Health inspection·February 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 placed Resident 1's hand on her genital area without Resident 1's consent. This failure resulted in Resident 1 experiencing emotional distress. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Care Plan indicated, .The resident has impaired cognitive function; impaired thought processes r/t [related to] dementia . initiated 7/24/24, indicated .Interventions .Keep the resident's routine consistent . A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. [resident's name] was pleasant, polite and cooperative throughout our conversation and he continued to smile and was friendly. He did not exhibit any signs or symptoms of anxiety or distress right after the incident . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on Page 1 of 10 056483 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [LN1] that while [Resident 2] was seated in the hallway near t[Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [ at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD 056483 Page 2 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, but mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional distress for Resident 1 and behaviors for Resident 2 was initiated. During an interview on 2/12/14 at 12:19 with the Social Services Director (SSD), the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated that nurses should chart monitoring for 72 hours after incident. During a concurrent interview and record review on 2/12/25 at 3:00 p.m. with the Director of Nursing (DON), the DON acknowledged that nursing staff did not document monitoring for emotional distress for Resident 1 or for behaviors for Resident 2 for 72 hours after incident. The DON stated it was the expectation that nurses monitor and chart in the progress notes for 72 hours after incident. The DON also acknowledged that Resident 1 did not have a care plan created for this incident, and it should have been created by nursing at the time of the incident. The DON stated that facility uses traveling nurses frequently and procedures may not have been followed. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 8/2006, indicated .Our residents have the right to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including .other residents . A review of the facility's P&P titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .shall be thoroughly and promptly investigated by facility management . A review of the facility's P&P titled Charting and Documentation, revised 8/2008, .All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record .All observations .must be documented in the resident's clinical record .All incidents, accidents, or changes in the resident's condition must be recorded . A review of the facility's P&P titled Care Plans-Comprehensive, revised 9/10, indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . 056483 Page 3 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Department a written report of the results of an abuse investigation within 5 working days of an incident that involved an abuse allegation of inappropriate touching for two of three sampled residents (Resident 1 and Resident 2). Residents Affected - Few This failure had the potential to delay the Department's investigation of abuse allegations which may have led to continued abuse. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. Writer called [Resident 1]]'s wife to notify her of the occurrence and an . [a report of Suspected Adult/Elder Abuse] was documented and forwarded to CDPH [California Department of Public Health-The Department], The Ombudsman's office [an advocate for residents in nursing homes] and FBPD [Fort [NAME] Police Department]. Staff will monitor the residents and keep them separated . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP [Responsible Party] . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). 056483 Page 4 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 was moderately cognitively impaired. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [Licensed Nurse 1] that while [Resident 2] was seated in the hallway near [Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP . A review of Resident 2's Progress Note, dated 8/5/24 at 5:24 p.m. indicated . [report name] regarding this incident was documented and faxed to CDPH . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .reporting requirements. Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, and mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional 056483 Page 5 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few distress for Resident 1 and behaviors for Resident 2 was initiated. The DSD stated she referred the incident to the SSD to follow up. During an interview on 2/12/14 at 12:19 p.m. with the SSD, the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated she completed the Incident Investigation Report. The SSD stated she did not send the investigation report to the Department because, at the time of the incident, she was not aware that the report needed to be sent to the Department within 5 working days of the incident. The DSD stated she was not aware of the regulation because she was new to the position, but now she knows to send the report. A review of the facility's Policy and Procedure (P&P) titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .Shall be thoroughly investigated by facility management .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident . 056483 Page 6 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent one of two sampled residents (Resident 3) from an avoidable fall, when Resident 3, assessed as high risk for falls, was found on the floor by the bathroom after she had attempted to transfer and ambulate without one staff assistance and supervision to prevent falls. This failure resulted in Resident 3 sustaining a left femoral neck fracture (left hip fracture) that required surgical repair placing Resident 3 at risk for surgical complications including pain, infection, and decreased mobility. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in July 2024 with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following intracranial bleed (bleeding in the brain), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), heart failure (heart disorder which causes the heart to not pump the blood efficiently), and diabetes (disorder characterized by difficulty in blood sugar control). A review of Resident 3's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/16/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 8 out of 15 that indicated Resident 3 was moderately cognitively impaired, Resident 3 required one person staff assistance for toileting needs and mobility. A review of Resident 3's Morse Fall Scale [tool to assess risk for falling], dated 7/10 24, indicated Resident 3 was at a high risk for falling. A review of Resident 3's Progress Note, dated 7/10/24 at 2:35 p.m., indicated . Patient arrived here at approximately 1500 [3:00 p.m.] . She is a 85 yr [year] old female, alert and oriented x 2 [person and place], no obvious acute distress, she speaks only [name of language spoken]. She had a prior CVA [Cerebrovascular Accident- stroke- disrupted blood flow to the brain causing brain tissue death] with Left sided weakness and she is a max [maximum] assist for most ADLs [Activities of Daily Living] with setup for meals .She is incontinent of both bowel and bladder.she has a dx. [diagnosis] of schizoaffective d/o [disorder, mental illness] and has a very flat affect .She is a high fall risk, and we will have various family members sit with her as much as possible and every night. Call light in place as well as her bed control, Fx [fracture mats, padded mats to reduce injury from falls] pads placed on each side of the bed with the bed in its lowest position . A review of Resident's 3's Progress Note, dated 10/2/24 at 5:22 p.m., indicated .Writer was assisting Activities in the Dining room yesterday around 5pm and today around 4pm. On both days, [Resident 3] became agitated, tearful and exhibited some unsafe behaviors ie [that is]- trying to get out of her wheelchair unassisted and asking hysterically to leave and go find her family. She was inconsolable. She believes she should be leaving to go find her family and her house . A review of Resident 3's Progress Note, dated 10/6/24 at 12:50 p.m., indicated .Pt [Patient] was 056483 Page 7 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0689 found on floor, complained of left hip and cranial [skull] pain. Slightly confused and could not explain how she fell .Pt was transferred to hospital to r/o [rule out] fracture . Level of Harm - Actual harm Residents Affected - Few A review of Resident 3's Progress Note, dated 10/6/24 at 4:27 a.m., indicated .pt was observed on the floor by the bathroom, on 10/5, @ 2350 [at 11:50 p.m.], was slightly confused from her baseline. she was not sure how she fell. complained of left hip pain which got severe with movement .Also complained of left cranial [skull, head] pain no skin tear observed, Little elevated VS [ measurements of basic functions of the body] (168/99) [blood pressure, high], and pulse (116) [heart rate, high] .Transferred to hospital to r/o Fracture . A review of Resident 3's Progress Note, dated 10/6/24 at 12:14 p.m., indicated .There are several factors that contributed to the fall on 10/4/24: 1) The family did not want to continue the Seroquel [antipsychotic medication-medication to treat schizophrenia and mental health disorders] and therefore this was discontinued. The purpose of this medication was nightly active visual hallucinations and delusions for which the Seroquel was managing effectively and allowed this patient to have more effective sleep patterns. With out it she was unable to sleep as these symptoms overwhelmed the patient preventing sleep and increasing unsafe responses. 2) In the admission agreement, the family agreed to be present in the room allowing a nightly 1:1 [one-to-one sitter with resident to keep safe] to ensure the patient did not get off bed w/o [without] assistance and manage any other unsafe behaviors that would occur w/o constant supervision. This agreement was not continued for various family reasons leaving this safety support vacant. Finally, I had requested that [Physician] review, and if necessary, add another medication modality or increase the current dosage to alleviate our staff from spending excessive amounts of time to ensure the patient was safe and to strive for the best sleep patterns possible and his response is pending but did not occur d/t [due to] the family not wanting to continue the medication . A review of Resident 3's PT [Physical Therapy] Recert [Recertification, Progress Report & Updated Therapy Plan, dated10/5/24, indicated Resident 3 had decreased balance, decreased functional capacity. A review of Resident 3's Discharge Summary from hospital, dated 10/10/24, indicated Final Diagnosis: .Left displaced femoral neck fracture .Status post left hip hemiarthroplasty [surgical procedure to replace the hip with a prosthetic implant- artificial hip joint] . A review of Resident 3's Care Plan initiated 7/10/24 .Fall. Potential For D/T [due to] Impaired Gait, Impaired Balance r/t [related to] CVA w/ [with] left sided weakness. sundowner sx [symptoms such as behavioral and emotional changes that occur in people with dementia when the sun sets], difficulty to re-direct, non-compliance with agitation .Interventions .Provide staff assistance as needed for support and balance while resident is standing at bedside .Provide staff assistance of one person as needed for any Transfer activity .Observe resident for attempting to get out of bed, or attempting a self-transfer without staff assistance. Offer to assist the resident to the bathroom for a toileting activity before assisting the resident back to bed .Observe the resident closely for any unsafe actions or activities. Take actions as needed to minimize the risk of harm .Observe the resident closely for impulsive behaviors that put the resident at risk for falls. Take prompt actions as needed to minimize the risk of falls and harm . During an interview on 2/12/25 at 12:27 p.m. with the Director of Nursing (DON), the DON stated Resident 3 fell on [DATE] at approximately midnight. Resident 3 was found on the floor near the bathroom by the nurse. The DON stated Resident 3 complained of hip pain and was transferred to the hospital 056483 Page 8 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0689 Level of Harm - Actual harm Residents Affected - Few where an x-ray confirmed a left hip fracture. The DON stated Resident 3 was alert and oriented only to her name and place, was a fall risk, had a history of climbing out of bed at night, and had one or two falls prior to the fall on 10/5/24. The DON stated that Resident 3's family had agreed, upon admission to the facility, to stay with Resident 3 overnight in Resident 3's room to act as a one to one sitter but had stopped coming in to stay with Resident 3. The DON stated the family was not expected to stay with her any longer so Resident 3 was moved closer to the nurse's station. The DON stated several factors contributed to Resident 3's fall including dementia, a current urinary tract infection (bladder infection) that increased her confusion, and discontinuation of psychotropic medications [medications to treat mental health conditions], per family request, that controlled her delusions and hallucinations which increased her anxiety. The DON also stated Resident 3 had urge incontinence (an urgent, uncontrollable need to urinate frequently) so she wanted to get up every fifteen minutes to go to the bathroom. The DON further stated, In a perfect world, would have had one- to- one sitter. It was not possible due to staffing [not enough staff]. During an interview on 2/12/25 at 2:19 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 3 was confused and had sundowner's syndrome at night. CNA 1 stated that Resident 3 was able to move herself to the end of the bed and maneuver out of bed. CNA 1 stated Resident 3 was not able to use her call light [to call for help]. CNA 1 stated when Resident 3 returned to facility after hip fracture, the staff offered her a bedpan which helped keep her in bed. During an interview on 2/12/25 at 2:44 p.m. with the Physical Therapist (PT), the PT stated Resident 3 was a high fall risk due to decreased safety awareness and needed lots of care for safety. During a concurrent interview and record on 2/12/25 at 3:00 p.m. with the DON, the DON acknowledged that Resident 3's Morse Fall Scale, dated 7/10/24, indicated Resident 3 was a high fall risk. The DON stated that interventions to prevent falls were that bed was kept in lowest position and fracture mats were at bedside. When asked what other interventions or measures could have been used to prevent fall since family was no longer staying with Resident 3, the DON stated, One- to- one would have been ideal. Not done due to staffing. Family pulled out of agreement to provide one- to- one sitter. That agreement was made with family in order to accept resident at facility .The Administrator made that agreement because it was a big risk accepting her. A review of the facility's Policy and Procedure (P&P) titled Fall Risk Assessment, revised 12/2007, indicated .The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls .The staff will look for evidence of a possible link between the onset of falling .and recent changes in the current medication regimen .Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls .The staff .will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try and minimize the consequences of risk factors that are not modifiable . A review of the facility's P&P titled Falls and Fall Risk, Managing, revised 12/2007, 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 and minimize complications from falling The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .If underlying causes cannot be readily 056483 Page 9 of 10 056483 02/12/2025 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0689 Level of Harm - Actual harm identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Residents Affected - Few 056483 Page 10 of 10