Autumn Hills Health Care Center

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the trash bins were properly covered and in sanitary receptacles in accordance with the facility's policy and procedure titled, Sanitation and Infection Control: Waste Control and Disposal. The facility failed to ensure: 1. There was no large puddle of green, foul-smelling water pooled underneath the dumpsters and in the dumpster area on 6/23/26. 2. One of two large dumpster bins was not overflowing with trash with the lid unable to close on 6/23/26. 3. The facility staff did not dispose of an empty box carton onto the large puddle of green, foul-smelling water on the ground of the dumpster area then walked away on 6/23/26. 4. A bag of trash was not left on the ground in the dumpster area on 6/26/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential mechanical equipment in safe operating condition in accordance with the facility's policy and procedures titled Fire System Maintenance and Sanitation and Infection Control: Dishwashing Procedures (Dish machine). 1. The facility's dishwashing machine's thermometer was not reading accurately for an unknown amount of time between 6/16/26 to 6/23/26. This deficient practice had the potential to expose residents to foodborne illnesses (any sickness caused by eating or drinking foods contaminated with harmful germs [like bacteria or viruses] or toxic chemicals) due to improperly sanitized dishware. 2. The facility's sprinkler system had a leak for weeks and was not repaired until 6/24/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for 86 of 86 residents, the facility's staff, and the public when water from the facility's roof leaked into a large puddle of green, foul-smelling water in the dumpster area on 6/23/26. This failure created unsanitary conditions and increased the risk of pests, odors, and potential health hazards in an area accessible to staff and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy and maintain dignity during the provision of personal hygiene and dressing for four of eight sampled residents (Resident 66 , 16, 10 and 77) in accordance with the facility's policy and procedure titled Resident Dignity & Personal Privacy. This deficient practice had compromise residents' privacy and dignity that could result in embarrassment, emotional distress and a loss of personal respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and hazard free environment for three (3) of 18 sampled residents (Resident 46, Resident 93, and Resident 6) by failing to: 1. Ensure a bed pad alarm (a weight sensitive mat placed under a resident that alerts staff when they are attempting to get out of bed without supervision or assistance) was connected and functioning for Resident 46. 2. Identify and address potential risks of accident for Resident 93, who was diagnosed with dementia (a severe decline in memory, thinking, and reasoning skills that interferes with a person's ability to perform everyday tasks) and had a pattern of grabbing and pulling on objects including his gastrostomy tube (GT-the tube inserted into the abdomen used to deliver liquid food and medications). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food safety and sanitation to prevent foodborne illness (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, or viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps) for 84 of 86 residents in accordance with the facility's policy and procedure (P&P) titled Sanitation and Infection Control: Personal Hygiene and Sanitation and Infection Control: Handwashing when: 1. [NAME] 1 did not wash his hands upon entering the kitchen and handled food during meal preparation service 2. Dietary Aid (DA) 1 did not wash his hands upon entering and starting work in the kitchen 3. DA 1 did not put on a hair net upon entering the kitchen and during meal prep service. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure the facility obtained a signed informed consent (written document that demonstrates the resident or the resident's legally authorized representative about the resident's provision of care) prior to using bolster (a long, firm cylindrical or wedge-shaped cushion device secured to the bed frame with straps that restricted the resident to freely move in bed) for one of two sampled residents (Residents 67) as indicated in the facility Policy and Procedure (P&P) titled Informed Consent dated 11/3/2025 and Physical Restraints Management. This deficient practice resulted in the resident receiving treatment or interventions without informed consent, compromising the resident's right to make informed healthcare decisions, autonomy, dignity, and self - determination.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the advance directive (a legal document that outlines your preferences for medical care) documentation was readily retrievable by any facility staff for one of 18 sampled residents (Resident 7). This deficient practice had the potential to result in the resident receiving treatment or interventions without informed consent, compromising the resident's right to make informed healthcare decisions, autonomy, dignity, and self - determination having the potential for services not to be provided during medical emergencies according to the residents' wishes.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed maintain a safe, clean and homelike environment for one of 6 sampled residents (Resident 29) with soiled privacy curtains in the resident's room. This deficient practice had the potential to expose residents to an unsanitary environment and does not promote a clean and homelike living environment. During a review of Resident 29's Face Sheet (summary document of clinical information) indicated Resident 29 was admitted to facility on 7/3/2022 with a diagnosis that includes dementia (a decline in memory, thinking, reasoning), heart failure (heart cannot pump enough blood to meet the body' s needs), and glaucoma (eye diseases that decreases vision due to increased pressure in the eye). [...]

Inspectors wroteBased on observation, interview, and record review, the facility's failed to ensure one of 6 sampled residents (Resident 67) was free from physical restraints (any mechanical device or equipment that is attached to or adjacent to the resident's body, which restricts freedom of movement) in accordance with the facility 's policy and procedure titled Physical Restraints Management. Resident 67 was observed with Roll Bolster (long, firm cylindrical or wedge-shaped cushion, secured to the bed frame with straps) placed on the left side of the bed which restricted Resident 67 from shoulder to feet, which restricted her ability to sit up, or stand, resulting in the resident unable to reposition independently. The facility failed to: 1. Provide alternative methods to prevent falls prior to the use of Roll Bolster. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 63) who was a high risk for developing pressure ulcer (a skin injury due to prolonged unrelieved pressure or friction on the skin and body areas of the body) provided with bilateral (both sides) heel protector (a soft material designed to offload pressure from the heels, to prevent pressure ulcers) as ordered by the physicians order and in accordance with the facility's policy and procedures titled Pressure Ulcer/Injury Preventive Measures. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 's quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to post in the nursing stations an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 6/17/2026 up to 6/24/2026 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information misinforms the residents and responsible parties about sufficient staffing ratio per residents to meet their needs which affects their quality of care.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to privacy and dignity when staff photographed the resident without their permission while the resident was in a vulnerable position. This deficient practice resulted in Resident 1 verbalizing feelings of embarrassment and crying.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical abuse in accordance with the facility's Policy and Procedure, titled Abuse and Neglect Clinical Protocol, by failing to: 1. Identify physical abuse after Physical therapist (PT) 1 slapped Resident 1 on the right thigh on 2/23/2026. 2. Implement abuse protocols by not immediately reporting the incident to the Administrator (ADM). 3. Monitor Resident 1 immediately after the incident occurred on 2/23/2026. 4. Protect Resident 1 from PT 1 after PT 2 witnessed PT 1 slap Resident 1 on the right thigh and PT 2 continued to provide physical therapy services to Resident 1while PT 1 remained in the therapy room. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to immediately report physical abuse by Physical therapist (PT) 1 towards Resident 1 to the Administrator (ADM) within two (2) hours for one of five sampled residents, in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program. On 2/23/2026 while Resident 1 was beginning physical therapy, Resident 1 entered the rehabilitation (rehab) room and touched PT 1 on the back of the head. PT 1 reacted by slapping Resident 1 on the right thigh. PT 2 was also in the room. Neither PT 1 or PT 2 reported this incident on 2/23/2026 to the ADM. This deficient practice resulted in the facility not immediately reporting a witnessed physical abuse to the Administrator and delayed the investigation and protection for Resident 1 from further abuse. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for one of three sampled residents (Resident 1) who had a diagnosis of Type 2 Diabetes Mellitus ([DM] when a hormone called insulin does not work properly or there is not enough of it. This causes the level of glucose [sugar] in the blood to become too high) by failing to: 1. Ensre that its licensed nursing staff reviewed Resident 1's medical history of Type 2 Diabetes Mellitus (DM) and diabetes management prior to the readmission from the GACH on 1/11/2026. This medical history included Resident 1's diabetes management, such as checking and monitoring Resident 1's blood sugar levels by performing fingerstick tests. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the resident's authorized practitioners (Medical Doctor [MD] 1 and Nurse Practitioner [NP] 1) adequately supervised and managed the medical care of Resident 1 as required under physician services for one of three sampled residents. The facility failed to: 1. Ensure licensed nursing staff and MD 1 reviewed and addressed the General Acute Care Hospital (GACH) discharge orders, including the need to reorder fingerstick blood sugar monitoring (AC & HS) upon readmission for Resident 1 with Type 2 Diabetes Mellitus (DM) at the facility on 1/11/2026. 2. [...]

Inspectors wroteBased on observations, interviews and reviews, the facility failed to ensure monitoring and supervision was provided to one of three sampled residents (Resident 1), who was assessed as a high-fall-risk resident, by failing to: Develop and implement individualized care plan interventions to minimize the occurrence of falls in accordance with the Policy and Procedure (P&P) titled Falling Star Program. Identify specific monitoring required while Resident 1 was on the Falling Star Program. Conduct resident observations in accordance with the P&P for the Falling Star Program. Perform and document scheduled safety round as indicated by the P&P for the Falling Star Program. Determine and identify the type and frequency of supervision required in accordance with the facility's P&P for Safety and Supervision. [...]

Inspectors wroteBased observation, interview, and record review, n 12/14/2025, the facility failed to ensure one of two sampled residents ( Resident 1) received timely assistance with activities of daily living (ADLs), specifically incontinence care (timely assistance with personal hygiene, support , maintaining comfort, dignity, skin integrity, and health). This deficient practice resulted in Resident 1 experiencing moisture - associated skin damage ( MASD a medical term for inflammation, redness, and erosion of the skin from prolonged contact with moisture (urine, sweat, wound drainage, saliva, stool), often worsened by friction, pH, or microbes, leading to skin breakdown, especially in folds or around stomas/wounds0 and having the potential for further skin breakdown, pain, discomfort, and possible infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices (IPCP, a set of measures designed to protect patients and healthcare workers from avoidable infections) was implemented for one of three sampled residents (Resident 1) who was diagnosed with scabies (an itchy skin condition caused by a tiny bug, mite, that burrows into the skin), by failing to: 1. Place Resident 1 under contact precaution (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) on 5/13/25 when Resident 1 was diagnosed with scabies. Resident 1 was not placed under contact precaution until 5/15/25, two days after confirmed diagnosis. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a comprehensive care plan was completed for three out of three sampled residents (Resident 37, 9, and 64) in accordance to the facility's policy and procedure (P&P) for Comprehensive Plan of Care by failing to: 1. Ensure a care plan for the use of side rails was developed for Resident 37. 2. Ensure a care plan was implemented to apply side rails pads for Resident 9 who has diagnosis of seizure ( an abnormal electrical activity in the brain that cause uncotrolled jerking movements, loss of consciousness). 3. Ensure a care plan was developed for Resident 64 who was admitted with diagnosis of dementia (a progressive state of decline in mental abilities). This deficient practice had the potential for residents to sustian injuries and not receive care and services specific to their needs.

Inspectors wroteBased on observation and interview and record review the facility failed to follow its policy and procedure and the professional standards of practice on food storage and safety by failing to label the date the bag was opened and when to use by date an open plastic bag with 6 hashbrowns. This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumes it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 5) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Divalproex (medication used to treat mental/mood conditions). This deficient practice had violated Resident 5's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Resident 5's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 61 and 42) by failing to ensure: 1. Resident 61 ' s wall clock in the room indicated the accurate time of the day. 2, Resident 42 was provided a wall clock. These deficient practices had the potential to affect the quality of life and cause disorientation for both residents and led to Resident 42's verbalization of feelings of frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours of resident ' s admission to address the resident ' s medical and physical needs for one of one sampled resident (Resident 241) who was admitted on [DATE] with diagnoses that included chronic congested hear failure (CHF) (heart doesn't pump enough blood for your body's needs), history of pneumonia (an infection of the lungs) and history of acute respiratory failure with hypoxia (lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and hazard free environment to two of 3 sampled residents (Resident 12 and 9) by failing to: 1. Ensure to place a bed pad alarm (a weight sensor pad used to alert staff when resident gets out of bed which is the most effective tools for reducing falls within the elderly population) Resident 12 who was at high risk for fall as indicated on physician order and comprehensive care plan. 2. Ensure to place a sheep skin on the side rails and confirm placement every shift as indicated in the care plan and physician's order for Resident 9 who has a diagnose of epilepsy (a neurological disorder characterized by recurrent seizures (eratic electrical activity in the brain that causes uncontrolled movement of body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care to one of four sampled residents (Resident 8) as indicated in the physician ' s order and consistent with professional standard of practice by failing to ensure: 1. Nursing staff properly assessed and documented Resident 8 ' s baseline SpO2 level (oxygen saturation level/O2 [oxygen] a measurement of how much oxygen the blood is carrying as a percentage). 2. Ensure the oxygen tubing was not compressed in the side rail to ensure oxygen flow to the resident. 3. Perform respiratory assessment, and document signs and symptoms (S/S) of respiratory distress or shortness of breath (SOB) when providing oxygen therapy to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 did not document on the Medication Administration Record (MAR) and the Controlled Drug Record prior to the administration of the medication hydrocodone-acetaminophen (medication to control pain) for one of three sampled residents (Resident 314). This deficient practice had the potential for inaccuracies or discrepancies when administering medications.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled Residents (Resident 1) who had diagnosis of Non- ST (represents the interval between ventricular depolarization [blood flow into the left ventricle[[one of two large chambers located toward the bottom of the heart]]and repolarization [resting state of the heart]) segment elevation myocardial infarction (NSTEMI, a type of heart attack where a coronary artery is partially blocked, causing reduced blood flow to the heart and resulting in some heart muscle damage) received treatment and services in accordance with professional standards of practice, care plan and the physician's order for the management of the resident's chest pain. The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and ensure the residents right to access and use of a telephone by failing to: 1. Ensure Station B ' s portable phone was available forresidents to use. The portable phone was missing. 2. Ensure LVN 1 did not use her personal phone to contact residents ' families 3. Provide in services for staff including LVN1 that there was an additional cell phone available for residents to use in case the portable phone was not available (in use by other Residents, not working, or had a poor connection). These failures had the potential to negatively affect residents ' psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect in accordance with the facility ' s policy and procedure (P&P), titled Quality of life - Dignity while being assisted by certified nurse assistant (CNA)1, and ensure CNA 1 did not come in contact with Resident 1 after Resident 1 reported an incident that happened on 11/24/24, on 11/25/24 to the Administrator, when the Administrator brought CNA 1 to her room on 11/25/24, to make CNA 1 apologize to Resident 1 in accordance to the facility ' s P&P titled Abuse Prevention Program, and Abuse, Neglect, & Exploitation Prohibition. These deficient practices resulted in Resident 1 verbalizing feelings of being embarrassed and upset, and had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and Record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnoses of type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels) and required blood sugar checks, was provided with care and services by the licensed nurse (LN) in accordance to the facility ' s policy and procedure (P&P) titled Blood Glucose Test. This deficient practice had the potential for Resident 1 ' s blood sugar results to not be obtained properly and resulting in an inaccurate reading.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of unusual occurrence to the California Department of Public Health (CDPH) according to the facility ' s policy and procedure for one of three sampled residents (Resident 1). This deficient practice resulted in the facility underreporting allegations of abuse and placing Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident- centered care plan for one of three sampled residents. This deficient practice had the potential to delay care and services provided to Resident 1 according to Resident 1 ' s specific needs.

Inspectors wrote4. A review of Resident 79's admission Record (Face Sheet), indicated the facility originally admitted Resident 79 on 7/6/2023 and readmitted on [DATE] with diagnoses that include metabolic encephalopathy (a chemical imbalance that affected the brain and made it harder to think clearly and remember things), upper gastrointestinal bleed (bleeding that occurs anywhere in the esophagus [a muscular tube that food passes from the throat to the stomach], stomach, or upper part of the small intestine [long tube organ that helps digest food from the stomach]), and unspecified dementia (a loss of memory, language, and problem solving that is severe enough to interfere with daily life). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one kitchen staff was wearing a hair net prior to entering the kitchen and when properly storing foods in the refrigerator. 1. There were 26 applesauce containers not labeled or dated in the food storage. 2. There was one gallon of milk without a label on when it was opened. These deficient practices had the potential to result in food contamination (foods that are spoiled or tainted because of microorganisms, such as bacteria or parasites, or toxic substances that make them dangerous for consumption) and result in the resident to be exposed to food borne illnesses ( an illnesses contracted from eating contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was provided for one of two sampled residents (Resident 12), by ensuring the Certified Nursing Assistant 2 (CNA 2) had eye contact while sitting and feeding the resident. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth to Residents 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled resident's call light was within reach (Resident 25) during an observation conducted on 6/3/24 at 8:55 AM, inside the resident's room, in accordance with the facility's policy titled Call Lights-Answering Of. This deficient practice had the potential to harm Resident 25 (e.g., falling out of bed due to an unassisted transfer) by not being able to call for assistance when needed.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one of three sampled residents (Resident 79) was free of involuntary physical restraints (methods to purposefully limit or obstruct a person's freedom of movement) by failing to remove the overbed (an adjustable table designed to roll over a bed and provide a flat and stable surface with lockable wheels) table over the Resident 79 after breakfast. This failure resulted in Resident 79 restrained in his bed and unable to have freedom of movement with his overbed table over him.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent development of new pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction) or worsening of existing pressure ulcer for two of five sampled residents (Resident 56, and 76) in consistent with professional standards of practice and facility's policy and procedure by failing to: 1. Set the Alternating Pressure Mattress (APM) (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer ' s recommendation for Resident 56. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident maintained an acceptable parameters of nutritional status for one of two sampled residents (Resident 56) by failing to address and implement care plan interventions to monitor resident's food intake and hydration due to resident's significant weight loss of more than 5% in 30 days and monitor food intake for the month of May 2024. Resident 56's weights on April 2024 was 84.4 pounds and on May 2024 the resident's weight was 79.8 pounds a total of 4.6 pounds in a month. This deficient practice had the potential for Resident 56 to continue to lose weight that could result in medical complications such as tissue and organ failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 51) who required respiratory care and services was provided with the necessary respiratory care consistent with professional standards of practice by failing to: 1. Ensure the licensed nurses follow Resident 51 ' s physician order dated 5/5/2024, to administer oxygen of 3 liters per minute (LPM) as needed for shortness of breath and may titrate up to 5 LPM, and as indicated in the resident ' s plan of care titled At risk for decreased cardiac output. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Social Services Director (SSD) confirmed that the physician filled out the Physician Orders for Life-Sustaining Treatment (POLST, a form that communicates the individual's wishes regarding life-sustaining treatment and resuscitation) form completely for one of four sampled residents (Resident 46). This deficient practice had the potential for the facility not to fulfill the resident's end-of-life wishes when he stops breathing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Hospice binder (a binder that contains the care and services provided and being provided to residents under hospice care [end of life care]) was completed by the hospice nurses and used to communicate with the facility staffs) was completed by the hospice nurses during their visits and reviewed by the facility staffs for 2 of 2 sampled residents (Resident 59 and Resident 77). The Hospice binder contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurse ' s notes, care plans and treatment recommendations. [...]

Inspectors wroteBased on observation and interview and record review, the facility staff failed to provide a safe environment for residents by leaving a Hoyer Lift (a device that allows a person to be lifted and transferred with minimum physical effort) unattended in the resident ' s room. This had the potential for residents to be placed at risk for accidents and injury. Additionally the staff will have limited space in the room to comfortably provide care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had severely impaired cognition (thought process)who required extensive (means when a resident is totally dependent or requires weight - bearing support while performing part of an activity), two plus person physical assistance during transfer (how resident moves between surfaces Including to or from: bed, chair, wheelchair, standing position), and was at risk for falls was provided an environment free of hazard, assistance by facility staff, and a nursing care plan to decrease resident's risk of fall and injury. On 9/27/2023, Certified Nursing Assistant (CNA) 1 attempted to transfer the resident, who required maximum assist 2 people assist for transfer, from bed to wheelchair by herself. This deficient practice resulted in Resident 1 fall on 9/27/2023 at 11:00 AM. [...]