Health inspection·August 8, 2025

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 two of four sampled residents (Resident 1 and Resident 2) who were at risk for falls, were provided supervision to prevent further fall instances, by failing to: 1. Ensure Resident 1, who had severely impaired cognition (thought process) was frequently monitored as indicated on Resident 1's Care Plan.2. Accurately document and assess Resident 2's Fall Risk Assessment after Resident 2 fell on 5/25/25 and 7/27/25.This deficient practice resulted in Resident 1 sustaining a fall on 7/27/2025.This deficient practice resulted in Resident 2 sustaining a fall on 5/25/2025 and 7/27/2025 and Resident 2 not receiving appropriate preventative measures to prevent future falls. During a review of Resident 1's admission Record (AR), the AR indicated that resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension ( high blood pressure), Traumatic Subdural Hemorrhage without loss of consciousness (a serious injury where blood collects between the brain and its outer covering), and mood disorder due to known physiological condition (general emotional state or mood is distorted or inconsistent with circumstances and interferes with ability to function).During a review of Resident 1's History and Physical (H&P) dated 4/18/2025, the H& P indicated Resident 1 does not have a capacity to make medical decision.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/18/2025, the MDS indicated Resident 1's brief interview of mental status (BIMS, brief screener that aids in detecting cognitive impairment) score was 2 (a score of 0-7 indicated cognitive skills for daily decision was severely impaired ).The MDS indicated Resident 1's tub/shower transfer and toilet transfer was not attempted due to medical condition or safety concern. The MDS indicated Resident 1 required maximal assistant (helper dose more than half of the effort. Helper lifts or holds trunk or limbs and provide more than half the effort ) for personal hygiene, upper lower body dressing, toileting hygiene, oral hygiene, chair/bed to-chair transfer. The MDS indicated Resident 1 required partial moderate assistant (helper dose less than half the effort. Helper lifts, holds, or supports trunk or limb but provides less than half of the effort )During a Review of Resident 1 Change in Condition Evaluation dated 7/27/2025, at 8:15 AM, the Evaluation indicated Resident 1 sustained a fall at 8:15 AM and was found lying down on the floor on Resident 1's Left side.During a Review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 was at risk for falls.During a Review of Resident 1's Care plan for [Resident 1] is at risk for unavoidable falls with injury related to limited mobility , confusing , dec conditioning , gait balance problem incontinent , paralysis , unaware of safety needs , vison hearing problem recurrent falls attempting to get out of bed without assistance, revised on 6/11/25, the care plan indicated a goal for Resident 1 to be free of falls. The Care Plan intervention indicated to anticipate and meet the resident needs, be sure the resident call light is within reach and encourage the resident to use it as needed and frequent visual monitoring. During a review of Resident 2's AR, the AR indicated the Resident 2 was admitted Page 1 of 8 055523 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the facility on [DATE] with diagnoses including dependent on renal dialysis (Kidney dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), type 2 Diabetes (high blood sugar) , Depression (metal illness constant feeling of sadness).A review of Resident 2's History and Physical (H&P) encounter date 12/1/2024, the H&P indicated Resident 2 has the capacity to understand and make decision.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's BIMS, score was 13 (a score of 13-15 indicated cognitive skills for daily decision making is intact ). The MDS indicated Resident 1 required supervisor and touching assistant (helper provide verbal clues and/or touching steadying and /or contact guard assistance as Resident completes activity. Assistant may be provided throughout the activity or intermittently.) for sit to stand, chair/bed-to chair transfer toilet transfer, walk 10 feetDuring a Review of Resident 2 Change in Condition Evaluation dated 3/09/2025 at 00:40 AM, the Evaluation indicated Fall , and indicated Resident 2 reported that he fell in the front lobby when he attempting to stand up from his wheelchair, the strap from his boot got caught on his wheelchair and Resident 2 loss his balance and fell. The evaluation indicated that Resident 2 sustained two small cuts noted on his right shin.During a Review of Resident 2 Change in Condition Evaluation dated 5/25/2025 at 6:08 PM, the Evaluation indicated Fall , and indicated Resident 2 reported that he fell in the room, after losing balance. The Evaluation indicated Resident 2 fell knees first onto the floor. During a Review of Resident 2's Change in Condition Evaluation dated 7/27/2025 at 4:44 PM, the Evaluation indicated Fall and indicated Resident 2 was seen falling in front of his room by the door, holding his breakfast tray and suddenly lost his balance. The Resident quickly sat on the floor before nurses could stop the fall.During a Review of Resident 2's Fall Risk assessment dated [DATE] at 6:08 PM, the Assessment indicated the Reason for the assessment request was due to a Recent Fall. The Assessment indicated the number two (2) input for the history of falls within the last six (6) months, which indicated Resident had no history of falls. The Assessment indicated Resident 2 was not at risk for falls. During a review of Resident 2's Fall Risk assessment dated [DATE] at 5:05 PM, the Assessment indicated the Reason for the assessment request was due to a Recent Fall. The Assessment indicated the number two (2) input for the history of falls within the last six (6) months, which indicated Resident had no history of falls. The Assessment indicated Resident 2 was not at risk for falls.During an interview on 8/6/2025, at 11:25 AM, Resident 2 stated on 7/27/2025 around 8:10 AM, Resident 2 pressed his call light (a device in healthcare settings that allows patients to remotely request assistance from nurses or other staff members) so staff could take his empty breakfast tray away. Resident 2 stated waiting approximately 30 minutes, and that facility staff did not come to assist Resident 2 with his breakfast tray. Resident 2 stated he then decided to bring the empty breakfast tray to the staff, but then fell in front of his room. During an interview on 8/7/2025 at 11:02 AM with registered nurse supervisor (RNS), RNS stated Resident 1 was alert and oriented times 1(A/O x1: resident is alert and oriented to person only), and was a fall risk due to recurrent history of falls and was noncompliant with the use of his call light. RNS stated Resident 1 was forgetful and confused and that staff places Resident 1 in front of the facility nursing station to monitor and supervise Resident 1 to prevent a fall. RNS stated Resident 1 was placed in front of the nursing station for supervision, since there was not enough staff, and that when there was not enough staff, such a certified nurse assistant (CNA), residents were at risk for fall. During a concurrent interview and record review of Resident 1's Care plan for at high risk for unavoidable falls with injury related to limited mobility , confusion, deconditioning , gait balance problem incontinent , paralysis , unaware of safety needs , vison hearing problem recurrent falls attempting to get out of 055523 Page 2 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed without assistance , revised on 1/16/2025, on 8/7/2025 at 1:58 PM with the Director of Nursing (DON), the DON stated care plan goal indicated Resident 1 would be free from falls DON stated Resident 1 was confused resident and did not follow directions, so facility staff placed Resident 1 in front of the nursing station to prevent falls. The DON stated since resident 1 had a fall the care plan intervention were not effective and that the care plan should be more specific to Resident 1's needs to indicate the frequency of visual monitoring to prevent falls or accidents. During an interview on 8/7/2025 at 1:58 PM with the DON, the DON stated Resident 2 had a fall on 3/9/2025, 5/25/2025 ,and 7/27/2025. The DON stated after each fall it was protocol for the licensed nurse (LN) to conduct a fall risk assessment and based on the fall risk assessment a care plan was initiated. The DON stated when a resident was assessed for risk for falls, facility staff would need to implement interventions to prevent the resident for a fall.During a concurrent interview and record review on 8/7/2025 at 1:58 PM with the DON, Resident 2's Fall Risk Assessments dated 5/25/2025 and 7/27/25 were reviewed. The DON stated the two Assessments were not accurate since both Assessments indicated Resident 2 did not have a history of falls within the last six (6) months. The DON stated the 5/25/25 Assessment should indicate a fall since Resident 2 fell on 3/9/2025. The DON stated the 7/27/25 Assessment should indicate a fall since Resident 2 fell on 5/25/25. The DON stated it was essential to accurately assess and document on the fall risk assessment so facility staff would know if a resident was at risk for falls to provide interventions based on the assessment. During a review of the facility's Policy and Procedure titled, Falls and Fall Risk, Managing, revised March 2018, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). 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. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.During a review of the facility's Policy and Procedure titled, Fall Risk Assessment, with no date, indicated The nursing staff, in conjunction with the attending physician. consultant pharmacists, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiableDuring a review of the facility's Policy and Procedure titled, Certified Nursing Assistant , with no date, indicated Position summary :The purpose of your job position is to provide each resident with routine daily nursing care in accordance with the resident's assessment plan along with current federal, state, and local standards that govern the facility, and as directed by your 055523 Page 3 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervisions. essential duties and responsibilities :answering call lights ,ensure that all nursing care is provided in privacy, making residents comfortable (putting them in bed, bringing them water, etc.), assisting in feeding residents (by cutting their food and spoon feeding if needed), helping residents with their daily grooming, shower or sponge bath, proper lifting and transitioning residents from wheelchair to bed, bed to chair, etc, helping residents, sit, stand and walk, transporting residents to dining area (for meals and activities) and returning them to their room, timely reporting of change in resident's condition to the Nurse Supervisor. 055523 Page 4 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to :1-Provide adequate Certified Nursing Assistant (CNA) staff to respond to requests for assistance with toileting and activities of daily living (ADL) in a timely manner , for three of four sampled residents (Resident 2, Resident 3,and Resident 4).2- Implement the Facility Assessment and All facility Letter (AFL) 21-11 to meet requirement Direct Care Service Hours Per Patient Day (DHPPD) for CNA for minimum of 2.4 hours.This deficient practice resulted in Resident 2 sustaining a fall on 7/27/25 in the facility hallway, Resident 4 stated feeling helpless after facility staff did not address the call light timely to assist Resident 4 with his wheelchair, and Resident 3 waiting for two hours to assist with ADL's.This deficient practice resulted in not meeting the minimum requirements for CNA's to provide adequate care and necessary services needed for each resident in the facility.During a review of Resident 2's admission Record (AR), the AR indicated the Resident 2 was admitted to the facility on [DATE] with diagnoses including dependent on renal dialysis (Kidney dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), type 2 Diabetes (high blood sugar) , Depression (metal illness constant feeling of sadness).During a review of Resident 2's History and Physical (H&P) encounter date 12/1/2024, the H&P indicated Resident 2 has the capacity to understand and make decision.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 6/3/2025, the MDS indicated Resident 2's brief interview of mental status (BIMS, brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated cognitive skills for daily decision making is intact ). The MDS indicated Resident 1 required supervisor and touching assistant (helper provide verbal clues and/or touching steadying and /or contact guard assistance as Resident completes activity. Assistant may be provided throughout the activity or intermittently.) for sit to stand, chair/bed-to chair transfer toilet transfer, walk 10 feet.During a Review of Resident 2 Change in Condition Evaluation dated 7/27/2025 and timed at 4:44 PM, the Evaluation indicated the date and time Resident 2's responsible party (RP) was notified of Resident 2's fall was 7/27/2025 at 8:47 AM. The Evaluation indicated Resident was seen falling in front of his room by the door holding his breakfast tray and suddenly lost his balance. The Resident quickly sat on the floor before nurses can stop the fall.During a review of Resident 3's AR , the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including hearth failure (high blood pressure), pressure ulcer of sacral region (pressure ulcer of sacral region), and atherosclerosis of Aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta).During a review of Resident 3's H&P encounter date 7/11/2025, the H&P indicated Resident 3 has the capacity to understand and make decision.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 15 (a score of 13-15 indicated cognitive skills for daily decision making is intact).The MDS indicated Resident 3 is dependent (helper dose all of the effort . Resident done none of the effort to complete the activity or assistance of 2 or more helpers is required for the resident to complete the activity) on toileting , hygiene shower/bath self, personal hygiene, roll left and right . The MDS indicated sit to lying, lying to sitting , sit to stand toilet transfer did not attempt due to medical condition or safety concerns.During a review of Resident 4's AR, the AR indicated the Resident 4 was admitted to the facility on [DATE] with diagnoses including Diabetes (high blood sugar) , hypertension (high blood pressure) , and Syncope and collapse (sudden and temporary loss of consciousness and fall).During a review of Resident 4's H&P encounter date 4/23/2025, Resident 4 has the capacity to understand and make decision.During a 055523 Page 5 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's BIMS score was 13 (a score of 13-15 indicated cognitive skills for daily decision making is intact ). The MDS indicated Resident 1 required supervisor and touching assistant (helper provide verbal clues and/or touching steadying and /or contact guard assistance as Resident completes activity .Assistant may be provided throughout the activity or intermittently) for sit to stand, chair/bed-to chair transfer , toilet transfer. The MDS indicated Resident 4 required partial moderate assistant (helper dose less than half the effort. Helper lifts, holds, or supports trunk or limb but provides less than half of the effort) for walking 10 feet.During an interview on 8/6/2025 at 11:25 AM with Resident 2, Resident 2 stated on 7/27/2025 between 7:30 AM to 8 AM he pressed the call light so staff could take his empty breakfast tray, however no one showed up. Resident 2 stated he waited approximately 30 min then he decided to take the tray away himself but had a fall in front of his room.During an interview on 8/6/2025 at 11:40 AM with Resident 3, Resident 3 stated on 8/4/2025 around 1 AM she was wet and had bowel movement so she pressed the call light and screamed out the door, but no one came to change her until 3:00 PM (2 hours later). Resident stated no one came to provide care.During an interview on 8/6/2025 at 11:45 AM with Resident 4, Resident 4 stated on 8/4/2025 around 4 PM he needed help to be transferred to his wheelchair, however the wheelchair was not in the room, so he pressed to call light for help, but no one answered the call light. Resident 4 stated around 5 PM (an hour later) one of license nurses answered the call light and found the wheelchair. Resident 4 stated not getting helped and being stuck in the bed made him feel helpless.During an interview on 8/6/2025 at 12:13 PM with the Director of Staff Development (DSD) 1, DSD 1 stated based on the facility census (the total number of patients or residents currently residing in that facility) DSD 1 scheduled CNA's and that each shift was different. DSD 1 stated she followed the Nursing Hours Per Patient Day (NHPPD) for scheduling CNA's to meet 2.4 hours required hours by state. DSD 1 stated facility does not have waiver for staffing and the facility was not in compliance with the required hours for CNA which was 2.4 for direct care hours. DSD stated she reported to the DON and ADM about the staffing issue . DSD 1 stated using the registry would help with staffing. DSD 1 stated not having enough CNA's would result in poor quality of care and poor quality of life for Resident. In addition, residents ADL will not be met and there is potential for harm.During an interview and record review of Direct Care Services Hours Per Day (DHPPD), on 8/6/2025 , at 12:13 PM with DSD 1, DSD 1 stated:On 7/27/2025, the projected CNA staffing was 2.3 and the actual was 2.06 , Census inhouse116+ bed hold 5=121 (less than the required 2.4)On 7/28/2025, the projected CNA staffing was 2.09 and the actual was 2.08 , Census in house120+bed hold 4=124 (less than the required 2.4)On 7/30/2025, the projected CNA staffing was 2.05 and the actual was 2.06 , Census in house 119+bed hold 3= 122 (less than the required 2.4)On 7/31/2025, the projected CNA staffing was 2.33 and the actual was 2.09, Census in house 119+bed hold 5 =124 (less than the required 2.4)On 8/3/2025, the projected CNA staffing was 2.27 and the actual was 2.15 , Census in house 117+bed hold 3= 120 (less than the required 2.4)On 8/4/2025, the projected CNA staffing was 2.12 and the actual was 2.05 , Census in house 117+ bed hold 3= 120 (less than the required 2.4)During an interview on 8/6/2025, at 12:36 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she does not want to talk about whether the facility has staffing issue for CNA's since CNA 1 was scared that the facility would retaliate.During an interview on 8/6/2025 at 12:38 PM, CNA 2 stated she will get into trouble if she told the facility is under staff .During an interview on 8/6/2025, at 2:38 PM with Administrator (ADM), ADM stated he was aware of the staffing issue for 7/27/2025 however it got missed. The ADM stated facility was following All Facilities Letter (AFL) 21 -11 and the plan was for the facility to meet the required standard of direct care for staffing requirement of 2.4 055523 Page 6 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hours for CNAs.During an interview and record review of Direct Care Services Hours Per Patient Day (DHPPD), on 8/6/2025 , at 2:40 PM with the ADM, ADM stated:On 7/27/2025, the projected CNA staffing was 2.3 and the actual was 2.06 , Census inhouse116+ bed hold 5=121 (less than the required 2.4)On 7/28/2025, the projected CNA staffing was 2.09 and the actual was 2.08 , Census in house120+bed hold 4=124 (less than the required 2.4)On 7/30/2025, the projected CNA staffing was 2.05 and the actual was 2.06 , Census in house 119+bed hold 3= 122 (less than the required 2.4)On 7/31/2025, the projected CNA staffing was 2.33 and the actual was 2.09, Census in house 119+bed hold 5 =124 (less than the required 2.4)On 8/3/2025, the projected CNA staffing was 2.27 and the actual was 2.15 , Census in house 117+bed hold 3= 120 (less than the required 2.4)On 8/4/2025, the projected CNA staffing was 2.12 and the actual was 2.05 , Census in house 117+ bed hold 3= 120 (less than the required 2.4)ADM stated the facility was not in compliance with the required hours for CNA which is 2.4 for direct care hours.During an interview on 8/7/2025 at 10:55AM with Registered Nurse (RN) supervisor, RN supervisor stated Resident 2 had a fall on 7/27/2025 around 8:50 AM when he was carrying his empty breakfast tray out from room, and fell in front of his room. RN Supervisor stated the job description of CNA are assisting with ADL, feeding, showering, changing, answering call light. RN supervisor stated CNA pick up breakfast tray because they document how much the patient ate. RN supervisor stated the potential outcome of not having enough CNA's on floor was that the shortage could lead to safety issues, call light not answered timely , potential for harm and accidents.During a an interview on 8/7/2025 at 3:47 PM, CNA 3 stated that she was assigned to care for twelve residents more than one time in the last two weeks. CNA 3 stated she rushed care and could not provide proper care for residents. During a review of the Facility Assessment provided by facility updated date 7/6/2025 , indicated The Facility Assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider. The Facility Assessment will be the basis for surveyors to ascertain whether you are prepared to competently take care of the population you have identified that you serve. The facility will maintain a minimum of 3.50 hours PPD and will staff according to the needs of the residents. Will strive towards reaching 2.4 CNA PPD. Action already taken/on-going.During a review of the California Department of Public Health AFL 21-11 subject Guidelines for 3.5 Direct Care Service Hours Per Patient Day (DHPPD) Staffing Audits dated 3/17/2021, provided by facility indicated In accordance with HSC sections 1276.5 and 1276.65, and W&I section 14126.022, this notice provides updated guidelines for facility requirements during state audits for compliance with the 3.5 DHPPD staffing requirements, of which a minimum of 2.4 DHPPD shall be performed by certified nurse assistants (CNAs).The California Department of Public Health (CDPH) is replacing AFL 19-16 with AFL 21-11 to clarify the requirements and guidelines for the 3.5 and/or 2.4 (CNA) DHPPD staffing requirements in skilled nursing facilities (SNFs). The guidelines in this AFL are applicable to the audit period beginning July 1, 2020, and shall remain in effect until superseded.During a review of the facility's Policy and Procedure titled, Facility Assessment with no date indicated , A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing. training. equipment and supplies needed. 055523 Page 7 of 8 055523 08/08/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many It is separate from the quality assurance and performance improvement evaluation.During a review of the facility's Policy and Procedure titled, Staffing, Sufficient and Competent Nursing, revised August 2022 , indicated Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1.Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs.During a review of the facility's Policy and Procedure titled, Accommodation of Needs, revised March 2021, indicated Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and, well-being.1.The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.2.The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.4.ln order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example:a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity;b. arranging toiletries and personal items so that they are in easy reach of the resident.During a review of the facility's Policy and Procedure titled, Certified Nursing Assistant , with no date, indicated Position summary :The purpose of your job position is to provide each resident with routine daily nursing care in accordance with the resident's assessment plan along with current federal, state, and local standards that govern the facility, and as directed by your supervisions. essential duties and responsibilities :answering call lights ,ensure that all nursing care is provided in privacy, making residents comfortable (putting them in bed, bringing them water, etc.), assisting in feeding residents (by cutting their food and spoon feeding if needed), helping residents with their daily grooming, shower or sponge bath, proper lifting and transitioning residents from wheelchair to bed, bed to chair, etc, helping residents, sit, stand and walk, transporting residents to dining area (for meals and activities) and returning them to their room, timely reporting of change in resident's condition to the Nurse Supervisor.During a review of the facility's Policy and Procedure titled, Dignity, revised October 2017 , indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices,preferences, values and beliefs. This begins with the initial admission and continues throughout the residents facility stay.3. Individual needs and preferences of the resident are identified through the assessment process 055523 Page 8 of 8