleeding came from the residents [sic] forehead left side. Residents [sic] sustain a deep laceration on left side of the forehead .MD recommended to transfer resident to ED [Emergency Department] via 911 . A review of Resident 1's Acute Hospital discharge summary dated, 11/15/23, indicated, .# Mechanical fall .Reportedly was dropped at nursing facility .has left clavicle and left rib fracture. Has laceration to left head which was suture[sic] . During an observation on 11/17/23 at 10:10 am in Resident 1's room, Resident 1 was awake lying in bed with wound on left forehead and a left arm sling. Resident 1 mumbled when spoken to. During an interview on 11/17/23 at 10:35 a.m., with CNA 1, she stated Resident 1 was a two person assist during incontinent care. CNA 1 further stated, two persons should be there when turning Resident 1. During a telephone interview on 11/21/23 at 3:32 p.m., with CNA 2, she stated, she was positioned at the right side of Resident 1's bed when she was changing the resident's diaper. She was almost done cleaning her when the resident started bearing down having another bowel movement and urination. CNA 2 then moved to the left side of Resident 1's bed to change her diaper and clean her again. She stated the bed was raised at her waist level because she was still giving care. The resident was in the middle of the bed in right side lying position when CNA 2 moved to the left side of the bed. CNA 2 further stated, when she was grabbing the garbage bag on the floor, Resident 1 flipped and fell on the floor. CNA 2 stated Resident 1's bed did not have siderails and she had a low air loss mattress (a special mattress used to prevent bedsores). CNA 2 stated, she was doing the incontinent care alone because Resident 1 was a one person assist. During a telephone interview on 11/22/23, at 12:16 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated, CNA 2 called her to ask for help because Resident 1 had fallen. When LN 1 came to the room, Resident 1 was on the floor, facing the door in a right side lying position. Resident 1 was not moving but she was crying. LN 1 stated, CNA 2 said she was taking care of Resident 1 and she was going to pick something from the floor, then she saw Resident 1 falling and it was too fast for her to grab the resident. LN 1 further stated, according to CNA 2, Resident 1 was in the middle of the bed, however, LN 1 believed the resident was on a side lying position when she fell . LN 1 stated, the fall could have been prevented if she had not turned to pick up something but sometimes, we cannot avoid picking something up from the floor. During a telephone interview on 11/29/23 at 10:19 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated, Resident 1 required a two person assist based on her Quarterly MDS assessment dated [DATE] and Annual MDS assessment dated [DATE]. The MDSN stated, Resident 1 was supposed to be a two person assist based on the care needs and in bed mobility because when they are changing her diaper during incontinent care, they are turning the resident from side to side. She further stated, for all residents that are dependent for care especially in Resident 1's case, it is safer for her to be assisted by two staff. During an interview on 11/17/23 at 12:15 p.m., with the Director of Nursing (DON), the DON stated, she expected the staff to implement fall precaution and avoid behaviors that placed a resident at risk for a fall. The goal is for residents not to have falls. A review of the facility policy titled, Falls Management, revised 11/2012, indicated, .Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls .