Health inspection·June 26, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the residents' right for dignity for two of five sampled residents (Residents 3 and 4) when:A. Resident 3 was observed with a large wet stain in the inner and middle area of Resident 3's pants.B. Resident 4 was observed sitting in Resident 4's wheelchair in the facility dining room with a large wet stain on both sides and the middle area of Resident 4's shorts.These failures had the potential to result in low self-esteem and humiliation for Residents 3 and 4.Findings:A. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), hepatic encephalopathy (loss of brain function when a damaged liver doesn't remove toxins from the blood), and depression (persistent low mood affecting daily living).During a review of Resident 3's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 9/18/24, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 6/2/25, the MDS indicated Resident 3's cognitive (process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 3 was dependent on staff for toileting hygiene, bathing and upper/lower body dressing.B. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 diabetes mellitus (body has trouble controlling blood sugar), acquired absence of right and left leg below the knee (loss of leg at or below the knee), and a cognitive communication deficit (difficulties in communication).During a review of Resident 4's H&P dated 3/18/25, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had severely impaired cognitive skills, impairment on both sides in the lower extremities and used a wheelchair for mobility. The MDS indicated Resident 4 was dependent on staff for toileting hygiene.During an observation in the dining room on 6/26/25, at 5:10 p.m., Resident 3's pants had a large wet stain in the inner and middle area of Resident 3's pants.During an interview on 6/26/25 at 5:13 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated some residents wore double diapers or a towel was placed in place between the residents' legs so it cannot be seen when residents got wet.During a concurrent observation and interview on 6/26/25 at 5:21 p.m., with Resident 4 in the dining room, Resident 4's green colored shorts had a large wet stain on both sides and the middle area. Resident 4 stated Resident 4 did not spill anything on himself, and stated Resident 4 was wet from urine. Resident 4 stated Resident 4 told the nurse Resident 4 was wet, and that Resident 4 had been wet for two hours. Resident 4 stated the nurse (unidentified) told Resident 4 a nurse would take care of it but Resident 4 remained wet.During an interview on 6/26/25 at 5:25 p.m. with CNA 2, CNA 2 stated CNA 2 Page 1 of 8 055344 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was assigned to Resident 3. CNA 2 stated, CNA 2 started work today, 6/26/25 at 3:00 p.m. and showered another resident. CNA 2 stated CNA 2 would change Resident 3 as soon as CNA 2 got a chance. CNA 2 stated CNA 2 did not check Resident 3 today (6/26/25) when CNA 2 came in for work because CNA 2 started passing coffee. CNA 2 stated it was important to check the residents to prevent pressure ulcers (PU- lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) or rashes and to keep the residents clean.During a concurrent observation of Resident 3 and interview on 6/26/25 at 5:35 p.m. with CNA 2, CNA 2 stated Resident 3 was wet, and CNA 2 needed to change Resident 3. CNA 2 stated this was the first time today CNA 2 had a chance to change Resident 3's clothes.During an interview on 6/26/25, at 5:41 p.m. with Licensed Vocational Nurse 4(LVN 4), LVN 4 stated it was important to keep residents dry for comfort and it was the residents' right to be changed when wet. LVN 4 stated it was important for residents not to sit wet for extended period of time to prevent the development of PU.During an interview on 6/26/25 at 5:56 p.m. with the Director of Nurses (DON), the DON denied the facility had an issue with staffing.During an interview on 6/26/25, at 6:54 p.m. with CNA 3, CNA 3 stated CNA 3 was assigned to Resident 4. CNA 3 stated CNA 3 needed to check the residents assigned to CNA 3, 30 minutes to one hour of starting work. CNA 3 stated the residents (in general) were supposed to be checked before they went to the dining room and sometimes on 3:00 p.m.- 11:00 p.m. shift the residents were already in the dining room, and CNAs go to the dining room to check the residents. CNA 3 stated CNA 3's run (assignment) was switched by the Director of Staff Development (DSD) 45 minutes into CNA 3's shift. CNA 3 stated when CNA 3 got to her assigned area, Resident 4 was already in the dining room and CNA 3 assumed Resident 4 was already changed. CNA 3 stated it was important to keep residents dry to prevent skin breakdowns, chafing and rashes, and to keep the residents comfortable. CNA 3 stated the CNAs from 7:00 a.m.-3:00 p.m. (AM shift) do not change the residents before the CNAs leave because the residents were very wet and the chux pad (absorbent pad used under resident for incontinence) was wet. CNA 3 stated CNA 3 knew the residents have been sitting for a while because it shouldn't be on their chux pad, especially less alert and oriented residents. CNA 3 stated the facility was short of staff because staff quit or call off sick all the time. CNA 3 stated that residents complain all the time that night shift CNAs took a long time to respond to the call lights and/or change the residents.During a review of the facility's Policy and Procedure (P&P), titled, Resident Rights- Quality of Life, revised March 2017, the P&P indicated facility staff promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. The purpose of the P&P was to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. 055344 Page 2 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received adequate supervision to prevent an elopement (when a patient leaves a healthcare facility without authorization or proper discharge).On 6/23/25, Resident 2 was found on the ground outside the facility with a bleeding laceration (type of open wound) on Resident 2's left eyebrow area.This failure resulted in Resident 2 sustaining bruising around the left eye and a laceration on Resident 2's left eyebrow which required 3 stitches. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for evaluation and for stitches to left eyebrow laceration after Resident 2 fell on 6/23/25.Findings:A review of Resident 2's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included Parkinsonism (refers to brain conditions that cause slowed movements, rigidity (stiffness), and tremors (involuntary, rhythmic shaking movements in various parts of the body), abnormalities of gait and mobility (a range of walking or movement patterns that deviate from the typical), and unspecified macular degeneration (eye disease causing vision loss), and unspecified dementia (thinking and social symptoms that interferes with daily functioning).A review of Resident 2's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 11/25/24, indicated that Resident 2 did not have the capacity to understand and make decisions due to (d/t) dementia (thinking and social symptoms that interferes with daily functioning). Resident 2's H&P indicated Resident 2 had an unsteady gait (abnormal walking pattern characterized by a lack of coordination, balance, or stability, increasing the risk of falls).A review of Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 4/11/25, indicated that Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS indicated that Resident 2 used a manual wheelchair and walker as mobility devices and required supervision/touch assistance with sit to stand.A review of Resident 2's Physician's Order, dated 6/23/25, indicated that Resident 2 may be sent out to General Acute Care Hospital (GACH) 1 for further evaluation status post (s/p) an unwitnessed fall.A review of Resident 2's Situation, Background, Assessment, and Recommendation (SBAR - used to convey information clearly and concisely to ensure that important information is shared effectively between healthcare professionals) Form dated 6/23/25 at 5:37 p.m., indicated Resident 2 had a skin tear noted above left eyebrow 3.5 centimeters (cm) x 1 cm and bleeding was noted. The SBAR indicated that Resident 2 was transferred to GACH 1.A review of Resident 2's Elopement Evaluation, dated 4/11/25, indicated Resident 2 was at risk for elopement due to a history of elopement or behavior of attempting to leave the facility without informing staff, due to verbally expressing the desire to go home, and due to wandering behavior.A review of the emergency room Discharge Summary (ERDS), dated 6/23/25, indicated that Resident 2 was admitted to GACH 1 with a facial laceration. The ERDS indicated Resident 2 had left periorbital (around the eye) bruising and three stitches.A review of Resident 2's At Risk for Falls Care Plan, revised 4/18/25, indicated to anticipate and meet the needs of the patient and to assist Resident 2 with locomotion (movement or the ability to move from one place to another) on and off the unit.A review of Resident 2's Quarterly Fall Risk Evaluation (FREprocess used to identify individuals who are at higher risk of falling) Form, dated 10/25/24 and 4/11/25, indicated Resident 2 was at risk for falls. Resident 2's admission FRE, dated 5/21/25, indicated Resident 2 was at risk for falls. The FRE indicated that Resident 2 fell on [DATE], 11/28/24, 1/22/25, 5/21/25, and 6/23/25.During a phone interview, on 6/26/25, at 1:08 p.m., with Family (FAM 1), FAM 1 stated Resident 2 frequently goes around the facility in Resident 055344 Page 3 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2's wheelchair. There are double doors that lead to the lobby and out the front door and to a driveway and to the street. FAM 1 stated nobody/no staff are ever at the front desk or in the front lobby area because they all leave at 5 p.m. FAM 1 stated FAM 1 has witnessed several times there were no staff in Nurse Station 1 near an exit. FAM 1 stated Resident 2 went outside of the facility through the front doors (second set of double doors). FAM 1 stated Resident 2 was found sitting on the concrete outside in the front of the facility where there are rocks and bushes. FAM 1 stated Resident 2 sustained an injury that required sutures (threads used to close wounds) on Resident 2's left eyebrow, around temporal (lateral portion located toward the temples) and orbital (bony cavity in the skull that houses eyeball/eye socket) eye area. FAM 1 stated there was inconsistent administration and high turnover so, they don't get to know the residents well enough to anticipate certain behavior of residents.During an interview, on 6/26/25, at 2:12 p.m., with the Rehabilitation Director (RD), the RD stated that Resident 2 receives physical therapy (PT) services. The RD stated that Resident 2 self-propels all around the facility in the wheelchair. The RD stated if Resident 2 stands up from the wheelchair, Resident 2 will fall. The RD stated Resident has ataxia (lack of muscle coordination) and dyskinesia (abnormal, involuntary, and sometimes repetitive muscle movements). The RD stated Resident 2 had a history of (h/o) trying to go outside.During an interview, on 6/26/25, at 3:00 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated LVN 1 Desk Nurse used to be in Nurse Station 1 (in front of the facility). LVN 1 stated we have a lot of wandering residents. LVN 1 would sit in Nurse Station 1 in front of the facility. LVN 1 stated LVN 1 handled paperwork, communicated with physicians, and assisted physicians, and monitored the residents. LVN 1 stated that approximately two weeks ago, the DON moved LVN 1/the Desk Nurse to the back of the facility and now we sit in the back of the facility in Nurse Station 2.During an interview, on 6/26/25, at 3:53 p.m., with the Assistant Director of Nurses (ADON), the ADON stated the ADON heard the door alarm. The ADON stated no staff were observed at Nurse Station 1. The ADON stated that the ADON responded to the double door alarm at the front of the facility and the ADON found Resident 2 outside the facility. The ADON stated Resident 2's wheelchair was on the cement. The ADON stated Resident 2 appeared to have fallen out of the wheelchair because the wheelchair was upright. The ADON stated Resident 2's left eyebrow was bleeding, and a drip of blood was coming down Resident 2's face.During an interview, on 6/26/25, at 4:55 p.m., with LVN 3, LVN 3 stated Resident 2 was in the [NAME] leaning to left side but, in a sitting position and Resident 2's wheelchair was tilted in the direction of resident. LVN 3 stated Resident 2 had a skin tear to left eyebrow area and Resident 2 was bleeding. LVN 3 stated Resident 2 stated when asked what happened, I don't know, I was trying go out and I fell. LVN 3 stated Resident 2 has a h/o asking where the door is and verbalizing the desire to go home, and staff (in general) just must redirect Resident 2. LVN 3 stated everyone was busy with dinner and for that second or moment, things happened so quickly. LVN 3 stated it is important to prevent resident falls to prevent injury.During an interview, on 6/26/25, at 5:56 p.m., with the Director of Nurses (DON), the DON stated it is important to determine root cause analysis (problem solving method used to identify the underlying reasons why a problem or event occurred) for a fall and if the resident did not get hurt or if the fall was preventable, we can prevent injuries.During a review of the facility's Policy and Procedure (P&P) titled, Wandering and Elopement, dated 2/10/23, the P&P indicated, The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition determine their risk of elopement. The IDT will develop and implement a plan of care considering the individual risk factors of the resident.During a review of the facility's P&P titled, Fall Management Program, revised March 2021, 055344 Page 4 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0689 Level of Harm - Minimal harm or potential for actual harm indicated the purpose of the facility's Fall Management Program is to provide residents a safe environment that minimizes complications associated with falls. The facility will implement a Fall Management Program that supports providing an environment free from fall hazards. Residents Affected - Few 055344 Page 5 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), had a history of fall (unintentionally coming to rest on a lower-level surface) on 6/1/25, and was assessed at a high fall risk on 6/1/25, received care needs and services to prevent a fall on 6/19/25 by failing to ensure:Licensed Vocational Nurse (LVN) 2 monitored (observed and checked) and promptly (quickly/rapidly/immediately) redirected Resident 1 (direct Resident 1 to a new or different place or purpose) when Resident 1 got up from Resident 1's wheelchair unassisted while Resident 1 was at Nurses' Station 1 on 6/19/25 [at around 10 am].As a result, on 6/19/25, at approximately 10 am, Resident 1 fell out of Resident 1's wheelchair, in front of Nurses' Station 1. Resident 1 sustained fractures (break in the bones) of the left 8th, 9th, and 10th ribs (are commonly referred to as false ribs [12 paired bones which form a cage to protect the lungs and the heart]. Unlike the first seven ribs, which directly connect to the sternum [breastbone]). Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia, a history of falling, cognitive (ability to think and understand information) communication deficit (communication difficulties stemming from impaired cognitive functions rather than direct speech or language problems), difficulty in walking and impulse disorder (inability to resist urges and impulses [acting without forethought]).During a review of Resident 1's untitled Care Plan (CP), dated 8/8/24, revised 5/9/25, the CP indicated Resident 1 was at risk for falls related to dementia, the aging process, poor safety awareness, and a history of falls. The CP interventions included anticipating and meeting Resident 1's needs, promptly response to all of Resident 1's requests for assistance and removing any potential causes of falls if possible.During a review of Resident 1's History and Physical (H&P, physician examination of a resident), dated 1/27/25, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had an unstable gait (abnormal walking pattern characterized by a lack of coordination [the ability to use different parts of the body together smoothly and efficiently]), balance, or stability, and increasing the risk of falls.During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/25/25, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from staff for transfers (moving from bed to chair or wheelchair), and walking.During a review of Resident 1's Fall Risk Evaluation (FRE), dated 6/1/25, the FRE indicated Resident 1's fall risk score was 15 due to Resident 1 required the use of assistive devices (cane, wheelchair, walker, furniture) while standing and walking, and had one to two falls in the past 3 months. The FRE indicated a score of 10 or higher, placed Resident 1 at high risk for fall. The FRE indicated Resident 1 was considered at high risk for potential falls (an increased likelihood of a person experiencing a fall, which can lead to injuries) when Resident 1's fall risk score was 10 or greater. The FRE indicated for nursing staff (in general) to focus on Resident 1's risk for falls with a goal for Resident 1 to be free of falls, and interventions to assist Resident 1 with ambulation (the ability to walk from place to place) and transfers.During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 6/1/25 and timed at 11:50 pm, the SBAR indicated Resident 1 had a fall, was unresponsive to verbal questions, and sustained an open skin tear to the left side of Resident 1's face due to the Residents Affected - Few 055344 Page 6 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0744 Level of Harm - Actual harm Residents Affected - Few fall. During a review of Resident 1's Risk for Falls Care Plan (CP), dated 6/1/25, indicated Resident 1 was transferred to General Acute Care Hospital (GACH) 2 Emergency Department (ED) (on 6/1/25) due to a fall on 6/1/25. The CP interventions included assisting Resident 1 with walking, transferring, and placing Resident 1 in front of the Nurses' Station for monitoring (observing and checking) [Resident 1's behavior to prevent falls].During a review of Resident 1's Fall Investigation Report (IR), dated 6/19/25 and timed 10:16 am, the IR indicated on 6/19/25 at 10 am, Resident 1 got up from Resident 1's wheelchair and fell on the floor in front of Nurses' Station 1. The IR indicated LVN 2 was on the computer with the Activities Director (AD) in Nurses' Station 1 on 6/19/25 [at 10 am]. The IR indicated LVN 2, and the AD saw Resident 1 walking towards Nurses' Station 1 unassisted, but LVN 2 and the AD were not able to get to Resident 1 in time due to the incident happened too fast. During a review of Resident 1's SBAR Form, dated 6/19/25 and timed at 10:25 am, The SBAR indicated [on 6/19/25, at 10 am], Resident 1 got up from Resident 1's wheelchair and fell on the floor in front of Station 1.During a review of Resident 1's SBAR Form, dated 6/20/25, and timed at 7:15 pm, the SBAR indicated Resident 1 was observed grimacing (to distort one's face in an expression usually of pain) in pain (pain was unrated) upon palpation (hands and fingers used to examine the body) of Resident 1's left lower quadrant (LLQ- the area below the belly button and to the left of the midline [the vertical line that runs down the center of the abdomen]). The SBAR indicated Resident 1's Primary Physician/Medical Doctor (MD) 1 recommended Resident 1 to get an X-ray (picture of the inside of the body).During a review of Resident 1's X-ray Report, dated 6/21/25, the X-ray Report indicated the reason MD 1 ordered an X-ray of Resident 1's ribs was due to Resident 1 having acute pain (a short-lived, sharp, and sudden onset pain that typically arises from a specific injury) due to trauma (physical injury due to violence or an accident). The X-ray Report indicated Resident 1 had an acute nondisplaced fracture (a break in a bone where the broken pieces of bone are still lined up correctly) of the left 8th, 9th, and 10th ribs.During an interview, on 6/26/25, at 10:06 am, with LVN2, LVN 2 stated Resident 1 was a fall risk and Resident 1 had a history of getting up (from bed and or wheelchair) unassisted. LVN 2 stated, on 6/19/25, at approximately 10 am, LVN 2 and the AD, were on the computer in Nurses' Station 1 looking for some information. LVN 2 stated, while looking for information on the computer, LVN 2 and the AD heard another resident (unidentified) make a sound to alert others that something was about to happen. LVN 2 stated LVN 2 and the AD went outside of Nurses' Station 1 and found Resident 1 lying on Resident 1's left side, on the floor. LVN 2 stated Resident 1 complained of pain (unable to rate the pain) but Resident 1 was not able to state where Resident 1's pain was. LVN 2 stated Resident 1 was placed near Nurses' Station 1 so LVN 2 could monitor Resident 1's behavior of getting up from Resident 1's wheelchair due to Resident 1 being at a high risk for falls and having behavior of getting up while sitting on wheelchair.During an interview, on 6/26/25, at 3 pm, with LVN 1, LVN 1 stated Resident 1 was constantly (always, continuously over a period of time) trying to get up from Resident 1's bed and or wheelchair, unassisted. LVN 1 stated Resident 1 needed one-to-one care (1:1, one staff caring for/supervising one resident). LVN 1 stated Resident 1 would get up out of the wheelchair unassisted even when a staff (in general) was sitting in front of Resident 1. LVN 1 stated, on 6/19/2025, (unable to recall exact time), Resident 1 was taken to the activity room for the morning activities (doing something such as action, movement, exercise), but Resident 1 was brought back in front of Nurses' Station 1 quickly (for additional monitoring) due to Resident 1 tried to get up (in the activity room) while sitting in Resident 1's wheelchair.During an interview, on 6/26/25, at 3:46 pm, with the Activities Director (AD), the AD stated, on 6/19/25 (unable to remember exact time), the AD walked up to Nurses' Station 1 and saw Resident 1 in Resident 1's 055344 Page 7 of 8 055344 06/26/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0744 Level of Harm - Actual harm Residents Affected - Few wheelchair in front of Nurses' Station 1. The AD stated the AD went inside Nurses' Station 1 and asked LVN 2 for assistance with the AD on the computer. The AD stated while looking for information on the computer with LVN 2, the AD heard a crashing noise. The AD stated the AD walked around to the front of Nurses' Station 1 and saw Resident 1 lying on Resident 1's left side on the floor. The AD stated Resident 1 liked to stand up a lot and forgot to use Resident 1's wheelchair.During a concurrent interview and record review, on 6/26/25, at 3:53 pm, with the Assistant Director of Nursing (ADON), Resident 1's Physician's Order, dated 1/24/25, was reviewed. Resident 1's Physician' s Order, dated 1/24/25, indicated for staff to monitor Resident 1 for episodes of getting up from the wheelchair and the bed unassisted every shift (each and every designated work period within a 24-hour cycle). The ADON stated Resident 1 had a history of getting up from Resident 1's wheelchair unassisted and needed to be monitor [for the behavior of getting up from the wheelchair unassisted].During an interview, on 6/26/25, at 5:56 pm, with the Director of Nursing (DON), the DON stated, it was important to determine the root cause analysis (problem solving method used to identify the underlying reasons why a problem or event occurred) for Resident 1's fall [on 6/1/25] to prevent further fall and injuries [on 6/19/25].During a review of the facility's policy and procedure (P&P) titled, Dementia Care, dated 10/2017, the P&P indicated, The Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide comprehensive care for residents) would seek to identify and address the root cause of challenging resident behaviors to determine whether there is a medical, physical, environmental cause of the behavior. The P&P indicated the IDT would develop plans of care and implement interventions to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the resident's needs/preferences. 055344 Page 8 of 8