Every finding on record at Complete Care at Middlebury

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident who required staff assistance for mobility, had leg rests applied on the wheelchair prior to pushing the wheelchair. The failure resulted in a fall with injury. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident who required staff assistance for mobility, had leg rests applied on the wheelchair prior to pushing the wheelchair. The failure resulted in a fall with injury. The findings include: Resident #1 had diagnoses that included legal blindness, abnormal posture, and anxiety. Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified Resident #1 was alert and oriented (score fourteen out of fifteen). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was dependent on staff for mobility in the wheelchair. The Resident Care Plan (RCP) dated 7/14/2025 identified Resident #1 had limited physical mobility related to weakness. Interventions directed one (1) person assist for transfers with rolling walker, and out of bed to wheelchair with ROHO cushion. The Situation, Background, Assessment, and Recommendation (SBAR) nursing note dated 8/28/2025 at 5:30 P.M. (completed by RN #1) identified Resident #1 fell forward from the wheelchair onto the ground, striking his/her face. RN #1 identified that Resident #1 had skin tears on the forehead, right hand, right elbow, bilateral knees, a scrape on the bridge of the nose, and a laceration to the right forehead. A facility reportable event (RE) form dated 8/28/2025 at 5:30 P.M. identified Resident #1 was being pushed in his/her wheelchair outside the building and fell on the pavement, resulting in a laceration to the right forehead. The fall was witnessed by Housekeeper #1. Resident #1 was transferred to the hospital for evaluation and returned with one (1) suture to the right forehead. Review of RN #1's nursing post fall review dated 8/28/2025 identified Resident #1 had a witnessed fall outdoors while being transported in the wheelchair without leg rests. Housekeeper #1's written statement dated 8/28/2025 identified at 5:30 P.M., she was pushing Resident #1 back to his/her room when his/her foot got stuck in the wheel on the wheelchair, and Resident #1 fell forward out of the wheelchair onto the pavement. The hospital Discharge summary dated [DATE] identified Resident #had a laceration above his/her right eye/right frontal scalp and required one (1) suture. Interview and facility documentation review with Housekeeper #1 on 9/19/2025 at 10:31 A.M. identified on 8/28/2025 at approximately 5:30 P.M., she assisted Resident #1 back inside the building after an outdoor recreation activity. While she was pushing the wheelchair, Resident #1's foot got caught, and Resident #1 fell forward onto the pavement. Housekeeper #1 stated Resident #1's leg rests were not on the wheelchair during transport. Housekeeper #1 identified on 8/28/2025 that she was unsure if Resident #1 required leg rests on the wheelchair during transport, and that she should have asked if leg rests were required before transporting Resident #1. Interview with the Director of Nursing Services (DNS) on 9/19/2025 at 10:45 A.M. stated on 8/28/2025 identified there were no leg rests on Resident #1's wheelchair when Housekeeper #1 was pushing the wheelchair, and Resident #1 fell out of the wheelchair and sustained a laceration to his/her forehead. The DNS stated Housekeeper #1 should not have transported Resident #1 without the leg rests in place on the wheelchair. The DNS stated Resident #1 was dependent on staff for wheelchair mobility, and all residents who are dependent for wheelchair mobility require the use of leg rests when staff are pushing the wheelchair. The DNS stated staff are responsible for ensuring that leg rests are on wheelchairs during resident transport. Interview failed to identify why the leg rests were not on the wheelchair. Although requested, a wheelchair transport policy was not provided. Facility documentation review identified staff education was initiated on 8/28/2025 and included all residents who are dependent for wheelchair mobility must have leg rests on the wheelchair. Audits of wheelchair leg rests were initiated on 8/28/2025, and a QAPI meeting was held on 8/28/2025. Based on review of the facility documentation, past- compliance was identified.

Based on review of facility documentation, review of facility policy, and interview, the facility failed to review the infection prevention control program policies and procedures at least annually, and failed to have a current list of communicable diseases that are reportable to the local and state health authorities and failed to maintain appropriate tracking for Multi-Drug Resistant Organisms (MDRO). The findings include: a. Review of the facility's Infection Control Program Policies and Procedure Manual on 9/21/23 at 10:57 AM identified the policies and procedures were last reviewed on 2/2/22. Interview with the DNS on 9/21/23 at 10:57 AM identified that the review and approval of the infection control policies and procedures was the responsibility of the Infection Preventionist and the Administrator. A policy for review and renewal of the infection control program policies and procedures was requested but was not provided by the facility. Interview with the DNS on 9/25/23 at 1:58 PM identified she was unable to locate a policy but identified that it was the practice of the facility to review and renew policies and procedures annually. b. Review of the Infection Control Program Policies and Procedure Manual on 9/21/23 at 10:57 AM identified a document entitled Connecticut Epidemiologist, dated July 2022, changes to the list of Reportable Diseases, Emergency Illnesses and Health Conditions, and the list of Reportable Laboratory Findings. According to the Connecticut Department of Public Health the most current list of communicable disease that are reportable to local and state health authorities was issued by the Connecticut Epidemiologist, with the current list of Reportable Diseases, Emergency Illnesses and Health Conditions, and the list of Reportable Laboratory Findings was in January 2023. Interview with the DNS on 9/21/23 at 10:57 AM identified that the document provided was what she found in the Infection Control Manual. The DNS indicated that she had only been working at the facility for a few weeks as the DNS and was unable to get things in order in such a short time. A policy on Reportable Communicable Disease was requested but was not provided by the facility. In an interview with the DNS on 9/25/23 at 1:58 PM identified that she was unable to locate such a policy in the Infection Control Manual. c. Review of the facility's infection control surveillance data for Multi-Drug Resistant Organisms (MDRO) on 9/21/23 at 10:57 AM identified two sets of MDRO lists that were updated on January 13, 2023, with a total of 12 residents listed, and another list updated on December 22, 2022, with a total of 12 residents. Interview with the DNS on 9/21/23 at 10:57 AM identified that only 2 of the residents on the list dated January 13, 2023, were still at the facility and all the other residents no longer resided at the facility. The DNS failed to identify why the MDRO's were not tracked or how the facility tracked MDRO's, as she was new to the facility. In an interview with the DNS on 9/25/23 at 1:38 PM identified that MDRO's would not be checked monthly but required an ongoing tracking as residents would be added to the MDRO's list as they identified whether through admission or laboratory testing results. Review of the facility's policy on Surveillance of Infections identified that it was the responsibility of the infection preventionist to review resident's records, laboratory reports, and to document a current line list of infections and review and update as needed.

Based on review of facility policy, and interviews, the facility failed to have a designated Infection Preventionist responsible for the Infection Control Program. The findings include: Interview with the DNS on 9/21/23 at 10:57 AM identified that the person that was hired for the infection preventionist position was in the process of going through the infection prevention and control program training to obtain their Infection Preventionist (IP) certification; however, the person has not assumed the position because she is currently functioning in the position of day shift nursing supervisor. The DNS further identified the IP position was still open. The DNS further noted that she was overseeing the infection control program. The facility's job description for the Infection Preventionist identified that the IP's responsibility was to plan, organize, develop, and coordinate the infection control program and related activities in accordance with federal, state, and local standards/regulations.

Based on clinical record review, and interviews for one of five sampled resident (Resident #33) reviewed for unnecessary meds, the facility failed to ensure that physician ordered monitoring for orthostatic blood pressures and for bleeding were implemented. The findings include: Resident #33's diagnoses included dementia, bipolar disorder, anxiety disorder, adjustment disorder, depression, hypertension, and a history of a coronary vascular accident. A quarterly MDS assessment dated [DATE] identified Resident #33 had intact cognition, did not display behavior symptoms, and required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 8/15/23 identified Resident #33 had some impaired short- and long-term memory deficits with interventions that included: provide orient to day, time, and appropriateness of decision making. The RCP further identified a self-care deficit with interventions to assist with bathing, bed mobility, dressing, eating, oral care, hygiene, and toilet use. In addition, the RCP addressed identified the resident had diagnoses of depression, anger, and anxiety with interventions to administer meds as ordered, assess needs to process feelings, monitor for signs of anxiety, redirect, encourage activities, monitor, and document side effects of meds, and psychiatric evaluations. The signed physician's orders dated 8/28/23 included the following medication orders: Plavix (used to treat blood clots) 75 mg daily, and Olanzapine (antipsychotic) 10 mg daily and 5 mg at hour of sleep. The orders further included an order that directed orthostatic blood pressures to be obtained on a monthly basis while on psychotropic medications and to obtain a stool Guaiac (a test that detects hidden (occult) blood in a stool sample) on a monthly basis while on anticoagulant medication. Further review of the physician's orders identified that the orders were in place during the period of April/2023 through September/2023. Review of the Treatment Administration Records (TAR) for Resident #33 for the months of April/2023 through September/2023 indicated that the orders for orthostatic blood pressures monthly and guaiac stools monthly were transcribed onto the TARs but were not signed off as completed for those months. Review of the nurse's notes and blood pressure records for the months of April through September failed to show documentation of those orders being completed. Interview and record review with LPN#1 on 9/21/23 at 9:45 AM identified that she was not aware that there were orders for monthly orthostatic BPs and monthly stool guaiac to be done for Resident #33. LPN#1 confirmed the presence of the orders for the BP and guaiac monthly. The facility was unable to provide a policy that addressed monthly orthostatic blood pressures, monthly stool guaiac or failure to follow an MD order.

Based on clinical record review, observations, facility policy review, and interviews for two sampled residents (Resident #12 and Resident #51) observed for dining, the facility failed to ensure that staff maintained a dignified dining experience by not standing while assisting residents to eat. The findings include: 1. Resident # 12's diagnoses that included cerebral atherosclerosis, vascular dementia, type 2 diabetes mellitus, anxiety, and Parkinson's disease. The quarterly MDS assessment dated [DATE] identified Resident #12 had severe cognitive impairment and required total assistance with eating. Monthly physician's order for September/2023 directed to provide a chopped mechanically soft diet. Observation of breakfast meal on 9/18/23 at 8:30 AM identified Resident #12 was set-up to eat breakfast at the bedside and NA #1 was standing on his/her right side of the bed not at eye level to Resident #12 while assisting him/her to eat his/her breakfast meal. Interview with NA #1 on 9/18/23 at 9:10 AM identified that she was aware that she should be at eye level with the resident while feeding. She further identified that she did not sit down at eye level while feeding the breakfast meal to Resident #12 because she was also supervising his/her roommate at the same time. 2. Resident #51's diagnoses that included Alzheimer's, anemia, hypertension, and atrial fibrillation. The quarterly MDS assessment dated [DATE] identified Resident #51 had severe cognitive impairment and required limited assistance with eating. An active physician's order for the period of September 2023 directed to provide no added salt diet. Observation of breakfast meal on 9/18/23 at 8:30 AM identified Resident #51 was set-up to eat breakfast at the bedside and NA #2 was standing on his/her left side of the bed not at eye level to Resident #51 while assisting him/her to eat his/her breakfast meal. Interview with NA #2 on 9/18/23 at 9:00 AM identified that she was aware that she should be at resident eye level while feeding; however, she identified Resident #51's bed was already in a high position, so she decided to feed him/her while she was standing up. She further identified that she could have lowered Resident #51 bed so she could be at resident eye level while feeding his/her breakfast meal. Interview with the DNS on 9/18/23 at 9:30 AM identified that staff should be at eye level with the resident when feeding in the community dining room or in resident rooms. Review of facility feeding the resident policy identified that staff would assist residents at eye level when feeding to ensure resident's dignity and respect (rather than standing over the resident).

Based on clinical record review, facility policy review, and staff interviews for one sampled resident (Resident # 48) reviewed for advanced directives, the facility failed to ensure the monthly physician's orders reflected the resident's correct code status. The findings include: Resident #48's diagnoses included right femur fracture, hypertension, type 2 diabetes mellitus and hyperlipidemia. Review of the signed advance directive consent form dated [DATE] identified Resident #48 had selected a code status of Do Not Resuscitate (DNR), which means a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops. The physician's admission order dated [DATE] identified Resident #48 had a code status of DNR. The baseline care plan dated [DATE] identified Resident #48 had a code status of DNR. The admission MDS assessment dated [DATE] identified Resident #48 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. The monthly physician's orders for September/2023 identified Resident #48 had a code status of full code. A full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. Interview with LPN #1 on [DATE] at 2:00 PM identified that when checking the code status of a resident, she would check the resident's advance directive consent form and the current physician's orders. She further identified that the current monthly physician's orders should reflect the most recent advanced directive of the resident. Interview and clinical record review with RN #1 (nursing supervisor) on [DATE] at 10:00 AM identified that when checking the status of a resident's code status, the nurse would check the resident's advanced directive consent form and the most current monthly physician's orders to identify the resident's code status. Review of Resident #48's advanced directive consent form with RN #1 identified the election of a code status of DNR, and the physician's admission orders dated [DATE] indicated a code status of DNR. Review of the September/2023 monthly physician's orders identified Resident #48 had a code status of full code. RN #1 could not provide documentation that Resident #48's advanced directives had changed from DNR to Full Code. She further identified that the [DATE] monthly physician's orders should have reflected a code status of DNR. Interview with the DNS on [DATE] at 11:30 AM identified that the nurse would check the resident's advanced directive consent form and the current monthly physician's orders to identify the resident's code status. She also identified that the monthly physician's orders should reflect the most recent advanced directive. Review of the facility's advanced directives policy identified that residents would be informed of his/her right to make health care decisions and to execute advanced health care directives under state law upon admission.

Based on review of facility documentation, facility policy, and interview, the facility failed to provide a system of records as well as receipt and disposition reconciliation for controlled medications. The findings include: Review of the narcotic disposition record for Resident #49 identified 30 milliliters (ml) of Oxycodone was received by the facility on 9/8/22. The documentation identified that the medication was last administered on 10/22/22. The record identified that 29.8 ml of the medication remained. Review of the narcotic disposition records for Resident #12 identified the following: * 30ml of Morphine was received by the facility on 9/14/22. The documentation identified that the medication was last administered on 9/27/22 with 22.5ml remaining. * 473ml of Phenobarbital was received by the facility on 8/11/23. The documentation identified that the medication was last administered on 8/21/23 with 20ml remaining. * 473ml of Phenobarbital was received by the facility on 8/19/23. The documentation identified that the medication was last administered on 9/1/23 with 10ml remaining. A request for the narcotic reconciliation records (reconciliation records) was requested for the months of September/2022, October/2022, and August/2023 to determine the disposition of the leftover controlled medications for Resident #12 and Resident #49. The records were not provided. Interview with the DNS on 9/21/23 at 12:30 pm identified that narcotic reconciliation records could not be located. The DNS further noted that she had initiated a new system after she started in August of 2023. In addition, the DNS identified that she did not have any controlled medications that needed to be destroyed. Review of the medication acceptance on admission policy directed all drugs classified as controlled drugs must be taken to the office for destruction by the DNS and Licensed staff member.

Based on clinical record review, review of facility policy, and staff interviews for one of five sampled residents (Resident #33) reviewed for unnecessary medications, the facility failed to ensure a monthly pharmacy review of medications and failed to develop and maintain policies and procedures for the monthly drug regimen review. The findings include: Resident #33's diagnoses included dementia, bipolar disorder, anxiety disorder, adjustment disorder, depression, hypertension, and a history of a coronary vascular accident. A quarterly MDS assessment dated [DATE] identified Resident #33 had intact cognition, did not display behavior symptoms, and required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 8/15/23 identified Resident #33 had some impaired short- and long-term memory deficits with interventions that included: orient to day, time, and appropriateness of decision making. The RCP further identified a self-care deficit with interventions to assist with bathing, bed mobility, dressing, eating, oral care, hygiene, and toilet use. In addition, the RCP addressed identified the resident had diagnoses of depression, anger, and anxiety with interventions to administer meds as ordered, assess needs to process feelings, monitor for signs of anxiety, redirect, encourage activities, monitor, and document side effects of meds, and psychiatric evaluations. Resident #33's medications per the signed MD orders dated 8/28/23 included the following: Myrbetriq (used to treat overactive bladder)ER 25 mg daily, Amlodipine (used to treat high blood pressure and chest pain)10 mg daily, Oxybutynin XL (used to treat overactive bladder) 10 mg in PM, Ramipril (used to treat hypertension and heart failure)10 mg daily, Plavix (used to treat blood clots) 75 mg daily, Donepezil (used to treat Alzheimer's disease)10 mg daily, Olanzapine (antipsychotic) (10 mg daily and 5 mg at hour of sleep, Bactrim DS (antibiotic) 800/160 twice a day, Bupropion SR (antidepressant) 100 mg twice a day, Duloxetine DR(antidepressant and used to treat nerve pain) 60 mg twice a day, Lamotrigine (used to treat seizures and bipolar disorder)150 mg twice a day, Gabapentin (anticonvulsant and used to treat nerve pain)400 mg three times per day, and Atorvastatin (used to treat high cholesterol) 40 mg hour of sleep. Review of the pharmacy drug regimen reviews identified there was no documentation for July/2023. Interview with the DNS on 9/21/23 at 2:00 PM identified she did not know why Resident #33's clinical record did not contain documentation that the pharmacist consultant had completed the medication regimen review for July. Although requested, the facility did not provide a policy that addressed procedures for the monthly drug regimen review, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Based on observation, review of facility policy, and interview, the facility failed to store refrigerated medications appropriately. The findings include: Observation on 9/20/23 at 2:20 PM identified Core power protein shake, light and fit Greek yogurt, and Poland Spring 16.9 oz water stored in the medication storage fridge on the [NAME] wing. There was a sign posted on the front of the refrigerator that stated This refrigerator is only for medication not for nourishments or any other food. Thank you. Also stored in this refrigerator was IV medication Cefazolin (antibiotic). Interview with RN #1 on 9/20/23 at 2:25 PM identified this food was staff food/drink stored here for convenience due to the proximity of the nurse's station. Review of the refrigerated medications policy directed medications must be stored separately from food at all times and must be labeled accordingly.

Based on review of the clinical records, facility policy, facility documentation, and interview during a review of resident immunizations for two of five sampled residents (Resident #6 and Resident #47), the facility failed to offer and provide pneumococcal immunizations as required. The findings include: Resident #6's diagnoses included unspecified dementia, seizures, and anxiety disorder. Review of immunization records for Resident #6 on 9/25/23 at 12:00 PM failed to identify that the pneumococcal vaccine (PCV20) was offered. Resident #47 diagnoses unspecified dementia, heart failure, and hypertension. Review of immunization records for Resident #47 on 9/25/23 at 12:00 PM failed to identify that the pneumococcal vaccine (PCV20) or second dose of PPSV23 was offered. Review of the facility's pneumococcal pneumonia vaccination policy, resident consent/refusal of vaccine form, and vaccination tracking sheet on 9/21/23 at 10:57 AM failed to offer pneumococcal vaccine (PCV20) or assess for resident's pneumococcal vaccine (PCV20) vaccination history. According to the Centers for Disease and Control (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommends that adults aged [AGE] years or older who have received both pneumococcal vaccine PCV13 and pneumococcal vaccine PPSV23 but have not yet received a final dose of PPSV23 at age [AGE] years or older are recommended to complete their pneumococcal vaccine series by receiving either a single dose of PCV20 or PPSV23. Interview with the DNS on 9/25/23 at 12:58 PM identified that Resident #6 and Resident #47 wasn't offered the pneumococcal (PCV 20) vaccine, which is used for the prevention of pneumococcal disease (respiratory diseases). The DNS indicated that the facility's pneumococcal vaccination policy did not even include the PCV 20 vaccine, which is a part of the pneumococcal vaccination requirement. The DNS indicated that she was newly hired by the facility and is unable to speak to why the facility's policy failed to offer or assess resident's history of the PCV 20 vaccination. The DNS indicated that moving forward she will be updating the pneumococcal vaccination policy and offer the PCV 20 vaccine along with the new COVID-19 booster vaccine to eligible residents. Interview with the DNS on 9/25/23 at 2:15 PM identified she was unable to provide pneumococcal vaccination consent records for Resident #47. Review of facility's pneumococcal and Prevnar vaccines (PPSV23 and PCV 13) policies identified in November of each year resident's will be screened to determine pneumococcal immunization status and eligibility for receiving the new Prevnar 13 (PCV13) vaccine and the Pneumovax (PPSV23). All new admissions are required to provide their vaccination status if unknown, the facility will offer both pneumococcal vaccines. If a resident refused the pneumococcal vaccine in the past, the facility would offer it yearly.

Based on facility documentation review and staff interviews for one of three nurse aides (NA #3), the facility failed to complete an annual performance evaluation. The findings include: Review of NA #3 personnel file identified a hire date of 8/14/12 and failed to identify that a yearly performance evaluation was completed for 2022 or 2023. Interview with Payroll Staff Person #1 on 9/25/23 at 10:50 AM identified that all employees should have an annual performance review. She also identified each department head who is responsible for ensuring that employees receive their annual performance review. Interview with the DNS on 9/25/23 at 11:00 AM identified that each employee should have a performance review completed on an annual basis. She further identified that she could not find documentation to identify that performance reviews were completed for NA #3 for 2022 and 2023. Review of facility employee handbook identified in performance appraisal that all employees would receive feedback about their performance and employee would be evaluated on an annual basis by their supervisor.

Based on facility documentation review and staff interviews, the facility failed to ensure the facility assessment was reviewed and updated annually. The findings include: Review of the facility assessment tool identified that the facility assessment was last reviewed and/or updated on 5/24/22. Interview with the former Administrator on 9/25/23 at 12:50 PM identified that the former DNS was responsible for reviewing and updating the facility assessment. She also identified that she was aware that the facility assessment needed to be reviewed and/or updated on at least an annual basis. The former Administrator further identified that the last time the facility assessment was reviewed and/or updated was on 5/24/22. Attempts to interview the former DNS were unsuccessful.

Based on observations, review of facility documentation and interview, the facility failed to ensure that resident room walls were free of damage and well maintained. The findings include: Review of the East wing's maintenance request log dated 08/12/2021 identified an entry referencing room 33. The entry was a request from Person #1 to repair the wall behind the resident's bed as soon as possible. During tours of the facility on all days of the survey (9/8, 9/9, 9/10, 9/14 & 9/15) including observations made while with the Maintenance Director on 09/15/2021 at 9:33 AM identified the following: · Room #33 had shredded and damaged wallpaper located on the wall behind the bed closest to the window. · Room #21 had damage to the wall behind both beds. · Room #23 had holes in the wall at the head of the bed located closest to the room door. · Room #24 was noted with damaged wallpaper and wall located at the head of the bed that measured approximately four (4) feet by one (1) foot in area. · Room #28 was noted with scrapped wall damage located at the head of the bed located closest to the window. · Room #29 was noted to have holes and peeling wallpaper located at the head of the bed closest to the window. · Room #30 was noted with scrapped wall damage located at the head of bed closest to the window. · Room #6 was noted to have damaged wallpaper and holes in the wall. · Room #10 was noted to have holes in wall located at the head of bed closes to the window. · Room #14 was noted to have holes in the wall located at the head of bed closest to the room door. · Room #15 was noted to have holes in the wall located at the head of both resident beds. Interview on 09/15/2021 at 10:01 AM with the Maintenance Director identified that he conducted daily rounds and addressed repair requests (via logs). He further indicated that although he was aware of the condition of the rooms, it was impossible to keep up with repairs. The facility's daily building inspection policy/procedure noted that daily inspection included exterior building and grounds, exit doors, interior hallways and other areas but failed to identify and or address frequency or any other guidance related to inspection of and maintaining resident rooms.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #6) reviewed for unnecessary meds, the facility failed to transcribe a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Monthly orders and the medication administration records (MAR) for the months of April, May and June of 2021 reflected the resident had the same orders in place for [MEDICATION(S)]. The care plan dated 5/11/2021 identified resident #6 had periods of anxiety secondary to moderate cognitive deficits, becomes argumentative, yells at staff, and has paranoid thoughts. Care plan interventions included; administer medications as ordered, monitor and document for side effects and effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate per regulation. The annual MDS assessment dated [DATE] identified Resident #6 had severely impaired cognition, was frequently incontinent of bowel and bladder, required extensive assist of two with bed mobility, transfers, and toilet use, and was totally dependent on staff for eating and personal hygiene. The nurse's note dated 8/25/2021 at 2:00 PM indicated resident #6 was seen by psychiatric services and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further identified that Resident #6 had increased behaviors of restlessness and agitation during the month of August and the as needed [MEDICATION(S)] was administered more frequently than usual. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR for the month of August/2021 failed to identify that the resident was administered the scheduled dose of [MEDICATION(S)] every night at bedtime. Review of the APRN's progress note dated 9/1/2021 identified the resident was utilizing the as needed dose of Trazadone due to increased behaviors since being off of the bedtime dose of trazadone. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RN #1 on 9/13/2021 at 12:30 PM failed to reflect the order for [MEDICATION(S)] 50mg was carried over from the July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DNS on 9/14/2021 at 9:37 AM identified the 11-7 shift is responsible reviewing the orders and checking the orders on the next months MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS also identified that the order for the scheduled [MEDICATION(S)] was missed. It was not carried over from the July/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with APRN #1 on 9/14/2021 at 11:06 AM identified that she did write an order on 8/27/2021 for resident #6 for a psychiatric evaluation for resident's bedtime dose of [MEDICATION(S)]. She identified she wrote the order to confirm that the resident still required the medication and she did not recall if she was aware that resident #6 did not receive the scheduled [MEDICATION(S)] during the month of August. In addition, APRN #1 identified that if the psychiatric APRN orders a medication, she prefers that they review the meds. Interview with the APRN #2 (psychiatric) on 9/14/2021 at 12:00 PM identified that on 9/1/2021 she restarted the [MEDICATION(S)] 50mg at bedtime due to increased behaviors and it not being on the August MAR. Review of APRN #2's progress notes dated 8/4/2021 and 8/25/2021 identified that [MEDICATION(S)] 50mg at bedtime was noted as a current medication; however, review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APRN #2 indicated that she had not written an order to discontinue the scheduled [MEDICATION(S)] dose and noted that the resident should have been receiving the medication for the month of August/2021. Interview with the Pharmacy Consultant on 9/14/2021 at 12:11 PM identified that she had not entered the facility during the COVID pandemic. She noted that she worked remotely and identified her process for reviewing the monthly orders included: the pharmacy sends her a copy of the physician orders, the facility sends her copies of her previous reports, labs and physician notes would be sent upon request. The Pharmacy Consultant indicated that Resident #6 was only on as needed [MEDICATION(S)] for the month of August/2021 but she could not identify when the order for the scheduled [MEDICATION(S)] was discontinued. In addition, the Pharmacy Consultant indicated that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A second interview with RN #1 on 9/14/2021 at 1:30 PM indicated that she could not recall when it came to her attention that the scheduled dose of [MEDICATION(S)] was missed. Interview with LPN #2 on 9/14/2021 at 3:36 PM indicated that she should have noticed the discrepancy in the [MEDICATION(S)] order sooner and noted that when she realized the medication was not active on 8/27/2021, she reported it to the DNS. Review of the facility's editing policy and the policy/procedure for reviewing the monthly physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also directs that the last day of the month before MAR's are switched the new computerized MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, review of facility documentation and interviews, the facility failed to follow infection control standards for donning and doffing face masks. The findings include: Observation on 09/13/2021 at 4:35 PM identified NA #1's face mask was positioned below her chin and did not cover her mouth or nose. At the time of the observation NA #1 was moving residents on the west wing and placing overbed tray tables in front of the residents. Observation on 09/14/2021 at 3:54 PM identified NA#1's face mask was positioned over her mouth but did not extend over her nose. Observation on 09/14/2021 at 4:03 PM with the nursing supervisor (RN#1) identified NA #1 with the face mask positioned as described above. Interview with RN #1 identified that NA#1 was improperly wearing her face mask. Interview with NA#1 on 09/14/2021 at 4:16 PM identified that her face mask frequently falls down and it was not her fault. Interview on 09/15/21 at 8:36 AM with the Infection Preventionist (RN #2) identified the facility has provided many in-services and education with the staff regarding the proper use of personal protective equipment. RN #2 further identified that the staff are required to wear surgical face masks while working with the residents to prevent the spread of communicable diseases like COVID-19. Review of the facility's infection control policy and procedure noted in part: Masks will be worn by staff at all times while in the facility.

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for 1 of 6 residents reviewed for accidents (R#1), the facility failed to provide adequate supervision or assistance to prevent to prevent an accident. The findings included: 1a) Resident #1 ' s diagnoses included [CONDITION(S)], anxiety disorder, abnormal posture, [CONDITION(S)], left hand contracture and a history for displaced fracture of the left femur 5/11/2019. A quarterly assessment dated [DATE] identified the resident as severely impaired for decision-making skills, requiring total assistance of two staff for bed mobility, transfers and as having impaired functional the limitation in ROM to LLE the (left lower extremity). The RCP updated on 9/24/19 identified risk for falls as the focus. Interventions included bed in lowest position, keep most frequently used personal items within reach, mats on the floor at bedside and 2 -1/4 side rails up in bed as an enabler and a reminder not to get OOB without assistance. Review of the RE/investigation dated 12/7/19 at 1:30 P.M. identified in part, the resident was on the floor by the windows, next to the bed, on the left side, facing the door, calling out. Review of the RE/investigation identified a statement dated 12/7/19 was provided by the resident ' s assigned nurse ' s aide (NA#1) who noted in part that he/she turned to grab a brief from the resident ' s closet. When NA#1 turned back around, he/she heard the bed alarm and saw the resident on the right side of the bed, the quarter side rails were up. On 3/23/21 at 11:57 A.M. an interview and review of the RE/investigation dated 12/7/19 at 1:30 P.M. with NA#1 indicated he/she clearly remembers what had happened and felt remorseful about the fall because he/she walked 10 steps away from R#1 who was lying in bed to get an incontinent brief out of the resident's closet. On 3/26/21 at 1:09 P.M. an interview and review of the clinical record, facility documentation and NA#1 ' s interview with the DNS in the presence of the Administrator indicated he/she would have expected NA#1 to have gathered all supplies prior to the start of incontinent care per the facility policy. According to the facility perineal care/incontinent care policy and procedures, identified in part that the first steps of the procedure is to gather proper equipment and needed supplies. b. The RCP dated 9/24/19 identified a focus for ADL self-care performance deficit. Interventions included LLE immobilizer on at all times, Remove for care only. Keep leg immobilized during care. Physician monthly orders for December 2019 directed in part, LLE immobilizer on at all times, remove for care only, keep leg immobilized during care. Review of the RE/investigation dated 12/7/19 at 1:30 P.M. identified in part, the resident was on the floor by the windows, next to the bed, on the left side, facing the door, calling out. A review of the nurse supervisor ' s (RN#1) investigative findings regarding the fall noted the resident was lying on his/her left side facing the door on the floor. The resident bed was in the high position. R#1 was positioned near the side of the bed on his/her side which may have produced enough momentum to precipitate falling out of the bed. Attempts were made to contact RN#1 for an interview on 3/23/21 at 9:50 A.M., 11:21 A.M., 2:15 P.M. and on 3/24/21 at 10:10 A.M. 1:27 P.M. and on 3/25/21 at 11:01 A.M. were unsuccessful. On 3/23/21 at 11:57 A.M. an interview and review of the RE/investigation dated 12/7/19 at 1:30 P.M. with NA#1 indicated he/she was remorseful about the resident fall and clearly remembers what had happened and during care he/she did not remove the resident ' s leg brace/immobilizer. NA#2 further indicated he/she believes the resident fell from the bed due to the weight of the resident ' s leg brace/immobilizer pulling the resident over and off the bed. On 3/26/21 at 1:09 P.M. an interview and review of the clinical record, facility documentation and NA#1 ' s interview with the DNS in the presence of the Administrator indicated he/she would have expected NA#1 to follow the resident ' s plan of care regarding the immobilizer. c. The RCP updated on 9/24/19 identified a focus for ADL self-care performance deficit. Interventions included total assistance of two for turning and repositioning in bed as necessary for bed mobility. Review of the RE/investigation dated 12/7/19 at 1:30 P.M. identified in part, the resident was on the floor by the windows, next to the bed, on the left side, facing the door, calling out. A review of the RE/investigation statement provided by NA#3 dated 12/7/19 noted in part, he/she was ready to assist NA#1 in getting R#1 up. R#1 was positioned on his/her side, quarter side rails up with mats on the floor. When an alarm for another resident (R#7) went off, NA#3 had to leave the room to assist R#7. Attempts were made to contact NA#3 for an interview on 3/23/21 at 9:54 A.M., 11:27 A.M., 2:19 P.M. and on 3/24/21 at 10:15 A.M., 2:25 P.M. and on 3/25/21 at 11:10 A.M. were unsuccessful. On 3/23/21 at 11:57 A.M. an interview and review of the RE/investigation and with NA#1 indicated that he/she was in the room alone with R#1, walked 10 steps away from the bed to get an incontinent brief from R#1's closet, when the resident fell out of his/her bed. On 3/24/21 at 10:15 A.M. an interview and review of the clinical record and RE/investigation dated 12/7/19 at 1:30 P.M. with LPN#1 indicated that prior to R#1 ' s fall, NA#1 called to LPN#1 from the doorway of R#1 ' s room requesting a dressing change for the resident because it was soiled. LPN#1 indicated he/she was in the hallway at the time and upon entering R#1 ' s room, LPN#1 saw R#1 lying on the floor with NA#1 in the room alone with the resident. On 3/26/21 at 1:09 P.M. an interview and review of the clinical record an facility documentation with the DNS indicated he/she would have expected NA#1 to wait for NA#3 to return to the room before providing additional care being that two nursing assistants were required to assist the resident with bed mobility during care. Subsequent to the resident falling out of bed, R#1 was transferred to the ED on 12/7/19 and was diagnosed with a right proximal humeral (shoulder) fracture and NA#1 and the facility staff received in-service/education on appropriate protocol for ADL care.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of six sampled residents (Resident #2) reviewed for accidents the facility failed to review and/or revise the plan of care regarding the ambulation/transfer status. The findings included: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required limited assistance from staff for transfers and ambulation, utilized hearing aids and glasses. The RCP dated 9/18/19 identified Resident #2 had an ADL self-care performance deficit and limited physical mobility with interventions that included, resident is able to transfer and ambulate independently with walker in the facility, requires extensive to limited assistance at night at times, provide supportive care and assistance with mobility as needed. Review of the interdisciplinary resident data collection form dated 9/14/19 identified Resident #2 was noted to have a recent change, Resident #2 was noted to have difficulty with standing, sitting, and understanding direction i.e., where to go. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No ambulation, utilize wheelchair for mobility per O.T. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A reportable event report dated 10/4/2019 at 8:30 PM identified in part, Resident #2 was ambulated to the weight room with his/her wheeled walker and as NA #2 turned from the resident to turn on the scale, the resident fell backwards. Further review of the RCP noted that documentation was lacking to reflect that the changes made to the resident's transfer/ambulatory status via physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 3/23/21 at 12:49 PM with the MDS/Care Plan Coordinator (RN#2) indicated the specific physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of 6 residents reviewed for accidents (R#2), the facility failed to review and/or revise the plan of care regarding the ambulation/transfer status. The findings included: Resident#2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment identified the resident as severely cognitively impaired requiring the use of hearing aids and glasses and limited assistance from staff for transfers and ambulation. The RCP updated on 9/18/19 identified ADL self-care performance deficit/limited physical mobility as the focus. Interventions included for transfer/ambulation: the resident is able to transfer and ambulate independently with walker in the facility, requiring extensive to limited assistance at night, at times; provide supportive care, assistance with mobility as needed. Review of the interdisciplinary resident data collection form dated 9/14/19 identified in part, (R#2) noted to recent have a change. Difficulty with standing, sitting, and understanding direction i.e., as to where to go. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No ambulation utilize wheelchair for mobility per O.T. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RE dated 10/4/2019 at 8:30 P.M. identified in part, R#2 was ambulated to the weight room with his/her wheeled walker and as the NA#2 turned from the resident to turn on the scale, the resident fell backwards. Upon further review of the clinical it was noted that documentation was lacking to reflect that the changes made to the resident's transfer/ambulatory status via physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/23/21 at 12:49 P.M. an interview and review of the clinical record with the MDS/Care Plan Coordinator (RN#2) indicated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of the clinical record, review of policy and interviews for one resident (Resident #1) reviewed for Resident Rights, the facility failed to ensure the resident's family members receive a scheduled weekly visit in accordance to facility practice and the Centers for Disease Control Prevention (CDC) recommendations. The findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required assist with bed mobility, transfers, toileting, personal care and noted independent with eating. The care plan dated 11/10/20 identified Resident #1 had a potential for extreme sadness and anxiety related to visitation restrictions. Interventions included: offering of Skype with families in the recreation room, Facetime and, to offer reassurance as needed. A Recreation Calendar dated 12/14/20 noted Resident #1 was scheduled for a Skype visit at 11:00 A.M. (visitor not identified). A Therapeutic Recreation log for Resident #1 dated 12/14/20 was blank for Skype visitation. An electronic communication dated 12/15/20 submitted by Person #1 noted a concern related to not receiving a weekly scheduled Skype visitation at 11:00 A.M. with no contact from the facility with an explanation why the visit did not occur. A social service note dated 12/16/20 noted Social Worker ( SW #1), the Administrator and the Director of Nursing Services ( DNS) had a one hour and five minute meeting with Person #1 in regard to a letter sent to the Ombudsman and state agency where ongoing daily changes were discussed and continued communication with families would continue. Person #1 recommended a Zoom meeting that she/he would arrange with the Ombudsman, families and interdisciplinary team. A telephone line placed in Resident #1's room and Person #1 was provided with the phone number. Recreation was directed to be in contact with Person #1 to arrange Skype calls, and a recreation therapist would be designated on the unit to provide assist. An interview on 2/22/21 at 11:18 A.M. with the Administrator identified the recreation department scheduled visits, including Facetime and Skype visits between residents and their family members were scheduled through the recreation department. An interview on 2/22/21 at 12:43 P.M. with the Recreation Director identified all visitation including Skype and Facetime was arranged through the recreation department. When there was a scheduled visit, nursing staff were provided a schedule of daily visits, so residents were up and prepared for a private visit. The recreation staff would make repeated attempts to reach family members if they were unable to make initial contact. If unsuccessful, the staff would move onto the next scheduled visit for another resident. The Recreation Director indicated while there was no requirement to document a missed visit or rationale, staff were made aware of the need to continue to try to make contact with families. The Recreation Director indicated she could not recall a time when Person #1 reported not being able to reach Resident #1 for a scheduled visit but was aware that Person #1 would contact the facility reporting she/he had a scheduled Skype visit. Staff were unsuccessful in reaching Person #1 and moved onto another scheduled resident visit. An interview and facility documentation review on 2/22/21 at 1:09 P.M. with Recreation Therapist #1 (RT #1) and Recreation Therapist #2 (RT #2) identified Person #1 was scheduled every Monday for a Skype visit. Often, the facility was not able to reach Person #1 for the scheduled visit after repeated attempts and indicated the visit would need to be rescheduled. RT #1and RT #2 were unable to identify through their documentation instances where scheduled visits had to be rescheduled. RT#1 and RT #2 did not know why December 14, 2020 on the Recreation schedule was left blank and unsure if a separately scheduled Skype meeting for the following Friday (December 18, 2020) was rescheduled from a missed Skype visit on December 14, 2020 or a Skype visit with an alternate family member. RT #1 and RT #2 indicated there was no process in place to tracked missed virtual visits and follow up for the missed visits. An interview on 2/22/21 at 1:45 P.M. with Licensed Practical Nurse ( LPN #1) identified nursing staff were provided written notification from the recreation staff with notation of daily scheduled virtual visits. LPN #1 could not recall a time when Person #1 notified her of a missed scheduled virtual visit. An interview and social worker progress notes review on 2/22/21 at 1:56 P.M. with SW #1 identified an hour-long telephone meeting had taken place that included the Administrator, DNS, Person #1 and herself to discuss a letter submitted to the Administrator by Person #1. The letter detailed, in part, a missed Skype meeting scheduled for 11:00 A.M. (no date provided) and reported no one at the facility contacted her/ him by 11:15 A.M. According to SW #1, Person #1 alleged she/he contacted the facility following the missed meeting and Receptionist #1 indicated all administrative staff were in a meeting and indicated the staff would need to get back to her/him. Person #1 was not happy with the response she/he called the charge nurse (LPN #1) who also indicated she was not sure why the facility had not contacted Person #1 regarding a missed scheduled Skype meeting. SW #1 indicated at that time, some staff in the recreation department were limited to assist with visits due to underlying medical conditions and confirmed the scheduled meeting did not take place. The nursing staff at the time did not get involved with visits as it was managed by recreation. Since the incident, nursing staff were directed to assist with virtual calls when recreation staff were not available . An interview on 2/22/21 at 2:35 P.M with Receptionist #1 identified while she spoke to Person #1 often, she could not recall the incident. A subsequent interview on 2/22/21 at 3:10 P.M with the Administrator identified the facility had residents with known COVID during the month of December 2020. The Administrator had spoken to Person #1 on several occasions after receiving a couple of harsh letters from Person #1 demanding staff follow up and reporting poor communication. The Administrator indicated she set up a meeting on 12/16/20 with SW #1 to discuss addressing Person #1's concerns. Person #1 was to set up a separate meeting (at her/his request) with the Ombudsman, the facility staff and other family members who Person #1 had indicated also had concerns but she/he never heard anything more about the separate meeting . The Administrator felt Person #1's concerns were addressed at the meeting and even had a phone installed in Resident #1's room to facilitate more direct communication. The Administrator also forwarded the letter herself to the state agency as she felt she was in good communication with Person #1. The policy for Visitation dated 2/5/21 noted the facility would set up virtual visitation through the recreation department. In accordance to the Centers for Disease Control and Prevention (CDC) guidance dated 9/15/20 recommends visitors to healthcare facilities be limited in the context of the COVID-19 pandemic, regardless of known community transmission. Facilities should apply alternatives for direct interaction between visitors and patients, including setting up remote communications (e.g., telephone or internet connection) in isolation area to allow for video or audio calls.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents reviewed for accidents (Resident #22), the facility failed to implement interventions to reduce the risk of a fall which resulted in Resident #22 sustaining a fall with an injury. The findings include: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had moderately impaired cognition, and required the assistance of 1 person to transfer and walk. The MDS further identified Resident #22 had two falls (one with injury) since 12/5/18. The Resident Care Plan (RCP) dated (MONTH) 2019 identified a problem with being at risk for falls related to [MEDICAL CONDITION] drug use, unsteady gait, a history of falls and [MEDICAL CONDITION]. Interventions included to anticipate needs, ensure items are within reach, provide non-skid socks after supper, and keep environment safe. A Reportable Event form dated 4/26/19 at 12:25 AM identified Resident #26 was found sitting on the floor along the window side of his/her bed with no injury. Interventions to prevent similar incidents included to add non-skid strips to the window side of Resident #22's bed to prevent further falls. A Nurse's note dated 5/2/19 at 7:00 PM identified while providing hours of sleep care toileting Resident #22, the Nurse Aide (NA) reported Resident #22 went to stand up to hold on to his/her walker, his/her arm let go of the walker and Resident #22 fell to the floor sustaining no apparent injury. A Nurse's note dated 5/3/19 at 10:00 PM identified Resident #22 was placed at the nurse's station for safety and was repeatedly getting up to ambulate without assistance. A Nursing progress note dated 5/4/19 at 10:15 AM identified Resident #22 was found sitting on the floor of his/her room with his/her head against the recliner (upon observation of Resident #22's room on 5/7/19 at 4:02 PM identified the recliner chair is located on the window side of the bed where non-skid strips were to have been placed). A 3 centimeter laceration with large amounts of blood was noted on the back of Resident #22's head. 911 was called and Resident #22 was transferred to the emergency room for an evaluation. A Nursing progress noted dated 5/4/19 identified Resident #22 returned from the hospital at 3:45 PM. A Physician order [REDACTED].#22's head every shift. Observation on 5/7/19 at 4:02 PM failed to provide evidence of non-skid strips on the floor along the window side of Resident #22's bed. Interview and review of the East wing maintenance book with the Maintenance Supervisor on 5/8/19 at 9:30 AM identified a request was placed in the book by nursing on 4/26/19 for the non-skid strips, but had not been placed on the floor of the window side of Resident #22's bed. The Maintenance Supervisor identified he/she was responsible to apply the non-skid strips to the floor and failed to do so because he/she did not have enough material to complete the job. The Maintenance Supervisor further identified he/she forgot to order more non-skid tape. Interview on 5/9/19 at 11:30 AM with LPN #2 identified he/she was on duty when Resident # 22 fell on [DATE]. LPN #2 identified he/she found Resident #22 on the floor in front of his/her recliner along the window side of the Resident # 22's bed (without the benefit of non-skid tape that had been identified as an intervention from a fall on 4/26/19). Subsequent to surveyor inquiry, on 5/8/19 one nonskid strip was applied to the floor in front of Resident #22's recliner on the window side of Resident #22's bed and an order for [REDACTED].>A review of the facility's resident falls policy identified if a resident falls an appropriate intervention needs to be placed in the care plan immediately to possibly prevent another fall. Although the facilility intervention was to apply non-skid floor tape after Resident #22 sustained a fall on 4/26/19, non-skid floor tape was not applied and Resident #22 fell on the same side of the room that the floor tape was to be applied and sustained a laceration occiptal area requiring 10 staples.