**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #8) reviewed for positioning and range of motion, the facility failed to develop a comprehensive care plan to address the specific type of assistive device being utilized, how often the device should be worn, and the general care or monitoring of the device as it relates to the resident. The findings include: Resident #8 was admitted to the facility in August of 2024 with diagnoses that included rheumatoid arthritis of the left elbow, right pubis fracture, muscle weakness, and multiple rib fractures. The admission MDS assessment dated [DATE] identified Resident #8 was cognitively intact, had impaired range of motion to bilateral upper and lower extremities. It further identified the resident was dependent on staff for personal hygiene, lower body dressing, toileting hygiene, transfers, mobility, was non-ambulatory and utilized a wheelchair. Observation on 9/23/24 at 10:34 AM identified Resident #8 seated in a chair with an overbed table positioned in close proximity in front of him/her with a black colored splint that encompassed most off the upper and lower portion of the left arm. The resident identified that the splint was worn during the day and removed at bedtime. A review of the physician's orders for August/2024 failed to address the use of a splint to the left arm. A review of the care plan dated 8/23/24 failed to identify Resident #8 utilized a splint addressed the application of the splint and removal of the splint, and/or when to check the integrity of the resident's skin as it relates to the use of the splint. Resident #8's nurse aide care card failed to identify the use of the splint. Observation on 9/24/24 at 11:02 AM identified Resident #8 seated in a chair with the overbed table positioned in close proximity in front of the resident, with the black colored splint in place to the left arm. Observation on 9/26/24 at 9:54 AM identified Resident #8 was lying in bed with the black colored splint in place to the left arm. Observation with the Charge Nurse (RN #4) on 9/26/24 at 11:29 AM identified Resident #8 lying in bed with the splint in place to the left arm. Interview with the day-shift Nursing Supervisor (RN #3) on 9/26/24 at 11:37 AM identified that the physician's orders did not contain an order directing the use of the splint to the left arm and the care plan also did not reflect the use of the splint. RN #3 further identified that a physician's order, the care plan, and the nurse's aide care card should reflect when the splint is to be applied, and removed, and to check the resident's skin integrity. Interview with NA #2 on 9/26/24 at 11:40 AM identified she applied the splint to the left arm as Resident #8 requested. NA #2 identified that when a resident utilizes a splint, it is usually written in the NA care card. Interview with the MDS Coordinator (RN #5) on 9/26/24 at 12:10 PM identified that he was responsible for completing the comprehensive care plans within 14 days after the resident is admitted to the facility. He also identified that Resident #8 should have had a physician's order for the use of the splint as the physician's order directs the care of the resident which is added to the care plan. RN #5 indicated that the physician's order would direct how and when to apply the splint, and the checking of skin integrity. Further, RN #5 was unable to identify why the care plan lacked the inclusion of the splint as it should have included the splint, as it was a part of Resident #8's care routine. Interview with the Occupational Therapy Assistant (OTA #1) on 9/26/24 at 12:00 PM identified that when a resident is admitted to the facility with a splint, the nursing staff is supposed to notify the therapy department for the device to be evaluated. OT #1 further identified that a physician's order would be required for the use of the splint to direct the appropriate care for the resident. Interview with the DNS on 9/26/24 at 12:28 PM identified that Resident #8 should have had a care plan and a physician's order directing the use of the splint to the left arm. The DNS identified that it was the responsibility of therapy to ensure that a physician's order was in place after they evaluated the resident and trained the staff on how to apply and remove the splint. She further identified that the splint was visible to staff, hence if the resident brought the assistive device in the facility after admission, it was the responsibility of the nurses to ensure that therapy was aware, and orders were in place. The DNS identified that the care plan should have been completed to indicate the use of the splint, when to apply and remove the splint, and for the checking of the skin on applying and removing of the splint. Interview with the Occupational Therapist (OT #2) and the Director of Rehabilitation on 9/27/24 at 11:40 AM identified that OT #2 completed Resident #8's admission evaluation and identified that Resident #8 utilized a splint to the left arm for positioning and comfort, following a surgery to the left elbow years ago. OT #2 further identified that she applied the splint to the left arm in the morning when caring for the resident. OT #2 identified that she had told the Director of Rehabilitation that Resident #8 utilized a splint but had not provided training to the staff. The Director of Rehabilitation identified that OT #2 mentioned that Resident #8 utilized a splint but assumed that she had followed the procedures that included an evaluation, and training of the staff. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further identified that assessments are ongoing, and care plans are revised as information about the resident and resident's conditions change. Review of the Assistive Device and Equipment policy identified that recommendation for the use of devices and equipment are based on comprehensive assessment and documented on the resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #8) reviewed for positioning and range of motion, the facility failed to ensure a physician's order was in place directing the use of an assistive device. The findings include: Resident #8 was admitted to the facility in August of 2024 with diagnoses that included rheumatoid arthritis of the left elbow, right pubis fracture, muscle weakness, and multiple rib fractures. The admission MDS assessment dated [DATE] identified Resident #8 was cognitively intact, had impaired range of motion to bilateral upper and lower extremities. It further identified the resident was dependent on staff for personal hygiene, lower body dressing, toileting hygiene, transfers, mobility, was non-ambulatory and utilized a wheelchair. Observation on 9/23/24 at 10:34 AM identified Resident #8 seated in a chair with an overbed table positioned in close proximity in front of him/her with a black colored splint that encompassed most off the upper and lower portion of the left arm. The resident identified that the splint was worn during the day and removed at bedtime. A review of the physician's orders for August/2024 failed to address the use of a splint to the left arm. A review of the care plan dated 8/23/24 failed to identify Resident #8 utilized a splint addressed the application of the splint and removal of the splint, and/or when to check the integrity of the resident's skin as it relates to the use of the splint. Resident #8's nurse aide care card failed to identify the use of the splint. Observation on 9/24/24 at 11:02 AM identified Resident #8 seated in a chair with the overbed table positioned in close proximity in front of the resident, with the black colored splint in place to the left arm. Observation on 9/26/24 at 9:54 AM identified Resident #8 was lying in bed with the black colored splint in place to the left arm. Observation with the Charge Nurse (RN #4) on 9/26/24 at 11:29 AM identified Resident #8 lying in bed with the splint in place to the left arm. Interview with NA #3 on 9/26/24 at 11:20 AM identified that the nurses' aides apply splints and other assistive devices after therapy provides them with training, she further noted that after training, it is placed on the care cards. In addition, she noted that sometimes therapy applies the splint and removes the splint. Interview and review of Resident #8's physician's orders and administration records with RN #4 on 9/26/24 at 11:29 AM failed to reflect a physician's order directing the use of a splint to the left arm. RN #4 identified that whenever a resident utilized a splint a physician's order should be in place that directed how and when the splint should be worn, and when to complete skin checks. RN #4 identified that she had not applied the splint that morning, and assumed the resident had a physician's order. She further identified that it would have been the responsibility of the admitting nurse to obtain an order. Interview and review of Resident #8's clinical record with the day-shift Nursing Supervisor (RN #3) on 9/26/24 at 11:37 AM failed to reflect physician's orders directing the use of the splint to the left arm. RN #3 identified that a physician's order, should have been completed to indicate when the resident to wear the splint, to check skin integrity and when to remove for care, as it was a part of the resident's care. Interview with the NA #2 on 9/26/24 at 11:40 AM identified that she was the nurse aide who took care of Resident #8 and had applied the splint to his/her left arm on all the days she worked since the beginning of the week, which was Monday, Wednesday and Thursday, as the resident had requested the splint to be applied. NA #2 identified that if a resident utilized a splint or splint it would be written in the electronic nurse's aide care card. However, upon reviewing the nurse aide care card of resident #8's with NA #2, she failed to identify on the care card that Resident #8 utilized a splint to the left arm. Interview with the Occupational Therapist Assistance (OT #1) on 9/26/24 at 12:00 PM identified that when a resident utilizes a splint/splint at home and it is brought into the facility, the nursing staff should notify the therapy department for it to be evaluated. OT #1 was asked if a physician's order would be needed if the splint was not a part of the occupational therapy care goals, which she identified that a physician's order would be required as the order would direct how and when to apply and remove the device and when to check the resident's skin integrity. OT #1 identified that an order was necessary so that staff would be able to provide the resident with the appropriate care when utilizing the assistive device to meet the goal/purpose of the device usage. Interview with the DNS on 9/26/24 at 12:28 PM identified that Resident #8 should have had a physician's order directing the use of the splint to the left arm. The DNS identified that it was the responsibility of therapy to ensure that a physician's order was in place after they had evaluated the resident and trained the staff on how to apply and remove the splint. She further identified that the splint was visible to staff, and it was the responsibility of the nurses to ensure that therapy was aware, and orders were in place. Interview with the Charge Nurse (LPN #1) on 9/27/24 at 10:33 AM identified that she had observed Resident #8 wearing the splint to the left arm since admission to the facility and had assumed that all the necessary paperwork was completed (physician's order, nurse's aide care card, and care plan) and in place. Interview with the DNS on 9/27/24 at 11:10 AM identified that although the policy does not mention the requirement of a physician's order for assistive devices, it is the practice of the facility to have a physician's order in place along with a therapy evaluation, and education provided to staff. Interview with the Occupational Therapist (OT #2) and the Director of Rehabilitation on 9/27/24 at 11:40 AM identified that OT #2 completed Resident #8's admission evaluation and identified that Resident #8 utilized a splint to the left arm for positioning and comfort, following a surgery to the left elbow years ago. OT #2 further identified that she applied the splint to the left arm in the morning when caring for the resident. OT #2 identified that she had told the Director of Rehabilitation that Resident #8 utilized a splint but had not provided training to the staff. The Director of Rehabilitation identified that OT #2 mentioned that Resident #8 utilized a splint but assumed that she had followed the procedures that included an evaluation, and training of the staff followed by a written order in the resident's chart as this was the facility's practice. Review of the Assistive Devices and Equipment policy identified that the facility would maintain and supervise the use of assistive devices and equipment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for one of two residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided safely to prevent a fall. The findings included: Resident #1 was admitted to the facility with diagnoses that included dementia with behavioral disturbance, Alzheimer's disease, receptive-expressive aphasia, muscle weakness and lack of coordination. A nursing Fall Risk assessment dated [DATE] identified that Resident #1 was at high risk for falls due to history of falling, impaired gait and forgets limitations. The fall risk assessment directed to implement high risk fall prevention interventions. An admission Minimum Data Set (MDS) dated [DATE] identified that Resident #1 was severely cognitively impaired requiring extensive assistance of 2 staff for bed mobility and transfer, noted the resident did not ambulate in room or on unit. Additionally, the admission assessment noted Resident #1 needed extensive assistance with 1 staff member for movement on the unit. A care plan dated 3/24/22 identified that Resident #1 requires the use of antipsychotic medication for targeted behaviors of biting, hitting, kicking, and banging and due to her/his diagnosis of dementia directed staff to keep environmental stimuli to a minimum. The care plan for at risk for falls due psychotropic medication use, impaired cognition and decreased mobility dated 3/16/22 and updated 3/26/22 noted the resident sustained a fall on 3/26/22. Interventions included floor mats, slipper socks when in bed and bed in low position. A nursing fall risk assessment dated [DATE] identified that Resident #1 was at high risk for falls due to history of falling, secondary diagnosis and forgets limitations. The fall risk assessment directed to implement high risk fall prevention interventions. A physician's order dated 4/1/22 noted Resident #1 is alert and oriented times 1 (knows who s/he is but not the time of day or where s/he is at) requiring multi-modal cuing (verbal, visual and touch) to complete her/his activities of daily living. An Occupational Therapy evaluation note dated 4/28/22 identified that Resident #1 had decreased trunk control affecting ability to perform lower extremity dressing with static (still) balance deficits as evidenced by decreased ability to maintain upright sitting requiring cues (reminders either verbal or touch) due to decreased attention span. A Speech Therapy evaluation note dated 4/28/22 identified that Resident #1 has difficulty with short term memory recall that impacts safety and increases fall risk as well as deficits in judgement. Decision making ability is impacted due to decreased safety awareness. A nursing progress not dated 5/22/22 at 7:53 PM identified that Resident #1 had a witnessed fall in the morning at 9:30 AM. Resident #1 was seated on the bench, leaned too far to the right, and slid off the bench to the floor, landing on her/his right arm. No injury noted. A facility Post Fall Investigation form dated 5/22/22 at 10:30 AM completed by RN #2 identified that Resident #1's cognitive and behavioral factors at the time of the fall included confusion /memory impairment, poor safety awareness and balance problems identifying herself and OT #2 as the only witnesses to the fall. Interview with RN #2 on 6/22/22 at 9:00 AM identified that she was the nurse on shift on 5/22/22 but did not witness the fall. She arrived on the scene Resident #1 was already on the floor. She stated that she had assessed Resident #1 and there were no visible injuries. She continued by stating that Resident #1 gets very agitated at times especially when s/he is in her/his wheelchair as s/he likes to have her/his feet flat on the ground. RN #2 further indicated the NAs transferred the resident to the bench to try to calm Resident #1. She could not recall ever seeing Resident #1 on the bench prior to that day. She continued by stating she did not believe it was a safe place for Resident #1 to be placed on the bench as it only had support on either side pointing to the bench (2-person width, with back support with an approximately 48-inch-wide seating area with arm rests on either side) in front of the nurse's station. RN # 2 could not recall if anyone was at the desk when she arrived or in the area other than OT #2 who had seen Resident #1 fall. Interview with Occupational Therapist (OT #1) on 6/22/22 at 10 :00 AM identified that she would not have recommended that Resident #1 be transferred to the bench from the wheelchair. She was aware Resident #1 became agitated by being in her/his wheelchair at times. OT #1 continued by stating that the primary concern with the bench was not Resident #1's trunk balance but that Resident #1 had poor safety awareness. While Resident #1 was on the bench, s/he would require contact and/or verbal cuing (reminders) by a staff member to stay safe due to the resident's impulsive behavior. Resident #1 should have been supervised to maintain her/his safety. Interview with NA #1 on 6/22/22 at 11:00 AM identified that on 5/22/22, Resident #1 was in the dining room for breakfast in her/his wheelchair and was becoming increasingly anxious in the chair. Resident #1 continued to fidget in her/his wheelchair and began banging on the table becoming increasingly upset and agitated. NA #1 further indicated that she knew Resident #1 did not like her/his new wheelchair and at times just removing the footrests would calm Resident #1 down, but it did not affect Resident #1's behavior at that time. NA #1 thought it was the footrests that upset Resident #1 as in her experience with Resident #1, Resident #1 would sometimes calm down if her/his feet were on the ground. NA #1 stated that Resident #1 was continuing to become more fidgety and when Resident #1 started to bang on the table, she wheeled Resident #1 into the common area in front of the nurse's station, got another NA to help and proceeded to transfer Resident #1 to the bench, thinking that would make Resident #1 more comfortable and would help her/him calm down. NA #1 continued by stating that she and NA #2 left the Resident #1 on the bench as s/he seemed calmer, and both returned to work with the other residents and did not let anyone know Resident #1 had been agitated and that she had transferred her/him out of the wheelchair. NA #1 stated that she should not have left Resident #1 alone on the bench without making sure someone was keeping an eye on Resident #1. NA #1 continued by stating that the bench was in the common area, and she thought that Resident #1 would always be within eyesight of someone. NA #1 also indicated that she did not see any staff member in the immediate area and since the incident, she was educated that she should have stayed with Resident #1 to monitor her/him after she transferred Resident #1 out of her/his wheelchair. NA #1 continued by stating that she had not transferred Resident #1 previously to the bench but had worked with the Resident #1 a lot over the past few months. NA #1 continued that stating that she had been focusing on getting Resident #1 to a place where the resident's feet could touch the floor. Interview with the Unit Manager (RN #1) on 6/22/22 at 12:30 PM identified that the incident with Resident #1 had occurred on the weekend and she was not on shift that day. She continued by stating she would expect if a NA transferred an agitated resident from a wheelchair to another seat in order to address the resident's agitated behavior, she would expect the NA to stay with the resident and to also report the incident to the nurse. RN #1 continued by saying she was aware that Resident #1 could become agitated when she was in her/his wheelchair, and she would expect the staff to observe the resident to provide if needed cueing to the resident for safety if on the bench. Interview with Certified Occupational Therapy Aide (COTA) # 2 on 6/22/22 at 1:00 PM identified that she was down the hallway and assisting another resident when she saw Resident #1 from afar roll to the right and slip off the bench. She was unable to respond quick enough to provide any verbal or touch redirection or to prevent the fall. She identified that she did not observe any staff in the area as she approached Resident #1. She continued by stating that due to Resident #1's poor safety awareness she would have anticipated that a staff member be within visual distance of the Resident #1 to provide appropriate cuing to maintain safety. Interview with the Director of Nurses on 6/23/22 at 10 :00 AM identified it was reported to her that Resident #1 was transferred safely to the bench in the past without incident although, she never observed this herself and that her investigation concluded that the staff had followed the plan of care. The DNS further indicated after the fall, the care plan was updated on 5/23/22 to direct that Resident #1 should not be left alone when sitting in a standard chair or on the bench. The facility policy Falls and Fall Risk, Managing directs in part based on previous evaluations and data, staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling. Although requested the facility could not provide a policy for identification of high risk fall interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews and a review of the facility policy, for four of five residents (Resident #6, #8, #10, and #15), reviewed for immunizations, the facility failed to ensure an immunization program for the prevention of pneumococcal pneumonia in accordance with the standards of practice. The findings include: 1. Resident #6 who was born in 1929, was admitted to the facility on [DATE] with diagnoses that included pneumonia, anemia, heart failure, renal insufficiency and was dependent on supplemental oxygen. Physician's orders dated 6/20/19 failed to identify an order for Pneumococcal vaccinations. Review of facility immunization informed consent form dated 6/20/19 identified Resident #6 declined Pneumococcal (PPSV 23) vaccine at the facility due to having already received this vaccine. A date as to when PPSV 23 was administered was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. The admission Minimum Data Set (MDS) dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. 2. Resident #8 who was born in 1937, was admitted to the facility on [DATE] with diagnoses that included a fractured femur and pneumonia. Review of facility immunization informed consent form dated 3/29/19 identified Resident #8 had been administered PPSV 23 prior to admission, however a date was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. The quarterly MDS dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. Physician orders dated 4/16/19 failed to direct the administration of Pneumococcal vaccinations. 3. Resident #10 who was born in 1920, was admitted to the facility on [DATE] with diagnoses that included a left femur fracture, and a history of a cerebral vascular accident. The admission orders dated 7/15/16 failed to identify the administration of Pneumococcal vaccines. Review of the clinical record failed to identify if Pneumococcal vaccines had been administered and/or if they were consented for. The annual MDS dated [DATE] identified intact cognition and the Pneumococcal vaccine was up to date. 4. Resident #15 who was born in 1933 was admitted to the facility on [DATE] with diagnosis that included a fractured right tibia, dementia with behavioral disturbance, and a delusional disorder. The MDS dated [DATE] identified moderate cognitive impairment and the Pneumococcal vaccine was up to date. Physician orders dated 8/16/19 failed to identify an order for Pneumococcal vaccines. Review of immunization informed consent form dated 8/18/19 identified Resident #15 had been administered PPSV 23 prior to admission, however a date was not identified. In addition, information regarding the administration of Prevnar (PCV 13) was not obtained. Interview with the infection control registered nurse (ICRN) on 10/9/19 at 11:25 AM identified Prevnar (PSV) 13 was not administered by the facility as the Medical Director indicated it was difficult to obtain accurate vaccination records and/or information from the residents on past vaccination schedules. Although requested, a tracking log for immunizations was not provided by the facility, as they do not utilize one. Further interview with the ICRN indicated all immunizations are in the computer however, the date of administration was not documented as the residents did not usually know when the immunization was administered. Other means of obtaining vaccination information was not conducted by the facility. A statement received from the Medical Director on 10/9/19 identified Prevnar 13 was not offered at the facility as the short term population typically discharges from the facilty prior to one year. Additionally, the Medical Director identified long term residents are not offered Prevnar 13 vaccine due to a unknown history of vaccine administration. The facility policy entitled Pneumococcal Vaccination of Residents directed in part that a Resident or responsible party would be asked on admission if they have previously had Pneumococcal vaccinations, and their age at the time of vaccination. If there was no prior evidence of the vaccinations, the vaccine would be offered to the resident at that time. The facility failed to address the administration of both Pneumococcal vaccinations in accordance with the guidelines from the Centers of Disease Control.