Every finding on record at Pickett Care and Rehabilitation Center

Based on facility policy review, medical record review, observation, and interviews, the facility failed to provide foot care to one resident (Resident #41) of 4 residents reviewed for foot care. The findings include: Review of the facility's policy titled Nail Grooming, dated 7/24/2018, revealed .nursing staff will provide observation and care of nails for all residents daily and as necessary .care of toenails will be performed by a licensed nurse or podiatrist . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Dysphagia, and Difficulty in Walking. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Review of the comprehensive care plan initiated 5/25/2026, revealed .provide the amount of assistance resident needs for completion of ADL [activities of daily living] cares .encourage resident to float heels while in bed .inspect skin when repositioning, toileting, and assisting with ADLs . Review of a Nursing Progress Note dated 5/22/2026, revealed .toenails are thick and dark in color . Review of a document titled Total PODIATRY Appointments, dated 6/1/2026, revealed Resident #41 was not on the list for podiatry services on 6/3/2026. During an observation on 6/16/2026 at 9:39 AM, revealed Resident #41 had very thick, yellow and brown toenails. The fourth and fifth toes of the resident's right foot had a brownish black substance caked under the toenails and the third toe of the resident's right foot appeared to have a hole in the nail. During an interview on 6/17/2026 at 4:00 PM, the Director of Nursing (DON) stated any member of nursing staff can make a referral for podiatry services. She further stated the Social Services Director (SSD) was responsible for adding residents to the podiatry list. The DON confirmed Resident #41 was not on the list for podiatry services on 6/3/2026. During an interview on 6/17/2026 at 4:29 PM, the SSD stated she is able to add residents to the podiatry list up until the day before the services are administered. SSD confirmed Resident #41 was not added to the podiatry list for 6/3/2026. During an interview on 6/17/2026 at 4:59 PM, the SSD stated she made the referral on 6/17/2026 for Resident #41 to receive podiatry services.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to properly store and secure medications for 2 residents (Resident #51 and Resident #18) of 14 residents reviewed for medication storage. Review of the facility's policy titled Medication Storage, dated 1/2025, revealed .the medication supply shall be accessible only to licensed nursing personal, pharmacy personnel, or staff members lawfully authorized to administer medications .this may include such containers as medication carts, medication rooms, medication cabinets . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, and Anxiety Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Medication Administration Record (MAR) dated 6/1/2026 – 6/15/2026, revealed Resident #51 was prescribed Triamcinolone Acetonide Cream 0.1% (percent) topical as needed for itching and dry skin and had not had an application of the medication. Review of the Physician Recapitulation Orders dated 6/17/2026, revealed Triamcinolone Acetonide Cream 0.1% (percent) topical as needed for itching and dry skin. During an observation and interview on 6/15/2026 at 2:29 PM, in Resident #51's room revealed a 1-pound container of Hydrocortisone Ointment 2.5% on the bedside table. The resident stated the container was not his. Resident #51 further stated the ointment had not been applied to his skin. During an observation and interview on 6/15/2026 at 3:50 PM, Registered Nurse (RN) C entered Resident #51's room and observed the container of Hydrocortisone Ointment 2.5% on the bedside table and stated, .I didn't know that was there . RN C confirmed Resident #51 the medication had not been stored properly. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Intervertebral Disc Degeneration. Review of a quarterly MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact. Review of Physician's Orders for Resident #18 revealed, .apply nystatin [antifungal powder] under bil [bilateral] breast q [each] shift . During an observation on 6/15/2026 at 2:30 PM, revealed a bottle of antifungal powder on Resident #18's bedside table. During an observation on 6/16/2026 at 9:16 AM, revealed a bottle of antifungal powder on Resident #18's bedside table. During an interview on 6/17/2026 at 3:31 PM, Registered Nurse D stated she was unaware Resident #18 had antifungal powder at her bedside. During an interview on 6/17/2026 at 3:40 PM, the Director of Nursing (DON) confirmed Resident #18 had antifungal powder at her bedside. During an interview on 6/17/2026 at 3:52 PM, the DON confirmed the medications had been at bedside for Resident #51 and Resident #18 and should not have been there. The DON stated the expectation was for the staff to properly store medications in the appropriate location under lock and key.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow infection control practices for 1 resident (Resident #13) of 3 residents reviewed. The findings include: Review of the facility's policy titled, Transmission Based Precautions, dated 1/31/2025, revealed .Transmission-Based Precautions [TBP] are initiated when a resident develops signs and symptoms of an infection or has laboratory confirmed infection .is at risk for transmitting the infection to another resident .meets criteria .has risk factors that increase the likelihood of transmission .may include .uncontained secretions .cognitive deficits that restrict or interfere with the residents ability to maintain precautions .The signage informs the staff of the type of CDC [Centers for Disease Control] precautions, instructions for use of PPE [Personal Protective Equipment] .before entering the room .Transmission-Based Precautions remain in effect until .criteria for discontinuation are met .Review of the facility's policy titled, Infection Control, dated 1/30/2026, revealed .Facility infection control practices are intended to facilitate maintaining a safe .environment .to help prevent and manage transmission of disease and infections .Facility infection control policies and practices apply equally to all personnel .establish guidelines .including Transmission-Based Precautions . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Osteoporosis, and Urinary Tract Infection.Review of a Urine Culture dated 2/3/2026, revealed .Organism 1 .Klebsiella Pneumonia, ESBL [Extended-Spectrum Beta Lactamases] .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident was incontinent of urine and independent with toileting and mobility. Review of a Urine Culture dated 5/15/2026, revealed .Klebsiella Pneumonia .Review of a Urine Culture dated 6/8/2026, revealed .Proteus Mirabilis, ESBL .Review of a Physician Order dated 6/8/2026, revealed .Ertapenem [an anti-infective agent, antibacterial, and Beta Lactam Antibiotic] injection 1 gram every day x 7 days for ESBL .Review of the Medication Administration Record (MAR) dated 6/8/2026 - 6/16/2026, for Resident #13 revealed the resident received Ertapenem reconstituted solution 1 Gram injection on 6/8/2026, 6/9/2026, 6/10/2026, 6/11/2026, 6/12/2026, 6/13/2026, 6/14/2026, 6/15/2026 at HS (hour of sleep). Further review revealed the medication stop date was 6/15/2026 at HS.Review of a Physician Order dated 6/9/2026, revealed .Contact precautions for ESBL .Start date 6/9/2026 .End Date 6/15/2026 at 1:35 AM.Review of the comprehensive care plan dated 6/9/2026, revealed Resident #13 had .Contact precautions related to ESBL .PPE .as indicated .During an observation on 6/15/2026 at 11:01 AM in front of Resident #13's room Contact Precaution signage underneath the room number with an indicator of Bed B. The signage indicated, .CONTACT PRECAUTIONS EVERYONE MUST: Put on gloves before room entry .Put on gown before room entry . Further observation revealed PPE was available hanging in a carrier on the outside of the door. During an observation and Interview on 6/15/2026 at 12:15 PM, in front of Resident #13's room, revealed Contact Precaution signage underneath the room number with an indicator of Bed B. The signage indicated, .CONTACT PRECAUTIONS EVERYONE MUST: Put on gloves before room entry .Put on gown before room entry . Further observation revealed PPE was available hanging in a carrier on the outside of the door. Housekeeper A entered the room with laundry, opened the closet door, placed the laundry in the B bed closet, and exited the room. The housekeeper stated she did not have to wear PPE for residents on Contact precautions, .I was only dropping off laundry and only have to wear it if I am touching the resident . The Housekeeper stated there was no difference between a resident on Enhanced Barrier Precaution (EBP) and Contact precautions because she does not provide high contact activities.During an observation on 6/15/2026 at 12:21 PM in front of Resident #13's room revealed Contact Precaution signage underneath the room number with an indicator of Bed B. The signage indicated, .CONTACT PRECAUTIONS EVERYONE MUST: Put on gloves before room entry .Put on gown before room entry . Further observation revealed PPE was available hanging in a carrier on the outside of the door. CNA A entered Resident #13's room to bring the resident ice. CNA A left the ice cart outside of the resident's room, filled a cup of ice and placed it on Resident #13's (Bed B) bedside table. CNA A stated she did not have to use PPE when entering a contact precaution room because she was not providing direct care. CNA A stated there was no difference between EBP and Contact precautions.During an interview on 6/15/2026 at 12:26 PM, in front of Resident #13's room revealed Contact Precaution signage underneath the room number with an indicator of Bed B. The signage indicated, .CONTACT PRECAUTIONS EVERYONE MUST: Put on gloves before room entry .Put on gown before room entry . Further observation revealed PPE was available hanging in a carrier on the outside of the door. CNA A and CNA B both stated they were not sure what the PPE differences were between EBP and Contact precautions.During an interview on 6/15/2026 at 12:35 PM, CNA A and CNA B returned and stated they only needed to wear PPE for high contact activities regardless of whether the resident is on EBP or Contact precautions. During an observation on 6/15/2026 at 12:40 PM, in front of Resident #13's room revealed Contact Precaution signage underneath the room number with an indicator of Bed B. The signage indicated, .CONTACT PRECAUTIONS EVERYONE MUST: Put on gloves before room entry .Put on gown before room entry . Further observation revealed PPE was available hanging in a carrier on the outside of the door. The Social Service Director (SSD) pulled a meal tray off the cart and entered the room. The SSD moved items from Resident #13's (B bed) bedside table and placed the tray on the table and exited the room. The SSD had not donned appropriate PPE prior to entering the room. The SSD confirmed she did not don PPE before entering the room. During an interview on 6/15/2026 at 12:55 PM, The Infection Preventionist Licensed Practical Nurse (IPLPN) stated the expectation was for the staff to wear appropriate PPE when entering rooms of residents who are on EBP and Contact precautions. The IPLPN confirmed the observations of staff entering Resident #13's room without wearing appropriate PPE.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews the facility failed to ensure MDS assessments were accurately coded for 1 resident (Resident #37) of 16 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, revised 3/18/2025, revealed .SECTION I .The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .This section identifies active diseases and infections that drive the current plan of care .ACTIVE DIAGNOSES .Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring .Nursing Monitoring includes clinical monitoring by a licensed nurse . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of a Pre-Admission Screening and Resident Review (PASRR) dated 12/14/2022, revealed Resident #37 had a Level 2 outcome related to a serious mental illness with diagnoses which included Post Traumatic Stress Disorder (PTSD), Anxiety, and Major Depressive Disorder. Further review of the PASRR Level 2 outcome revealed .The following specialized services should be provided to you .Someone with expertise in prescribing and monitoring psychiatric medications should continue to follow up with you to ensure your current medication regimen continues to be helpful .The following supports should be provided to you .You should be encouraged to engage .in various activities with others to improve social skills .You should be provided person-centered care to improve or maintain your functional ability so you can achieve your highest level of well-being possible .Staff should monitor your moods and behaviors closely and immediately report any changes to your care provider . Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for crying and social isolation. Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for making false accusations. Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for obsessive thoughts. Review of a Physician's order dated 9/12/2024, revealed .diazepam .5mg .given for anxiety .1 tablet .[twice a day] .[as needed] . Continued review revealed the medication continued to be active for the diagnoses of Anxiety. Review of Psychiatric Nurse Practitioner note dated 1/8/2025, revealed Resident #37 refused medications for depression and had a past medical history of PTSD. Further review of the Nurse Practitioner note dated 1/8/2025, revealed the resident had an active diagnosis of Anxiety and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident #37 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review of the quarterly MDS assessment revealed the resident did not have an active diagnoses of PTSD, Anxiety, or Depression documented. Review of the comprehensive care plan for Resident #37 revised 2/11/2025, revealed the residents' plan of care included goals and interventions for PTSD, Anxiety, and Depression. Further review of the comprehensive care plan revealed Resident #37 would give false information and tell stories that would later be deemed false with appropriate goals and interventions implemented. During an interview on 4/9/2025 at 2:44 PM, MDS Licensed Practical Nurse (LPN) E stated the diagnoses of Anxiety, and Depression would only be considered active if the resident received medications for the diagnoses. When asked if PTSD, Anxiety, and Depression would be considered an active diagnosis if the resident had a Level 2 PASRR and the facility was providing nonpharmacological interventions recommended in the PASRR for the treatment of those diagnoses, the MDS LPN stated No. During further interview the MDS LPN stated the diagnoses of PTSD, Anxiety, and Depression were in the residents medical record but were not active diagnoses. When asked if a significant change MDS or Significant Change PASRR should have been submitted related to multiple previous psychiatric diagnoses that were determined to be inactive by the facility, MDS LPN E stated No. MDS LPN E stated she did not not submit PASRRs to the state designated authority. During an interview on 4/9/2025 at 3:00 PM, the Clinical Reimbursement Specialist (CRS) stated the resident's diagnoses of PTSD, Anxiety, and Depression were not active diagnoses. The CRS further stated the nurses monitoring Resident #37 for behaviors (crying, social isolation, and making false stories) would not be considered monitoring for PTSD, Anxiety, or Depression.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASSR) timely after a new mental health diagnosis was added for 1 resident (Resident #5) of 7 residents reviewed for PASSR. The findings include: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASSR), revised 9/15/2023, revealed .PASSR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASSR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings .3. An individual is considered to have a serious mental illness if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders .A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability .Guidelines for Determining When A Significant Change Should Result in Referral for a PASSR Level II Evaluation: If a significant change in status assessment (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition .a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority for possible Level II PASSR evaluation must promptly occur as required .Referral should be made as soon as the criteria indicating such are evident-the facility should not wait until the SCSA is complete . Review of a PASARR Level 1 screen for Resident #5 dated 8/14/2023, revealed the resident had 2 mental health diagnoses which included Dementia and Depressive Disorder. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with a mental health diagnosis of Depression. Continued review revealed Resident #5 had been diagnosed with Generalized Anxiety Disorder on 7/28/2023 and with Bipolar Disorder, current episode manic without psychotic features, on 9/14/2023. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 1/9/2025, revealed Resident #5 had active diagnoses which included Depression and Bipolar Disorder. Continued review revealed Resident #5 had received Antipsychotic and Antidepressant medications. Review of the Comprehensive Care Plan revised on 1/22/2025 revealed Resident #5 had been care planned for Depression, Bipolar Disorder, and Anxiety. Review of a Psychiatry Progress Note, dated 3/19/2025, revealed Resident #5 had been referred to psychiatric services due to diagnoses which included Bipolar Disorder with Depression. Review of the medical record revealed a new PASARR for Resident #5 was not submitted after the new mental health diagnosis of Bipolar Disorder was added on 9/14/2023. During a record review and interview on 4/9/2025 at 2:48 PM, the Administrator stated it was his expectation that a new PASARR was to be completed after a new mental health diagnoses was added. The Administrator confirmed the facility failed to resubmit a new PASSR for Resident #5 to the state designated authority a new mental health diagnoses was added and identified by the facility.

Based on facility policy review, observations, and interviews the facility failed to label and store 1 prefilled insulin syringe on 1 medication cart of 2 medication carts observed for medication storage. The findings include: Review of the facility's policy titled, Medication Storage Storage of Medication, dated 1/2025, revealed .Insulin products should be stored in the refrigerator until opened .Note the date on the label for insulin vials and pens when first used .opened insulin pens should be stored at room temperature .Refer to specific product labeling for additional detail . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of a Physician's order dated 11/1/2024, revealed Resident #37 had a physician's order for a prefilled Semaglutide insulin pen to be administered once a week on Thursdays. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident #37 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 4/8/2025 at 8:10 AM, revealed a prefilled 3 milliliter (mL) Semaglutide insulin pen for Resident #37 stored on the Hope medication cart. Observation of the insulin pen revealed the packaging was opened, and the insulin pen was full indicating the pen had not been used. Further observation of the insulin pen packaging revealed .Boxed Warning .Refrigerate until opened .then store at room temperature .Date Opened . The insulin pen was not labeled with a date it was opened, indicating the pen should be stored in refrigeration. During an observation and interview on 4/8/2025 at 8:15 AM, Registered Nurse (RN) D observed the Semaglutide insulin pen and stated the insulin pen was full, unopened, and was not labeled with an open date or date the pen was removed from refrigeration. During further interview the RN stated she accepted the cart that morning and was unsure how long the insulin pen was on the cart and had been left out of refrigeration. The RN also stated the medication was available for resident use and confirmed the medication was not stored or labeled correctly. During an interview on 4/9/2025 at 2:07 PM, the Director of Nursing (DON) stated the Semaglutide insulin pen was stored on the medication cart and was available for resident use. During further interview the DON confirmed the Semaglutide pen was not labeled or stored correctly.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 2 dumpsters. The findings include: Review of the facility's undated policy titled, Dispose of Garbage and Refuse, revealed, .All garbage and refuse will be collected and disposed of in a safe and efficient manner .The Dining Services Director coordinates with the Director of Maintenance to ensure .the exterior dumpster area is maintained . During an observation of the outside dumpster area on 4/7/2025 at 11:20 AM, revealed the facility had 2 dumpsters. Continued observation revealed dumpster #2 did not have a dumpster plug in place and secured. During an interview on 4/7/2025 at 11:25 AM, the Dietary Manager (DM) confirmed the dumpster plug for dumpster #2 was missing, and a plug should be in place.

Based medical record review, facility assessment review, and interview the facility failed to ensure the facility assessment was accurate to include residents with a diagnosis of PTSD. The findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of the Facility assessment dated 2025, revealed .Assessment Period January 1 through December 31, 2024 .determine what resources are necessary to care for the facility's residents competently during both day-to-day operations and emergencies .discuss and document any diagnoses or special condition likely to be cared for in the coming year, care and services provided to meet the identified needs of the residents .Resident Population .Category .Psychiatric/Mood Disorders .Common diagnoses .Impaired Cognition . Further review of the 2025 facility assessment revealed residents with PTSD was not included in the resident population. During an interview on 4/9/2025 at 2:53 PM, the Administrator stated at the time of the facility assessment period, the facility had a resident with PTSD who received facility services for PTSD. The Administrator confirmed the facility provided service to residents with the diagnosis of PTSD and confirmed the facility assessment did not include the resident population with diagnoses of PTSD.

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to wear appropriate Personal Protective Equipment (PPE) when in the room for 3 residents (Resident #9, #2, and #57) of 16 residents reviewed for Infection Control. The findings include: Review of the facility's policy titled, Viral Respiratory Pathogens, dated 2/22/2025, revealed .guidelines are intended to ensure a comprehensive and effective response to respiratory illness outbreaks .PPE includes but is not limited to masks, gowns, gloves and eye protection .used as source control during outbreak situations .infection control policies and guidelines will be followed . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Cognitive Impairment, Cough, Need for Assistance with Personal Care, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Physician's order dated 4/2/2025, revealed Resident #9 was on isolation droplet precautions with a stop date of 4/12/2025. Review of a comprehensive care plan dated 4/3/2025, revealed Resident #9 had an active Coronavirus Disease 2019 (COVID-19) infection and the resident was on droplet isolation precautions with staff to wear PPE as indicated. During an observation and interview on 4/7/2025 at 1:00 PM, Certified Nursing Assistant (CNA) B was observed entering Resident #9's room wearing a gown, a mask, and gloves. Further observation revealed the CNA entered the room without eye protection. CNA B confirmed Resident #9 was on isolation for COVID-19 and did not wear eye protection. During an observation on 4/7/2025 at 3:00 PM, Resident #9 had a sign on the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Further observation of the signage revealed people entering the room were to wear a face shield or safety glasses. During an observation and interview on 4/8/2025, CNA C was observed entering Resident #9's room wearing a gown, a mask, and gloves. Further observation revealed the CNA entered the room without eye protection. CNA C confirmed Resident #9 was on isolation for COVID-19 and did not wear eye protection. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with readmission on 1/4/2022 with diagnoses including Rheumatoid Arthritis, Diabetes Mellitus, Alzheimer's Disease, Anxiety, and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan dated 3/31/2025, revealed Resident #2 had been care planned for .Infection Control .Resident has an active infection: positive COVID-19 . Review of the Physician Order Report for Resident #2 dated 4/1/2025-4/30/2025, revealed orders .COVID-19 (+) Positive diagnosis monitoring symptom(s) .Isolation Droplet Precautions (COVID-19) . with a start date of 3/31/2025 and end date of 4/10/2025. Review of a Nurse Practitioner Progress note dated 4/2/2025, revealed Resident #2 was .seen today after testing positive for COVID-19 .She was started on [anti-viral medication] and placed in isolation . Review of a nursing progress note dated 4/7/2025 at 11:59 AM, revealed Resident #2 .Continues to be on isolation precaution's for Covid positive . Continued review of a nursing progress note dated 4/8/2025 at 10:21 AM, revealed Resident #2 .Continues to be on isolation precaution's for positive COVID . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Diabetes Mellitus, Dementia, and Generalized Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #51 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Comprehensive Care Plan dated 3/30/2025, revealed Resident #51 had been care planned for .Infection Control .Resident has an active infection: positive COVID-19 . Review of the Physician Order Report for Resident #51 dated 4/1/2025-4/30/2025, revealed orders .COVID-19 (+) Positive diagnosis monitoring symptom(s) .Isolation Droplet Precautions (COVID-19) . with a start date of 3/30/2025 and end date of 4/9/2025. Review of a nursing progress note dated 4/7/2025 at 7:30 AM, revealed Resident #51 .continues to be on contact/droplet precautions . Continued review of a nursing progress note dated 4/8/2025 at 10:22 AM, revealed Resident #51 .Continues to be on isolation precaution's from positive COVID . During an observation on 4/7/2025 at 12:42 PM, revealed isolation signage posted outside of Resident #2 and Resident #51's door which stated that a gown, gloves, mask, and eye protection must be worn by everyone when entering room. Continued observation revealed CNA A entered the room wearing only a gown, gloves, and mask. No eye protection was utilized. During an interview on 4/8/2025 at 3:30 PM, the Infection Preventionist stated if a resident was on droplet precautions or had COVID-19, the staff were expected to wear face shields or eye goggles with other PPE every time they entered the room. During further interview the Infection Preventionist confirmed the facility failed to follow infection control guidelines for Residents #9, #2, and #57.

Based on facility policy review, medical record review, and interview, the facility failed to provide timely notification to the Power of Attorney and/or resident representative for 1 Resident (Resident #2) of a significant change in condition of 3 residents reviewed for notification, when Resident #2 had a significant mental status change which required a onetime injection of an antipsychotic medication. The findings include: Review of a facility policy titled, Notification of Change of Condition, revised 9/15/2023, revealed .to ensure appropriate individuals are notified of changes in condition .the facility must inform the resident, consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment significantly . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Idiopathic Gout, Diabetes Mellitus, Protein-Calorie Malnutrition, Dementia without Behavioral Disturbance, Anxiety Disorder, Urinary Tract Infection, Dysphagia, and Depressive Episodes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. No behaviors were noted during the assessment period. Review of the Nurse's Note for Resident #2 dated 10/25/2024 at 8:00 PM, revealed .Elder is up in hallway trying to enter other resident rooms stating, 'This is my room and I'm going in it.' Redirection from CNA [Certified Nursing Assistant] [CNA F] (1 on 1 with another elder) unsuccessful. Elder kicking and hitting at CNA [F] and trying to run her over with walker. CNA [G] then tries to deescalate situation and calm elder, elder also attempting to hit, kick and run over [CNA G] at this time. LPN [Licensed Practical Nurse] [LPN H] stated to this nurse when I entered into the nurses' station '[Medical Director] ordered a verbal one-time injection of Haldol r/t [related to] elders' behaviors.' This nurse and all staff fearful of elders' behavior towards staff and other elders. [LPN E] pulled Haldol injection to administer to elder. Elder being monitored by CNA [F] from 1 on 1 in elder's room . Review of the Nurse's Note for Resident #2 dated 10/26/2024 at 7:41 AM, revealed .Elder's son notified of last night's events. Son verbalized understanding with no questions at this time . During an interview on 2/10/2025 at 1:15 PM, the Director of Nursing (DON) stated .[Resident #2] did have an episode on 10/25/2024, with increased agitation, unable to be redirected, going into other resident rooms and attempting to remove the cover off one resident and attempting to remove other resident belongs .[the Medical Director] was in the facility and gave a onetime order for Haldol [antipsychotic medication] 5 mg [milligram] IM [intramuscular]. However, the family was not notified until the follow morning. With any significant change my [DON] expectation is that the family is notified as soon as the resident is safe. In this circumstance, if at all possible, I would have expected the family to be notified prior to the Haldol injection or as soon as possible after the injection which was not done .

Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to prevent misappropriation of property for 1 resident (Resident #9) of 6 residents reviewed for misappropriation of resident property. The facility was cited at F-602 at a Scope and Severity of D and was cited as past non-compliance. Noncompliance began on 4/10/2024, was corrected and ended on 4/12/2024. The facility is not required to submit a Plan of Correction for F-602. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .it is the organization's intention to prevent the occurrence of abuse . misappropriation of resident property .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Acute Kidney Failure, Nondisplaced Articular Fracture of Right Femur Methicillin Resistant Staphylococcus Aureus Infection, Osteopetrosis, Extended Spectrum Beta Lactamase (ESBL), Depressive Disorder, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Medication Administration Record (MAR) for Resident #9 dated 4/1/2024-4/30/2024, revealed Lasix 80 mg twice daily for edema, the medication was documented as administered as ordered. Review of the Physician's Note for Resident #9 dated 4/10/2024, revealed .asked to see and evaluate patient after a member of the nursing staff had taken some of the patient's Lasix out of her medication drawer. As far as the patient is aware however, she has not missed any medication doses. She takes this for peripheral edema. She denies any increased edema, dyspnea, or other complaints related to this. Upon chart review there is no history of CHF [congestive heart failure] but she does have a h/o [history of] neurogenic bladder and this intermittent edema may be nephrogenic in etiology .Peripheral edema appears euvolemic [having a normal amount of fluid in the body] at this time without any obvious adverse effects from the medication incident described . Review of a facility investigation dated 4/10/2024, revealed Resident #9 stated that as far as she knew she had never missed any doses of medication. Licensed Practical Nurse (LPN) C was suspended pending the investigation of alleged misappropriation of medication (Lasix). Resident #9 experienced no adverse effects per assessments. The facility substantiated the incident. The staff member was terminated During an interview on 2/5/2025 at 8:33 PM, LPN C stated .I was working several 12 hour and 16 shifts, there was a card of Lasix on in the bottom drawer [of the medication cart] the name had been torn off. I knew with no name we could not return it to the pharmacy without a name. My judgement was clouded, my father had been sick and lost his insurance he had suffered from CHF [congestive heart failure], he was getting blisters from all the fluid retention. I took two of the Lasix pills out of the card and put them in my pocket I put the card in my purse to dispose of later take it up front to the box that goes back to pharmacy .some pills were already missing from the card and there were some left on the card but I couldn't go through with it my conscience was eating at me .the nurse on the other hall was a newer nurse and she asked me to help her with a fall while I was helping her she asked me If I had anything for cramps or tampons, I told her yes in my purse. She went to look and that is when she saw the card [medication card containing the Lasix] that was somewhere around 1:00 or 2:00 AM [on 4/10/2024], That is when I guess she called whoever I didn't know she had seen it until the investigation. I did not leave the building with the card I put it in the shred box after I realized we couldn't get reimbursed because the name was torn off .I put the 2 pills in the sharp's container. I never left with any of the medication I just couldn't do it . During an interview on 2/5/2025 at 9:15 AM, the DON stated .[LPN D] called me around 5:00 AM [on 4/10/2024], and reported that she saw a pill card .in LPN C's bag [DON] notified the Administrator, and we came to the facility unannounced around 6:00 AM and spoke with LPN D. Requested her to do a witness statement as to what she saw then we approached [LPN C] and asked her. She [LPN C] originally denied the allegation .we [the Administrator and the DON] checked the shred it box. We found the pill card and the name label detached from the pill card in the shred box .we again ask [asked] LPN C about the medication, at that time she did state she had taken the card from the medication cart removed two of the pills for her dad she put the card in her purse .We checked the nurse's station where she was working including the shred it box and found the pill card minus the top part containing resident and medication information. We went through the shred it box to see if I could find the label and did not find it there. We then checked a different nurse's station she had worked on previously a couple of nights before and found the top of the medication card containing medication and resident information in that shred box. We then asked her about it that is when she said she had taken it and was going to use it for her dad. We suspended her during the investigation notified the pharmacy requested the medication replacement notified the Elder and her Spouse, and the MD [Medical Doctor] from what I gathered from what she [LPN C] told us is that she had removed the medication card containing the 80 mg Lasix removed 2 pills and then returned the card to the facility for disposal .I did count from the delivery date of 3/24/2024 to 4/10/2024 to see if it matched and the card was 2 pills off .we did substantiate misappropriation of resident property .she was terminated on 4/12/2024 . During an interview on 2/5/2025 at 10:08 AM, LPN D stated .I was working 3:00 AM to 7:00 AM. I went over to speak with [LPN C], she had gotten some tarot cards and told me they were cute to go look at them they are in my purse. I opened her purse, and I saw the pill card [medication card containing the Lasix]. I called the [Administrator] around 5:00 AM, my call did not go through the Administrator called me back at 5:12 AM. I Had another call from the Administrator at 5:40 AM, he was in route I think he got to the facility about 6:00 AM . During an interview on 2/6/2025 at 1:00 PM, the Medical Director stated .I saw [Resident #9] and assessed her, there was no physical evidence of any harm or any kind of distress. She reported not being aware of missing any of her medications. There was no evidence of any psychosocial changes in her behavior or any harm . The surveyor validated on site facility interventions and plan of correction as follows: Review of a facility investigation dated 4/10/2024, revealed the allegation was reported to the Nurse Licensure Board. Resident #9 stated that as far as she knew she had never missed mediation when needed. No staff or residents reported any concerns of misappropriation. Licensed Practical Nurse (LPN) C, Alleged Perpetrator (AP) was suspended following the allegation of the misappropriation of medication. Residents with a BIMS score of 8 or above were interviewed with no concerns. Residents with a BIMS score of 7 or below had complete head to toe physical assessments completed with no concerns. Staff working with the alleged perpetrator LPN C for the previous 30 days were interviewed with no concerns. Resident #9 was care planned previously for non-compliance with physician's orders. Resident #9 experienced no adverse effects per assessments. MD assessed and interviewed Resident #9. The facility substantiated the incident. The staff member was terminated. Staff educated and tested on misappropriation. Nursing staff and Medication Technician educated on medication disposal and drug diversion. Ongoing audits were initiated to mitigate misappropriation. On 2/12/2025 the surveyor reviewed the signed verification audits for each medication cart, 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. On 2/12/2025 the surveyor reviewed the signed verification audit Medication Administration Record Card Audit , 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. Reviewed signed verification audits for 4/10/2024-6/7/2024. On 2/12/2025 reviewed Pharmacy Delivery Manifests for affected resident validating delivery of resident's Lasix 80 mg on 3/1/2024, 3/24/2024, and 4/10/2024 60 count delivery manifests were signed by the nurse receiving the medications. On 2/12/2025 the surveyor reviewed the facility pharmacy statement validating the facility was billed for 18 80 mg Lasix for the affected resident. Interview with the DON confirmed 1 Lasix had been identified as unaccountable but to keep the medication card as evidence the facility had replace all 18 80 mg Lasix. On 2/12/2025 the surveyor reviewed the medical record confirming documentation of Resident notification. Reviewed the Physician's progress note dated 4/11/2024. On 2/12/2025 the surveyor reviewed the facility's submission form to the Tennessee Board of Nursing dated 4/10/2024. Interview with the Administrator validated communication with the Board or receipt and of completion of investigation. On 2/12/2024 the surveyor reviewed the facility self-report validating notification to the law enforcement, APS and the Ombudsman. On 2/12/2025 the surveyor reviewed the signed MAR card audit for all residents. , 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. On 2/12/2025 the surveyor Reviewed skin assessments and resident interview compared to resident roster. On 2/12/2025 the surveyor reviewed education for the abuse policy with emphasis on misappropriation of property completed on 4/11/2024. Staff signatures were compared to staff roster. Interviews conducted with 2 Registered Nurses, 2 Licensed Practical Nurses, 5 Certified Nursing Assistances 2 Activity Personnel, 2 Dietary Personnel, 2 Housekeeping Personnel, and 1 Therapy Personnel. All interviewed staff were knowledgeable of the abuse policy and misappropriation of property 100% of staff educated. On 2/12/2025 the surveyor reviewed education provided to all nursing staff and Qualified Medication Aide (QMA) validated with attendance signatures, staff roster and interview with 1 QMA, 2 RN, and 2 LPNs. Interviewed staff knowledgeable of disposal of medications when and where. On 2/12/2025 the surveyor reviewed the pharmacy refill audits conducted Monday-Friday dated 4/12/2024-2/10/2025. Validated with interview with the DON. On 2/12/2025 the surveyor reviewed the signed MAR Card Audits for 4/10/2024-6/7/2024. On 2/12/2025 the surveyor reviewed Ad Hoc minutes for 4/11/2024 for content and attendance. On 2/12/2025 the surveyor reviewed Ad Hoc minutes for 4/18/2024, 4/26/2024, 5/3/2024, 5/3/2024, 5/10/2024, 5/17/2024, 5/24/2024, 5/31/2024, and 6/7/2024 for content and attendance. On 2/12/2025 the surveyor interviewed 2 family representatives with attention to concerns for abuse or neglect, resident rights, resident protection, notification of changes in condition, administration, staffing, nursing services, medication administration, access to clinical services, or unresolved grievances with no concerns identified. During an interview on 2/12/2025 AT 11:55 the DON stated .education is provided to new hires during orientation, I call if an employee is on leave, vacation, or leave, otherwise the education is provided prior to their next shift. The facility was cited F-602 as past non-compliance and surveyor verified and validated the corrective actions on site on 2/12/2025. The facility is not required to submit a Plan of Correction.

Based on facility policy review, medical record review, and interview the facility improperly placed 1 of 2 (Resident #9) sampled residents on droplet transmission based precautions. The findings include: Review of the facility policy titled, Resident Rights revised 8/16/2018, revealed .Refuse transfer from a distinct part within institution . Review of the guidance titled, Centers for Disease Control and Prevention: Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities dated 9/6/2021, revealed .In most circumstances, quarantine is not recommended for unvaccinated residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with [CONDITION(S)]-CoV-2 infection. Quarantining residents who regularly leave the facility for medical appointments (e.g., [CONDITION(S)], [CONDITION(S)]) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine . Review of the facility policy titled, Novel Coronavirus (COVID-19) revised 10/28/2021, revealed .Unless otherwise defined by local, state or federal guidelines, qurantine is not recommened for unvaccinated residents who leave the facility for less than 24 hours (medical appoinments, community outings with family, etc.) and do not have close contact with someone with COVID-19 . Review of the facility policy titled, Novel Coronavirus (COVID-19) revised 11/15/2021, revealed .Unless otherwise defined by local, state or federal guidelines, qurantine is not recommened for unvaccinated residents who leave the facility for less than 24 hours (medical appoinments, community outings with family, etc.) and do not have close contact with someone with COVID-19 . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the physician orders dated 11/03/2021 to 11/17/2021, revealed .isolation r/t [related to] non vaccination . Observation of the door on 11/15/2021 to 11/17/2021, revealed signage for droplet precautions and PPE (personal protective equipment) outside of Resident #9's door. During an interview on 11/16/2021 at 10:07 AM, Resident #9 stated she was unvaccinated for COVID-19 and had gone out to eat with family. When Resident #9 returned to the facility she was placed on qurantine for 14 days. Further interview revealed Resident #9 had not been in contact with anyone with COVID-19 and had adhered to wearing a mask in public. During an interview on 11/17/2021 at 1:45 PM, Licensed Practical Nurse (LPN) #2 also known as the Unit Manager stated she confirmed the facility was following its policy at the time when Resident #9 was placed on droplet transmission based precautions. During an interview on 11/17/2021 at 4:00 PM, the Infection Preventionist confirmed Resident #9 did not stay overnight during the family outing and did not show signs and symptoms of COVID-19. Continued interview revealed the positivity rate was high and the facility felt they had to perform all the precautions for a resident upon return to the facility. During an interview on 11/17/2021 at 7:14 PM, the Interim Director of Nursing (IDON) confirmed the facility was following their policies provided by the corporate administration. During an interview on 11/17/2021 at 7:24 PM, the Administrator confirmed if the facility had the policy updates Resident #9 would not have gone into qurantine after coming from a family outing.

Based on facility policy review, medical record review, and interview the facility failed to revise 1 of 31 (Resident #62) sampled residents for comprehensive care plans. The findings include: Review of the facility policy titled, Comprehensive Care Plans revised [DATE], revealed .Care plans are ongoing and revised as information about the resident and the residents's condition change . Review of the medical record revealed Resident #62 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 died in the facility on [DATE]. Review of the Discharge orders dated [DATE], revealed comfort measures for Resident #62. Review of the Care Plan revised [DATE], revealed no problems or interventions for comfort measure related to Resident #62. During an interview on [DATE] at 4:18 PM, Licensed Practical Nurse (LPN) #2 also known as the Unit Manager confirmed she did not see comfort measures on the comprehensive care plan for Resident #62. Further interview confirmed the nurses were responsible for reviewing and updating the care plans. During an interview on [DATE] at 7:14 PM, the Interim Director of Nursing (IDON) confirmed if there were any changes to the resident's care, the resident's care plan needed to be updated.

Based on facility policy review, medical record review, observation and interview, the facility failed to label and date nebulizer tubing and store a nebulizer mask in a safe and sanitary manner for 1 of 12 (Resident #50) sampled residents reviewed receiving respiratory treatments. The findings include: Review of the facility policy titled Oxygen Administration using Simple Mask OR Venturi-Mask Clinical Practice Guidelines dated 10/23/2020, revealed .The purpose of this procedure is to provide guideline for safe oxygen administration .Follow relevant infection control procedures as appropriate . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the current physician orders dated 11/11/2021, revealed .change oxygen tubing every week Once a day on Tue (Tuesday); Night 1900-0700 [7 PM-7 AM] Check humidification bottle every shift, change when empty. Twice A Day; 0700-11:00 [7 AM-11:00 AM]; 19:00-23:00 [7 PM -11 PM] .[MEDICATION(S)] [a medication to treat wheezing and shortness of breath] Solution (2.5 MG/3ML [milligram/milliliter]) (0.083%) 1 inhalation [DX (Diagnosis) [CONDITION(S)], Unspecified] Four Times A Day; 8:00, 12:00, 16:00 [4 PM] Nebulization , 20:00 [8 PM] . Observation in the resident's room on 11/15/2021 at 10:40 AM, revealed Resident #50's nebulizer oxygen tubing was not dated and the nebulizer mask was not in a bag. Observation and interview in Resident #50's room with Licensed Practical Nurse #3 on 11/15/2021 at 3:15 PM, confirmed the resident's nebulizer oxygen tubing and nebulizer mask was not dated or stored in a bag. During an interview on 11/16/2021 at 9:30 AM, the Interim Director of Nursing (IDON) confirmed the nebulizer tubing and mask needed to be dated and stored in a bag when not in use.

Based on medical record review and interview the facility failed to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the care plan revised 9/20/2021, revealed .Resident has the following Advanced Directives: DO NOT Resuscitate (DNR) Category Advanced Directives . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/2021 at 4:18 PM, Licensed Practical Nurse (LPN #2) also known as the Unit Manager confirmed she did not see any orders for a DNR. Continued interview confirmed the nurses were to go over the residents choices and once decided update the orders and face sheet. During an interview on 11/17/2021 at 7:16 PM, the Interim Director of Nursing (IDON) confirmed an order was to be placed into the electronic record for a DNR.

Based on facility policy review, observation and interview, the facility failed to dispose of expired medications and biological's in the medication room and on 1 of 3 medication carts observed. The findings include: Review of the undated facility policy Medication Administration General Guidelines revealed .Manufacturer recommendations for beyond use dating should take precedence, taking into consideration 'not to exceed' limitations .The beyond date use dating, which only lists month/year, falls to the last day of that month . Observation and interview in the medication room with Licensed Practical Nurse (LPN) #5 on 11/16/2021 at 3:18 PM, revealed five unopened bottles of vitamin supplement tablets, expired on 8/21/2021. One container of disinfectant wipes expired on 10/2021. During an interview LPN #5 confirmed the five unopened bottles of vitamin supplements and one container of disinfectant wipes were expired. Observation and interview of the medication cart on Hope Hallway with Registered Nurse (RN) #1 on 11/16/2021 at 3:56 PM, revealed one bottle of iron tablets expired on 10/2021. During an interview RN #1 confirmed the iron tablets were expired. During an interview on 11/17/21 at 8:19 AM, with the Administrator and Interim Director of Nursing confirmed expired medications are not to be found on the medication carts or in the medication room. The Administrator confirmed the proper procedure would be to check all medications and dispose of expired medications in both the medication room and the medication carts.

Based on facility policy review, observation and interview, the facility failed to provide a sanitary environment to help prevent transmission of infection for 14 of 15 residents meal trays observed during the noon meal on 11/15/2021. The findings include: Review of the undated facility policy Policies and Practices-Infection Control revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Observation of Haven Hall on 11/15/2021 at 12:11 PM, revealed Certified Nurse Assistant (CNA) #1 removed a meal tray from the meal cart, took it into room [ROOM NUMBER] B and sat it on the over bed table. Continued observation revealed CNA #1 removed the lid from the tray and resident stated I do not want this can you get me something else. Further observation revealed CNA #1 brought the meal tray out of the room and placed it back on the meal cart. Observation of Haven Hall on 11/15/2021 at 12:16 PM, revealed CNA #1 and CNA #2 continued to deliver the other 14 meal trays. During an interview on 11/15/2021 at 12:21 PM, CNA #2 confirmed trays are not supposed to leave the room until after the meal and would be picked up when all trays are picked up. During an interview on 11/15/2021 at 12:22 PM, CNA #1 confirmed she took the refused meal tray from 124 B's room and placed it back on the remaining undelivered meal cart. During continued interview CNA #1 stated I am new and I am not sure of the rules. During an interview on 11/16/2021 at 9:52 AM, the Interim Director Of Nurse (IDON) confirmed when a tray is refused, it is not going to be put on the cart with the clean trays it stays in room until trays are removed from the room.

Based on facility policy review, medical record review, observation and interview, the facility failed to provide a sanitary and comfortable environment 1 of 60 (Resident #49) sampled residents reviewed. The findings include: Review of the undated facility policy titled, Resident Rights revealed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included [CONDITION(S)], Chronic Kidney Disease, Gastrostomy Status, Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with [CONDITION(S)]. Review of the 5-day Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Observation and interview in Resident #49's room on 11/15/2021 at 11:10 AM, revealed heavily soiled washcloth with brown debris was lying on his bed. When asked if he had requested to keep a washcloth with him in the bed he stated no. Observation in Resident #49's room on 11/15/2021 at 11:23 AM, revealed Certified Nurse Assistant (CNA) #2 was in the room assisting Resident #49 and did not remove the dirty washcloth from the bed. During an observation and interview in Resident #49's room with Licensed Practical Nurse (LPN) #3 on 11/15/2021 at 11:23 AM confirmed the CNA#2 was assisting Resident #49 and did not remove the soiled washcloth. During an interview on 11/17/2021 at 7:15 PM, the Interim Director Of Nursing confirmed we put the soiled linens in a bag and they go to the soiled utility room, it (soiled washcloth) should not have been left in the bed.

Based on facility policy review, medical record review, facility fall investigation review, and interview, the facility failed to develop a baseline care plan for fall risk for a resident at high risk for falls resulting in a fall with a laceration which required staples to the back of the head (harm) for 1 resident (Resident #7) of 7 residents reviewed for falls. The findings include: Review of the facility's policy, Falls dated 11/6/2019, revealed, .All residents will have a comprehensive fall risk assessment on admission/readmission .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .Care Plan will be implemented based on fall risk evaluation score with individual goal and interventions specific to each patient . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. Review of the Fall Risk Assessment Tool dated 6/9/2020, showed a score of 15, indicating Resident #7 was at high risk for falls. Review of the 5 day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had moderately impaired cognitive status. The resident required extensive assist of 1 staff with transfers, ambulation, and toileting, and the resident had a fall with a fracture in the month prior to admission to the facility. Medical record review revealed the facility did not develop a baseline care plan to address the resident's high risk for falls and previous history of falls. Review of the facility fall investigation dated 6/15/2020, showed Resident #7 had a fall at 3:00 PM and sustained a laceration to the back of the head. The resident had been in bed prior to the fall, no fall interventions were in place at the time of the fall, and the resident was transferred to the emergency room for evaluation. The laceration required 4 staples to close the wound. During an interview on 6/30/2020 at 11:16 AM, the MDS Coordinator confirmed Resident #7 had a fall risk assessment dated [DATE] with a score of 15 on the assessment, indicating Resident #7 was at high risk for falls. The MDS Coordinator confirmed the facility did not develop a baseline care plan to address Resident #7's fall risk prior to the fall that occurred on 6/15/2020. During an interview on 6/30/2020 at 11:20 AM, Licensed Practical Nurse (LPN) #1 stated Certified Nursing Assistant (CNA #3) had just left the resident's room where Resident #7 was lying on the bed, and when she came back to Resident #7's room, she found the resident on the floor. The resident stated he was trying to go to the bathroom and the resident had a laceration to the back of the head. LPN #1 was unable to remember if any fall interventions were in place at the time of the fall. During an interview on 7/1/2020 at 11:15 AM, the Administrator confirmed Resident #7 had a fall on 6/15/2020 which resulted in a laceration requiring 4 staples to the back of the resident's head. She confirmed the facility had not developed a baseline care plan with interventions to prevent falls prior to the fall on 6/15/2020. The Administrator stated if the resident had a fall risk care plan with fall interventions in place, he would have been less likely to fall. The Administrator confirmed the facility had not followed their policy for the development of a fall risk care plan for a resident who scored high risk for falls on the admission Fall Risk Assessment Tool. Refer to F-689

Based on facility policy review, medical record review, facility fall investigation review, and interviews, the facility failed to implement the care plan for 1 resident (Resident #4) of 7 residents reviewed for falls. The facility's failure to implement the care plan resulted in Resident #4 sustaining a shoulder fracture (Harm) from a fall while transferring to the chair. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 7/19/2018, revealed, .will include how the facility will assist the resident to meet their needs, goals and preferences .interventions are implemented after consideration of .problem areas and their causes .will reflect action, treatment, or procedure to meet the objectives toward achieving .goals .Care plans are ongoing and revised as information about .condition change . Review of the facility policy titled, Falls dated 11/6/2019, revealed, .2. A Comprehensive Care Plan will be implemented based on fall risk evaluation score with individual goal and interventions specific to each patient . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's comprehensive care plan dated 11/20/2019, revealed Resident #4 had an intervention for assistance which stated .Elder to have shoes on for transfers .Transfer with assist of 2 staff . Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of 2 staff members for transfers. Review of a facility fall investigation dated 11/25/2019, revealed .CNA (Certified Nursing Assistant) was assisting (Resident #4) with transfer CNA care plan not followed (assist of 2 staff for transfers) .Elder did not have on appropriate footwear . Review of a radiology report dated 11/25/2019, revealed Resident #4 sustained a shoulder fracture. During an interview on 6/30/2020 at 10:30 AM, the Administrator confirmed Resident #4's care planned fall interventions were not implemented, resulting in a fall with Harm to Resident #4. Refer to F-689

Based on facility policy review, facility fall investigation review, medical record review, and interview, the facility failed to ensure a safe transfer procedure for 1 resident (Resident #4), resulting in a shoulder fracture, and failed to prevent a fall with injury for 1 resident (Resident #7) who sustained a laceration with 4 staples placed to the back of the head. The facility failed to ensure the safety of 2 residents (#4, #7) of 7 residents reviewed for falls, resulting in Harm to Residents #4 and #7. The findings include: Review of the facility policy, Gait Belt dated 1/4/2019, revealed, .Each stakeholder who provides direct patient care shall use a gait belt during the ambulation, transfer or movement of residents .Each stakeholder .is required to have a gait belt on their person .should be worn around their waist . Review of the facility policy, Falls dated 11/6/2019, revealed, .It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], revealed Resident #4 was a high risk for falls. Review of Resident #4's comprehensive care plan dated 11/20/2019, revealed an intervention for assistance .Elder to have shoes on for transfers .Transfer with assist of 2 staff . Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact and required extensive assistance of 2 staff members for transfers. Review of a Progress Note dated 11/25/2019 at 12:50 PM, revealed Resident #4 was transferred to a local hospital via ambulance. Review of a X-Ray report dated 11/25/2019, revealed Resident #4 had a spiral [MEDICAL CONDITION] humeral diaphysis (shoulder fracture). Review of a facility fall investigation dated 11/25/2019, revealed .CNA (Certified Nursing Assistant) was assisting (Resident #4) with transfer CNA care plan not followed (assist of 2 staff for transfers) .Elder did not have on appropriate footwear .gait belt not used for transfer (per policy) . During an interview on 6/30/2020 at 3:35 PM, Licensed Practical Nurse (LPN) #3 stated on 11/25/2019, at the time of the fall, CNA #2 stepped out into the hallway and said she needed help. LPN #3 went into the room and saw Resident #4 on the floor, sitting up against the dresser. Resident #4 told LPN #3 he lost his balance. After assessing the resident, LPN #3 observed CNA #2 not wearing a gait belt around her waist, which was required to transfer the resident. LPN #3 stated CNA #2 had transferred the resident without the assistance of a second staff person. LPN #3 stated 2 staff members were present outside the resident's room at the time of the fall and were available to assist CNA #2, but the CNA had not requested assistance. During an interview on 7/1/2020 at 9:15 AM, Resident #4 stated CNA #2 came into the room to assist the resident with transferring from the bed to the chair. Resident #4 stated, .I am supposed to wear special shoes when I transfer .but I had on non-skid socks which did not work for me .(CNA #2) did not use good transfer skills, did not use a gait belt, and she was the only one in here. It takes 2 people to transfer me .I heard my arm break as I went down to the floor . During an interview on 7/1/2020 at 11:15 AM, the Administrator confirmed Resident #4 had a fall on 11/25/2019 when CNA #2 did not use a gait belt and assistance of 2 staff members to transfer Resident #4. This fall resulted in Harm for Resident #4 when he sustained a shoulder fracture. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. Review of the Fall Risk Assessment Tool dated 6/9/2020, showed a score of 15, indicating the resident was at high risk for falls. Review of the 5 day MDS assessment dated [DATE], showed Resident #7 had moderately impaired cognitive status. The resident required extensive assist of 1 staff with transfers, ambulation, and toileting, and the resident had a fall with a fracture in the month prior to admission to the facility. Review of the C.N.A. Care Report, undated, and the resident's baseline care plan in effect on 6/15/2020, revealed no documentation of interventions to prevent falls. Review of the facility fall investigation dated 6/15/2020, showed Resident #7 had a fall at 3:00 PM and sustained a laceration to the back of the head. The resident had been in bed prior to the fall, no fall interventions were in place at the time of the fall, and the resident was transferred to the emergency room for evaluation. Review of the emergency room documentation dated 6/15/2020, showed Resident #7 was transferred to the emergency room from the facility with a 3 centimeter laceration to the back of the head and a skin tear to the left elbow. The laceration on the back of the head required closure with 4 staples. Review of a Resident Progress Note dated 6/15/2020, showed Resident #7 returned to the facility with 4 staples intact to the back of the head. During an interview on 6/30/2020 at 11:14 AM, the Administrator confirmed Resident #7 had a fall on 6/15/2020, the resident was at high risk for falls based on the fall risk assessment dated [DATE], and interventions to prevent falls should have been developed and implemented prior to the fall on 6/15/2020. During an interview on 6/30/2020 at 11:16 AM, the MDS Coordinator confirmed Resident #7 had a fall risk assessment dated [DATE] with a score of 15, indicating the resident was at high risk for falls. The MDS Coordinator confirmed the resident did not have interventions to prevent accidents prior to the fall that occurred on 6/15/2020. During an interview on 6/30/2020 at 11:20 AM, LPN #1 stated she was assigned to Resident #7 on 6/15/2020, when the resident fell . LPN #1 stated CNA #3 had just left the resident's room where Resident #7 was lying on the bed. CNA #3 went to check on another resident, and when she came back to Resident #7's room, she noticed he was not in the bed and found him on the floor. The resident stated he was trying to go to the bathroom and the resident had a laceration to the back of the head. During an interview on 7/1/2020 at 11:15 AM, the Administrator confirmed Resident #7 had a fall on 6/15/2020 which resulted in a laceration requiring 4 staples to the back of the resident's head. She confirmed the facility had not developed interventions to prevent falls prior to the fall on 6/15/2020. The Administrator stated if the resident had interventions in place, the resident would have been less likely to fall.

Based on facility policy review, review of Re-Certification and Revisit survey findings, review of Quality Assurance Performance Improvement (QAPI) documents, medical record review, and interview, the facility's QAPI committee failed to audit, monitor, and maintain compliance with the Plan of Correction (POC) dated 11/19/2019, resulting in 2 residents (Residents #4 and #7) of 7 residents reviewed for falls sustaining falls with injuries (Harm). The findings include: Review of the facility's policy titled, Quality Assurance/Performance Improvement (QAPI) Program, dated 10/2/2019, revealed .the intent of this facility .QAPI .designed to systematically monitor evaluate and improve the quality and appropriateness of resident care .[MEDICATION NAME] both outcomes and processes .with the objective of improving the organization's overall performance . Review of the annual Re-Certification survey completed on 8/14/2019, revealed the facility was cited for failure to implement care plans and failure to provide supervision to prevent accidents, resulting in Harm to 1 resident. The facility failed to implement a care plan fall intervention for the assistance of 2 staff members for repositioning of the resident. A Certified Nursing Assistant (CNA) attempted to reposition the resident without assistance from another staff member, which resulted in a fall with a nasal fracture. Review of the facility's Plan of Correction (POC) dated 9/15/2019 for the deficiencies cited on the 8/14/2019 Re-Certification survey, revealed the CNA care plans were to be placed in a binder and kept at the nurses stations. The CNAs were to review and initial the care plans at the beginning of their shifts. During the monthly QAPI meeting, the committee would review and identify any concerns. The Director of Nursing (DON)/Unit Manager would audit the CNA care plans to ensure the CNAs had reviewed and initialed the care plans. Review of a revisit survey completed 10/1/2019, revealed the facility failed to implement the POC and the facility was recited deficient practice for failure to develop/implement comprehensive care plans and failure to provide supervision to prevent accidents/falls. Review of the facility's POC dated 11/19/2019, revealed the CNA care plans were to be reviewed for accuracy on all new admissions/re-admissions. The CNAs were to initial daily that the resident care plans were reviewed. The DON/Unit Manager/Administrator would audit the CNA care plan books to ensure the CNAs had initialed the care plans. Incidents would be reviewed in the monthly QAPI meeting. Documentation of audits would be reviewed monthly during the QAPI meeting and any concerns identified would be addressed immediately. Review of a Performance Improvement Plan (PIP) titled Quality Performance/Peer Review Facility Plan of Action/Continuous Quality Improvement dated 11/27/2019, revealed a PIP had been developed after Resident #4 sustained a fall with injury on 11/25/2019. Resident #4's care plan indicated the resident was to have 2 staff members to assist the resident with transfers. The facility policy Gait Belt dated 1/4/2019, indicated staff were to use a gait belt when transferring or moving residents. On 11/25/2019, CNA #2 transferred Resident #4 without a gait belt and without the assistance of 2 staff. The facility had identified in the investigation .policy not followed .care plan not followed . The facility PIP included to conduct ongoing audits of comprehensive care plans and CNA care plans, audits of signatures on CNA care plans, and incidents would be discussed in morning meetings with the monthly QAPI committee reviewing and recommending any further follow up. The PIP interventions were the same interventions on the submitted POCs that were to be implemented to sustain compliance. During a complaint survey conducted from 6/29/2020 - 7/1/2020, deficient practice was identified for the facility's failure to develop and implement care plans and failure to prevent avoidable accidents. Resident #4 sustained a shoulder fracture when CNA #2 transferred the resident from bed to a chair without use of a gait belt and without 2 person assistance, and Resident #7 receivied a laceration to the back of the head requiring 4 staples when the facility did not implement interventions to prevent avoidable accidents for a resident who was a high risk for falls. During an interview and review of residents' falls for the last 6 months on 6/30/2020 at 10:30 AM, the Administrator confirmed the QAPI committee met monthly. The Administrator confirmed the QAPI committee reviewed all care plans and accidents. The Administrator confirmed the 11/27/2019 PIP was not effective and a new PIP was not put in place. During an interview on 7/1/2020 at 11:15 AM, the Administrator confirmed the facility had experienced staff turnover and the QAPI plan needed to be reassessed. The Administrator stated falls had continued to increase and the QAPI plan for implementation of care plans to prevent accidents had not been effective. She stated the facility had planned to focus on nursing documentation and do a .deep dive . on falls. The facility had developed a PIP, but it had not been implemented. The facility was in the process of hiring hospitality aides, although she acknowledged they would not be allowed to assist in direct patient care. Refer to F-655, F-656, and F-689

Based on facility policy review, medical record review, review of facility falls investigation, and interviews, the facility failed to implement the care plan for 1 resident (#8) of 31 sampled residents, resulting in a nasal fracture (Harm) for Resident #8. The findings include: Review of the facility policy, Comprehensive Care Plans, dated 7/19/18, revealed .will include how the facility will assist the resident to meet their needs, goals and preferences .interventions are implemented after consideration of .problem areas and their causes .will reflect action, treatment, or procedure to meet the objectives toward achieving .goals . Medical record review revealed Resident #8 was admitted to facility on 3/23/16 with [DIAGNOSES REDACTED]. Medical record review of Resident #8's current active care plan revealed .7/19/2016 .Resident has ADL (Activities of Daily Living) Self Care Deficit & (and) is at risk for complications related to Deficit .Total assist with all her ADLS BED MOBILITY Total x2 (total dependence with assistance of 2 staff members) PULLING UP IN BED/POSITIONING . Medical record review of Resident #8's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, never or rarely understood, required total assistance with bed mobility of 2 persons, and total assistance with all ADLs with 2 person physical assist. Review of a facility fall investigation completed 8/3/19 revealed .Res (Resident #8) was in bed when CNA (Certified Nursing Assistant) was turning res (resident) over, res slid off opposite side of bed and hit the night stand (resident head-nose). Res is on air mattress which promotes sliding .when turned opposite to side CNA was standing slid off the bed .Investigation Summary: Resident slid off air mattress when CNA was reposition (repositioning) and hit nose on night stand. Res sustained nasal fracture . Medical record review of an Event Report dated 8/3/19, revealed, .Description FALL .Evaluation Notes: staff educated on elder to be turned & repositioned with 2 staff members . Interview with the Director of Nursing (DON) on 8/13/19 at 1:11 PM, in Resident #8's room, confirmed Resident #8 required the assistance of 2 staff members for turning and repositioning in bed, as indicated on the care plan. Telephone interview with CNA #1 on 8/13/19 at 7:26 PM, confirmed CNA #1 was the only staff member turning and repositioning Resident #8 when the fall occurred on 8/3/19. Continued interview revealed .we have a care plan book at the nurse's station to guide us with the resident care needs . Further interview revealed CNA #1 was not aware Resident #8 required the assistance of 2 people for bed mobility at the time of the fall on 8/3/19. Interview with the DON on 8/14/19 at 10:24 AM, in the DON's office, confirmed the facility failed to implement Resident #8's care plan intervention of 2 person physical assist. The facility's failure to implement the care plan resulted in Resident #8 sustaining abrasions to the nose and forehead, swelling and bruising to both eyes, and a nasal fracture. Refer to F-689

Based on facility policy review, medical record review, review of facility falls investigations, observation, and interview, the facility failed to implement appropriate interventions to prevent falls for 1 residents (#8) of 11 residents reviewed for falls. The facility's failure to ensure appropriate interventions to prevent accidents were implemented resulted in Resident #8 receiving a fractured nasal bone (Harm). The findings include: Review of the Facility Policy, Falls, dated 7/16/19, revealed, .POLICY STATEMENT: .It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .A Comprehensive Care Plan will be implemented based on fall risk evaluation score with individual goal and interventions specific to each patient . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #8's current active care plan revealed, .Problem .7/19/2016 .Resident has ADL (Activities of Daily Living) Self Care Deficit & (and) is at risk for complications related to Deficit .Total assist with all her ADLS BED MOBILITY Total x2 (total dependence with assistance of 2 staff members) PULLING UP IN BED/POSITIONING .7/19/2016 .risk for fall related injury Fall Risk factors present as determined .TOTAL ASSIST WITH ALL ADLS, does not transfer d/t (due to) contractures stays in bed. NON-AMUBLATORY . Further review revealed under the problem of risk for fall related injury, Goal dates of 7/19/16, 5/7/19, and 8/9/19, .Resident will not sustain a fall related injury by utilizing fall precautions through next review date .Approach (interventions to be implemented to prevent falls) .4/19/2016 .TOTAL ASSIST VIA LIFT AND 2 STAFF WITH TRANSFERS. TOTAL ASSIST WITH ALL ADLS . Medical record review of Resident #8's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was severely cognitively impaired, and never or rarely understood. Continued review revealed, for bed mobility (how the person turns from side to side in bed and positions body while in bed), the resident was totally dependent on staff and required total assistance of 2 or more persons for physical assist with bed mobility. Medical record review of the Fall Risk assessment dated [DATE], revealed Resident #8 had not had any falls in the previous 6 months, was completely immobilized, and was a low risk for falls. Medical record review of an Event Report dated 8/3/19, revealed Resident #8 had a fall at 4:57 AM. Review of a facility fall investigation for the fall on 8/3/19 revealed, .Res (Resident #8) was in bed when CNA (Certified Nursing Assistant #1) was turning res (resident) over, res slid off opposite side of bed and hit the night stand (resident head-nose). Res is on air mattress which promotes sliding .Contributing factors: Res on air mattress, has contractures .Res on air mattress and when turned opposite to side CNA was standing slid off the bed .Investigation Summary: Resident slid off air mattress when CNA was reposition (repositioning) and hit nose on night stand. Res sustained nasal fracture. Sent to ER (emergency room ) . Medical record review of a CT (Computed tomography) scan of the facial bones dated 8/3/19 revealed, Indications: Trauma, fall from bed, injury to nose, pain .Impression .Acute appearing minimally non-displaced [MEDICAL CONDITION] nasal bone with perinasal (near the nose) ecchymosis (bruising or discoloration of the skin) .Left infraorbital (around the eyes)/facial ecchymosis . Medical record review of the Nurses Note dated 8/3/19, timed 9:57 AM, revealed, .Spoke with staff at (local hospital) Elder returning to facility with nose injury .Elder noted to have abrasion to left side of nose and forehead with swelling noted to both eyes with bruising noted to left eye . Observation on 8/12/19 at 11:21 AM, in Resident #8's room, revealed Resident #8 was in bed and had bruising to the left side of the face, chin, forehead, cheek and mouth. Telephone interview with Resident #8's family member on 8/12/19 at 4:17 PM, revealed the family member was notified by the facility that Resident #8 was repositioned in bed by 1 staff member when the resident rolled out of bed and hit her head on the bed side table. Telephone interview with CNA #1 on 8/13/19 at 7:26 PM, confirmed she was the only staff member turning and repositioning Resident #8 when the fall occurred on 8/3/19, .I rolled her over like always .Her head fell off the bed and hit the night stand beside the bed .I then assisted the rest of her body to the floor . Continued interview confirmed .I was not aware resident required assistance of 2 people for bed mobility . Interview with the Director of Nursing (DON) on 8/14/19 at 10:24 AM, in the DON's office, confirmed the facility failed to provide 2 staff members for repositioning Resident #8, resulting in the resident falling to the floor and sustaining a nasal fracture.