Based on staff interviews, written statements and review of the facility's internal investigation, the facility failed to ensure that 1 of 3 residents reviewed for dignity (Resident #1) was treated with respect during care provided after a fall. Finding: Resident #1 experienced two falls on 5/26/25. The first fall, at approximately 11:25 a.m., was documented as a loss of balance. Staff appropriately used a mechanical lift to assist Resident #1 from the floor in accordance with the facility's no-lift protocol. The second fall, at approximately 4:50 p.m. near the nurse's station, was witnessed by Certified Nursing Assistant #1 (CNA), who observed the Resident #1 fall to his/her right side. CNA #1 responded immediately and held the resident's head until CNA #5 arrived. CNA #1 directed CNA #5 to notify the charge nurse, Licensed Practical Nurse #1. (LPN) CNA #1 reported that when LPN #1 arrived, she told staff that because the fall was witnessed, it did not count as a fall and instructed staff to stand the resident up. CNA #1 recalled a disagreement between RN #1 and LPN #1 regarding the use of a mechanical lift. LPN #1 disregarded the concern and proceeded to lift Resident #1 with CNA #5. CNA #1 stated that the resident provided no more than 10% effort. CNA #1 stated that she observed CNA #5 and LPN #1 pick Resident #1 up off the floor under [his/her] arms. CNA #2 reported observing CNA #5 and LPN #1 grabbing Resident #1 under the arms and drag [him/her] down the hallway to [his/her] room. CNA #2 described staff struggling to get Resident #1 into bed and stated she yelled for them to support him/her by the back of his/her pants to prevent another fall. CNA #2 stated that the resident was not bearing weight, and staff used substantial strength to complete the transfer. CNA #5 stated that LPN #1 said, Come on, let's just pick [him/her] up. CNA #5 acknowledged that lifting the resident manually was against facility protocol, but said he followed orders, stating, I was just following orders from my boss. CNA #5 described the resident as unable to walk, saying, It was more accurate to say that we were dragging [him/her]. Once in the room, CNA #5 reported that the resident pushed downward, appearing to try to return to the floor. LPN #1 responded, [He's/She's] just doing this on purpose. [He/She] does this. Staff then lifted Resident #1 into bed and swung his/her legs up. LPN #1 stated the Resident #1 mumbled but did not answer pain questions. She reported Resident #1 initially walked without signs of pain, later refused to continue, and became combative. She stated Resident #1 moaned during care but could not determine whether the pain was in the right or left leg. RN #1 stated she was informed by CNA #5 that the resident had a hard fall. When RN #1 arrived, the resident was still on the floor. Upon confirming it was the second fall of the day, RN #1 asked if the mechanical lift was being used. LPN #1 asked if the fall had been witnessed and if the resident had hit his/her head. When CNA #1 confirmed the fall had been witnessed and there was no head injury, LPN #1 said, Then [he/she] doesn't need the lift. We can just get [him/her] up. On 6/17/25 at 2:55 p.m., during an interview with the surveyor, the Director of Nursing (DON) stated that the facility does not have a formal written policy requiring the use of a mechanical lift after a fall. However, the DON confirmed that it is covered in new employee orientation and is considered part of facility protocol, as the facility operates as a no-lift environment. Staff are expected to use mechanical lifts rather than physically lift residents under normal circumstances, including post-fall .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 26 residents reviewed. (Resident #44) Finding: Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #44 has a Brief Interview for Mental Status (BIMS) 15 of 15 indicating he/she is cognitively intact. On 11/18/24 at 9:57 a.m. observation of Registered Nurse (RN) #1 giving Resident #44 medications via Percutaneous Endoscopic Gastrostomy (PEG) Tube. Privacy was not provided as the bedroom door was open, the surveyor observed residents and staff passing the room at this time. On 11/19/24 at 1:45 p.m., during an interview Resident #44 states he/she prefers to have privacy when receiving medication administration or feedings through his/her PEG Tube. On 11/19/24 at 2:00 p.m. the above information was discussed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain the facility in good repair and sanitary condition for three of three units. Findings: On 11/0/24 at approximately 10:00a.m. during the environmental rounding with the Facility Manager and the Administrator the following concerns were found: Unit A Dirty ceiling tile outside room A9/10 Dirty ceiling tile outside room A11/12 Stained ceiling tile outside room A13/14 Stained ceiling tile outside room A28 Dirty ceiling tile outside room A33/34 Unit B Dirty ceiling tile outside room B5/6 Bathroom for rooms B12, B10 and B9 where the tile meets the floor is dirty Bathroom for rooms B16 and B15 dirty floor Bathroom for rooms B22, B21, B20 and B19 is dirty, where tile meets the floor is dirty, tile behind toilet is falling off. Stained ceiling tile B19 Bathroom for rooms B25, B24 and B23 is dirty where the tile meets the floor. Bathroom B28 - sink is broken with broken pieces sitting on top of the wall cabinet Bathroom for rooms B31, B32, B30 and B29 has a strong urine smell and dirty floor Bathroom for rooms B36, B35, B34 and B33 - floor looks unclean. Spa room - along wall next to shower has chipped drywall. dirty floor Unit C Stained and dirty ceiling tile above Kitchen area Stained ceiling tile above windows in Kitchen Patched hole on wall near windows Excessive insects/debris in hanging lights in main hallway room [ROOM NUMBER]/2 patched paint holes on walls room [ROOM NUMBER] - several patched holes on wall near TV room [ROOM NUMBER] - Floor mat folded near bed with split end - (Facility has addressed the need and ordered new mats) Paint chipped off the wall outside 23/24 Dirty ceiling tile in Main Hallway near Birdcage The above list was confirmed with the Administrator at approximately 10:30a.m

Based on observations and interviews, the facility failed to adequately store, date and properly dispose of open biologicals according to manufacturer specifications in 2 of 2 medication carts observed on 1 of 3 units (Unit C). Findings 1. On 11/18/24 at 12:17 p.m., observation of Unit C's medication cart for rooms 21-40 with the Registered Nurse (RN #1), the surveyor noted an opened bottle of Acidophilous with manufactures directions of refrigerate after opening and an undated Lantus/Glargine pen with manufactures directions of, use within 28 days after initial use. At this time, RN #1 confirmed the Acidophilous was not stored according to manufacturer's directions and the Insulin pen was not dated with an open date. 2. On 11/18/24 at 12:21 p.m., observation of Unit C's medication cart for rooms 1-20 with the Licensed Practical Nurse (LPN #1), the surveyor noted an opened bottle of Acidophilous with manufactures directions of refrigerate after opening. At this time, LPN #1 confirmed the Acidophilous was not stored according to manufacturer's directions.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 3 units ( units A, B and C). Finding: On 8/31/2023, at 1:50p.m, during a tour of the environment with the Facilities Manager, the following observations were made: A Unit - Resident 28's - Dresser drawer will not close B Unit - Dining Room - 2 ceiling lights over resident eating area, burned out. Hallway light covers outside of Dining Room have dead insects visible through cover. Overbed table in TV area has chipped surface. Metal three drawer cabinet outside of resident 28's room has chipped surface. Hallway overhead light between resident rooms 7/8 and 9/10 had dirt visible debris. Resident 7's has dirty overbed tray table Resident 8's nightstand has heavy amount of dirt and debris on drawers. C Unit - Resident 34 has a stained ceiling tile above resident's head along the curtain track. On 8/31/2023, the above findings were confirmed with the Facilities Manager at 2:20p.m.

Based on interview and record review, the facility failed to ensure a baseline care plan summary (developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare instructions necessary to properly care for the resident), was provided to the resident, and/or resident representative, for 1 of 2 residents sampled for care planning (#40). Finding: On 8/29/23 at 3:01 p.m., in an interview with a surveyor, Resident #40's family stated they were concerned that important information hadn't been shared upon the resident's admission. The family stated they did not receive a copy of Resident #40's baseline care plan and did not attend a care planning meeting until a couple weeks after admission. A review of Resident #40's clinical record noted an admission date of 2/15/23. A progress noted, dated 3/1/23, stated the plan of care was discussed at the interdisciplinary team meeting, in which the resident's family attended. On 8/31/23 at 10:45 a.m., in an interview with a surveyor, the Social Worker reviewed Resident #40's electronic record and confirmed the baseline care plan was not shared with Resident #40's family until 2 weeks after admission. On 8/31/23 at 10:50 a.m., the finding was discussed with the Director of Nursing.

Based on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, the participation of the resident after each assessment for 1 of 1 sampled residents (#25). Finding: On 8/28/23 at 9:44 a.m. during an interview, Resident #25 stated he/she did not recall going to care plan meetings. Record review show quarterly Minimum Date Set (MDS) 3.0 assessments dated 3/31/23 and 6/28/23. On 8/31/23 at 11:25 a.m., in an interview with a surveyor, the Social Worker reviewed Resident #25's clinical record and confirmed that the last IDT meeting was held on 4/06/23. There was a lack of evidence that Resident #25 had been invited or participated in the IDT. The Social Worker stated that the next IDT meeting was scheduled for 9/26/23. On 8/31/23 at 11:35 a.m., the finding was discussed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, and review of Material Safety Data Sheets (MSDS) the facility failed to ensure that the residents environment was free of accident hazards relating to a patient lift and a missing a safety clip for 1 of 3 days of survey (8/28/23), failed to ensure that smoking saftey assessments for 6 of 6 residents who smoke were completed (Residents #'s 8, 18, 25, 63, 74, and 85), and failed to ensure that wood working equipment and tools were properly secured for 3 of 4 days of survey (8/28/23, 8/29/23, and 8/30/23). Findings: 1. On 8/28/23 at 6:50 a.m. a surveyor observed an Viking XL patient lift on the B Unit that was missing a safety clip that secures the lift pad on the swing arm when in use, on the small bar. In an interview with C.N.A. #1, when asked about the lift, he stated it was usually used for heavier people. When asked when the last time he used the lift, he stated, I used it this morning. On 8/28/23 at 7:25 a.m., this finding was confirmed with Registered Nurse # 1. The lift was removed from patient use. On 8/28/23 at 11:08 a.m., this finding was discussed with the Director of Nursing. 2. On 8/28/23 at approximately 09:55 a.m., during an interview Resident #25 reported that he/she smokes. When asked where he/she went to smoke, Resident #25 stated he/she goes to the curve at the entrance and doesn't always feel safe due to traffic. Resident #25 stated residents are not allowed to smoke on the facility property. The facility provided a list that indicated the following residents #8, 18, 25, 63, 74, 85, are smokers. On 8/31/ 23 at 10:50 a.m. in an interview with two surveyors, Registered Nurse #2, she stated that the facility does not complete smoking assessments on residents that smoke. She reported that the residents that smoke have the smoking materials in their rooms. On 8/31/23 at 10:52 a.m. these findings were discussed with the Director of Nursing. She confirmed that the facility does not conduct smoking assessments on the residents that smoke. She stated that they ask residents to turn in smoking materials to staff, however they refuse. She also stated the facility bought smoking bibs, however, the residents refuse to wear them. 3. On 8/30/23 a surveyor observed an area on the B company that was in the dining room across the door to the unit kitchen area where food is prepared without a door. A table in this area was set up as a wood working station. There were various glues, wood filler, paints, screws and tools on the table including: Two bottles of Gorilla Glue Two bottles of wood glue Tubes of acrylic art paint Minwax Stainable wood filler Three Styrofoam cups filled with small/individual flip top paints A tool to open up cans of paint One hammer A clear plastic bag full of long screws Under the table there was a plastic milk crate that contained a real saw with blades, a tool bag, and various tools. There were three hammers hanging over the side of a milk crate. Another milkcrate contained 9 cans of various interior and exterior paints. To the side of the table there was shelving unit that contained small acrylic paint bottles A review of MSDS sheets was completed with the following noted: The MSDS for High Gloss Enamel Interior/Exterior Paint and Primer, Base C Section 2 Hazards Identification: Keep out of reach of children. Obtain special instructions before use. Do not handle until all safety precautions have been read and understood. Wear protective gloves protective clothing and eye or face protection. Do not breathe vapor. Do not eat, drink or smoke when using thing product. Store locked up WARNING: Adequate ventilation required when sanding or abrading the dried film. Section 4. First Aid Measures: Includes: Eye Contact: Immediately flus eyes with plenty of water, occasionally lifting the upper and lower eyelids, Check for and remove any contact lenses Continue to rinse for at least 10 minutes. Get medical attention. Inhalation: Remove victim to fresh air and keep in a position comfortable for breathing . Get medical attention Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes . Continue to rinse for at least 10 minutes. Get medical attention. Ingestion: Wash out mouth with water. Remove dentures if any. If material has been swallowed and the exposed person is conscious, give small quantities of water to drink. Stop if the exposed person feels sick as vomiting may be dangerous. Do not induce vomiting unless directed to do so by medical personnel . Get medical attention. Advice on general occupational hygiene: Eating, drinking and smoking should be prohibited where the material is handled, stored, and processed. Conditions for safe storage, including any incompatibilities: Store in original container protected from direct sunlight in a dry, cool and well-ventilated area away from incompatible materials and food and drink. The MSDS sheet for Ceiling Paint Flat Interior notes: Section 2 Hazards Identification: This material is considered hazardous by the OSHA Hazard Communication Standard Signal Word: Danger Precautionary Statements: General: Read label before use. Keep out of reach of children. Prevention: Obtain special instructions before use. Do not handle until all safety precautions have been read and understood. Wear protective gloves protective clothing and eye or face protection. Do not breathe vapor. Do not eat, drink or smoke when using thing product. WARNING: Adequate ventilation required when sanding or abrading the dried film. Section 4. First Aid Measures: Includes: Eye Contact: Immediately flush eyes with plenty of water, occasionally lifting the upper and lower eyelids, Check for and remove any contact lenses Continue to rinse for at least 10 minutes. Get medical attention. Inhalation: Remove victim to fresh air and keep in a position comfortable for breathing . Get medical attention. Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes . Continue to rinse for at least 10 minutes. Get medical attention. Ingestion: Wash out mouth with water. Remove dentures if any. If material has been swallowed and the exposed person is conscious, give small quantities of water to drink. Stop if the exposed person feels sick as vomiting may be dangerous. Do not induce vomiting unless directed to do so by medical personnel . Get medical attention. Section 7 Handling and Storage: Advice on general occupational hygiene: Eating, drinking and smoking should be prohibited where the material is handled, stored, and processed. Conditions for safe storage, including any incompatibilities: Store in original container protected from direct sunlight in a dry, cool and well-ventilated area away from incompatible materials and food and drink. The MSDS sheet for Titebond II Premium [NAME] Glue Section 4. First Aid Measures: Includes: Eye Contact: Immediately flush eyes with plenty of water, occasionally lifting the upper and lower eyelids, Check for and remove any contact lenses Continue to rinse for at least 10 minutes. Get medical attention. Inhalation: Remove victim to fresh air and keep in a position comfortable for breathing . Get medical attention if needed. Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes . Continue to rinse for at least 10 minutes. Get medical attention. Ingestion: Wash out mouth with water. Remove dentures if any. If material has been swallowed and the exposed person is conscious, give small quantities of water to drink. Do not induce vomiting unless directed to do so by medical personnel. Get medical attention if needed. Section 7 Handling and Storage: Advice on general occupational hygiene: Eating, drinking and smoking should be prohibited where the material is handled, stored, and processed. Conditions for safe storage, including any incompatibilities: Store in original container protected from direct sunlight in a dry, cool and well-ventilated area away from incompatible materials and food and drink. The MSDS sheet for Minwax Stainable [NAME] Filler Section 2 Hazards Identification: Read label before use. Keep out of reach of children. Section 4. First Aid Measures: Includes: Eye Contact: Immediately flush eyes with plenty of water, occasionally lifting the upper and lower eyelids, Check for and remove any contact lenses Continue to rinse for at least 10 minutes. Get medical attention if irritation occurs. Inhalation: Remove victim to fresh air and keep at rest in a position comfortable for breathing. Get medical attention if needed. Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes . Continue to rinse for at least 10 minutes. Get medical attention if symptoms occur. Ingestion: Wash out mouth with water. Remove dentures if any. If material has been swallowed and the exposed person is conscious, give small quantities of water to drink. Do not induce vomiting unless directed to do so by medical personnel. Get medical attention if symptoms needed. Advice on general occupational hygiene: Eating, drinking and smoking should be prohibited where the material is handled, stored, and processed. Conditions for safe storage, including any incompatibilities: Store in original container protected from direct sunlight in a dry, cool and well-ventilated area away from incompatible materials and food and drink. Conditions for safe storage, including any incompatibilities: Store in original container protected from direct sunlight in a dry, cool and well-ventilated area away from incompatible materials and food and drink. The Safety Data sheet for Original Gorilla Glue noted: Section 2: Hazard Identification: Harmful if inhaled, causes skin irritation, causes serious eye irritation, may cause allergy or asthma symptoms or breathing difficulties if inhaled, may cause an allergic skin reaction, may cause respiratory irritation, suspected of causing cancer. Signal Word: Danger Precautionary Statements: Keep out of reach of children. Do not breathe vapors, mist, or spray. If inhaled: Remove person to fresh air and keep at a rest position comfortable for breathing. If in eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Call a poison control center or doctor if you feel unwell. Section 7: Handling and Storage: Avoid breathing vapours. Use only outdoors or in a well-ventilated area. Do not handle until all safety precaution have been read and understood. Conditions for safe storage, including any incompatibilities: Store locked up. Store in a well ventilated place. Keep container tightly closed. The MSDS sheet for Royal Brush Acrylic noted: Section 4: First Aid Measures: Eye Contact: Quickly and gently blot material from eyes. Ingestion: If product is swallowed or gets in mouth do not induce vomiting; wash mouth with water [NAME] give some water to drink. If symptoms develop or if doubt contact a poisons information centre or a doctor. The MSDS sheet for Atelier Interactive Artists' Acrylic Paint noted: Section 4. First Aid Measures: Ingestion: Have affected person drink two glasses of water. Never give anything by mouth to an unconscious person. Inhalation: Inhalation of vapour may cause irritation; move to fresh air. If irritation persists, consult a physician. Eye Contact: Direct eye contact may cause slight irritation; flush eyes with large amounts of cool water. If irritation persists, consult a specialist. The MSDS sheet for Delta Ceramcoat Acrylic Craft Paint noted: Section 7: Handling and Storage: Good industrial hygiene practice requires that exposure be maintained beow the TLV. This is preferabley achieved through the provision of adequate ventilation. When exposure cannot be adequately controlled in this way, personal respiratory protection should be employed. The B Unit had 33 Residents at the time of survey. Of these 33 residents 13 residents had diagnoses including dementia, Alzheimer's, and mild cognitive impairment. On 8/31/23 at approximately 8:50 a.m. the Director of Nursing confirmed the above findings were accident hazards. The wood working equipment and tools were removed from the area.