Based on record review, observation and interview the facility failed to ensure infection control practices were maintained during wound care for 1 (#120) of 2 (#78, #120) wound care observations. Findings: Review of the record for resident 120 revealed diagnoses in part: stage 3 pressure ulcer sacral region dysphagia, aphasia, cognitive communication deficits, hypertension, type 2 diabetes, adult failure to thrive, crohn's disease of the small intestine, pneumonia, neuromuscular dysfunction of bladder, and chronic obstructive pulmonary disease. Review of the April 2025 Physician orders revealed the following active orders: 04/10/2025 Clean stage 3 pressure ulcer to sacrum with wound cleanser, pat dry with 4 by 4, apply sure prep to periwound, apply collagen then Opticell silver to wound bed, cover with border foam dressing on Monday, Wednesday, and Friday and as needed if dressing becomes soiled/dislodged until resolved. On 04/30/2025 at 11:07 a.m., an observation of wound care by S3Registered Nurse (RN), Wound Care Nurse to resident #120 was conducted in the resident`s room. Observation revealed S3RN Wound Care Nurse sprayed dermal wound cleanser onto the sacral wound from the bottle that was dated 04/19/2025 and dried the area with a 4 by 4 gauze. S3RN Wound Care Nurse then got a small piece of collagen and attempted to place it on the sacral wound but it fell off onto resident #120's brief. S3RN Wound Care Nurse then got a piece of Opticell silver and picked up the collagen that had fallen on the resident's brief and placed it back on the wound, then applied the protective wipe and then border gauze dressing. On 04/30/2025 at 11:10 a.m., an interview with S3RN Wound Care Nurse confirmed she picked up the collagen dressing off of the resident #120's brief and placed it back on the wound after it fell in resident's brief. On 04/30/2025 at 11:48 a.m. review of the findings with S2Director of Nurses (DON) acknowledged S3RN Wound Care Nurse should not have picked up the dressing from the brief and placed it on the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#112) of 2 (#58 and #112) residents reviewed for restraints. The facility failed to identify that resident #112 had a wheelchair seatbelt in place. Findings: Review of the facility's undated Physical Restraint Policy revealed the following, in part: A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy specifies that devices that are used in conjunction with a chair such as trays, tables, bars or belts that the resident cannot remove easily and prevent a resident from rising out of the chair are included as restraints. Additionally, the undated Physical Restraint Policy specified that informed consent must be obtained prior to initiation of a restraint. Before a resident is restrained, the facility must complete a pre-restraining assessment and they must demonstrate the presence of a medical symptom that requires the use of restraints, and how the use of restraints would treat the medical symptom, protect the resident's safety, and assist in reaching the highest level of physical and psychological well-being. A physician's order is also necessary for the use of physical restraints and must be very specific. Use of restraints must be included in each resident's plan of care, addressing what restraint to use, when to use it, why it is used and measures to prevent decline in status. Review of the medical record for resident #112 revealed an admission date of 01/12/2024 with diagnoses including type 2 diabetes mellitus, monoplegia of upper limb following non-traumatic subarachnoid hemorrhage affecting right dominant side, abnormalities of gait and mobility, unsteadiness of feet, and paranoid schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that resident #112 was cognitively intact. Further review of the MDS revealed physical restraints were not in use for resident #112. Review of the April 2025 Physician's Orders revealed no order for a wheelchair seatbelt for resident #112. Review of resident #112's current plan of care revealed no documented evidence related to the use of a wheelchair seatbelt. Observations on 04/28/2025 at 1:29 p.m. and 04/29/2025 at 3:13 p.m. revealed resident #112 was seated in a wheelchair with a seatbelt in place and secured. On 04/30/2025 at 11:51 a.m., resident #112 was observed in the therapeutic dining area in a wheelchair. S8Restorative Certified Nursing Assistant (CNA) visually confirmed that a wheelchair seatbelt was in place and secured. On 04/30/2025 at 12:00 p.m., S2Director of Nursing (DON) was notified that resident #112 had a wheelchair seatbelt in place and secured. S2DON was also notified there was no documentation related to the use of the wheelchair seatbelt. S2DON confirmed he was unaware there was no physician order for resident #112's wheelchair seatbelt and that the resident currently had a wheelchair seatbelt in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible; and each resident received assistance devices to prevent accidents by failing to ensure a thorough investigation and appropriate interventions were initiated after each incident for 1 (#49) of 4 (#38, #49, #81, #107) sampled residents revealed for accidents. Findings: Review of the undated facility Accident/Incident Reports: Resident policy revealed the following, in part: Purpose: To assure appropriate follow-through on all accident/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action. Procedure: 10. Note the location and the time of the incident, the names of witnesses, and the exact circumstances of the incident. 12. Chart an objective account of the incident in the nurses' notes in the resident's medical record to include: b. Witnesses - their description of the incident. 14. Send accident/incident report to the Director of Nursing who: d. Submits accident/incident form and follow-up assessment form to Administrator, who then reviews the forms. All accident/incident reports are reviewed for causes, trends, patterns, and preventive measures. Review of the record revealed resident #49 was admitted to the facility on [DATE] with diagnoses including overactive bladder, mild vascular dementia with other behavioral disturbance, aphasia following unspecified cerebrovascular disease, muscle wasting and atrophy, lack of coordination, difficulty in walking, other reduced mobility, unsteadiness on feet, cognitive communication deficit, peripheral vascular disease, other specified depressive episodes, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated resident #39 had severe cognitive impairment. Further review revealed she required extensive - 2 person assistance with most activities of daily living and used a walker for ambulation. An observation of resident #49 on 04/28/2025 01:35 p.m. revealed she was ambulating in the hall with a rolling walker. Resident #49 had a large purple bruise and small dressing observed on the back of her right hand. An interview with resident #49 revealed she was alert but confused. Resident #49 reported she was unsure of what happened to her right hand. Review of resident #49's current care plan revealed she was at a high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs. Further review revealed the resident used a walker for ambulation. Review of the facility Incident Accident Report dated 04/09/2025 at 6:45 a.m. revealed S6Licensed Practical Nurse (LPN) was called to resident #49's room by staff a member. There was an open area to her left lower arm. The area was round and approximately the size of a half dollar coin with no bleeding noted. The walker was found across the room against the wall. The incident was not witnessed and the resident was unable to give a description of incident. Further review revealed S7Registered Nurse (RN) followed up on the above incident on 04/10/2025. When S7RN asked the resident what happened, resident #49 pointed to the handle on the rolling walker and stated I hit my hand on that. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/09/2025. Review of the facility Incident Accident Report dated 04/10/2025 at 6:35 a.m. revealed S6LPN was called to resident #49's room. A superficial skin tear approximately 3 centimeters (cm) round was noted on her lower right forearm surrounded with dark red and purple bruising. Bruising to the back of her right hand was also noted. Resident #49 was unable to give a description of the accident. S7RN followed up on the above incident on 04/11/2025. When she asked the resident what happened, resident #49 pointed to the handle on the rolling walker and stated I hit my hand on that. Geri-Sleeves were in place to bilateral arms. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/10/2025. There was no documentation of the following: an appropriate intervention to address the bruising to the resident's right hand and no evaluation of the resident's walker by therapy to ensure safety. Review of the Rehabilitation Screen - Physical/Occupational Therapy dated 04/10/25 revealed she was screened for rocking with transfers and a skin tear on 04/10/2025. Therapy was not recommended for resident #49 at that time. Further review revealed there was no documentation that therapy addressed the issue regarding potential safety concerns with the resident's rolling walker handle. Review of the facility Incident Accident Report dated 04/11/2025 at 6:39 a.m. revealed S4LPN entered resident #49's room to administer morning medications. S4LPN noticed a dried skin tear to right hand and no blood noted. S4LPN also noticed dried blood noted to left side of cheek and underneath fingernails. Discoloration was noted to the back of resident #49`s right hand. Resident had been scratching her hand causing skin tear and rubbed her face with right hand causing the dried blood to the left side of her cheek. The resident's fingernails were cut to prevent further injury. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/11/2025. Review of the Electronic Heath Record nurse's note dated 4/11/2025 at 07:40 a.m completed by S11LPN, revealed resident #49 was sitting on bench in front of the chapel as she was walking up the hallway. S11LPN stopped to talk with the resident #49 and she reached and grabbed the brakes, pushed them down (locked them) and then started to rock back and forth. Resident #49 then reached to grab the handle bar and hit her right hand on handle bar as she was pulling herself up. She shook her hand, looked at me, and laughed, It got me. A phone interview with S11LPN on 04/30/2025 at 3:30 p.m. revealed in her above nurses' note she had asked resident # 49 to demonstrate how she works the brakes on her rolling walker since she had an incident on 04/10/2025 where the resident bumped her hand on the handle of her rolling walker. S11LPN confirmed the above notation regarding resident #49 was not describing another incident and revealed the documentation was not clear. The facility failed to conduct a thorough investigation of resident #49's 04/11/2025 incident by not identifying the discrepancy with the 04/11/2025 nurses' note by S11LPN and the 04/11/2025 incident report completed by S4LPN. An interview with S2Director of Nursing (DON) on 04/30/2025 at 3:15 p.m. confirmed the following: there were no thorough investigations and no witness statements obtained regarding resident # 49's incidents on 04/09/2025, 04/10/2025, and 04/11/2025; no therapy evaluation of resident #49's rolling walker for the 04/09/2025 and 04/10/2025 incidents; and no appropriate intervention for the resident sustaining an injury to her right hand for the 04/10/2025 incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that an indwelling catheter was not used unless there is valid justification for catheterization and the catheter was discontinued as soon as clinically warranted for 1 (#70) of 3 (#70, #68, and #78) residents reviewed for urinary catheter or urinary tract infection. Findings: Review of the facility's undated Catheterization, Urinary: In and out, indwelling and suprapubic (Male and Female) Policy revealed the following, in part: an indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary dysfunction. Examples of clinical conditions demonstrating that catheterization may be unavoidable include: . , 2. Skin wounds, pressure sores, or irritations that are being contaminated by urine, 3. Terminal illness or severe impairment, which makes bed and clothing changes uncomfortable or disruptive. The facility is expected to show evidence of any medical factors which caused the intervention. Justification of catheter use should be found on the accumulative diagnosis form, catheter justification record, physician's order sheet, physician's progress note or plan of care. Review of the medical record for resident #70 revealed an admission date of 03/27/2025 with diagnoses that included chronic obstructive pulmonary disease, morbid obesity, age-related physical debility, lymphedema, chronic pain syndrome, and chronic osteomyelitis of right ankle and foot. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that resident #70 was cognitively intact. Further review of the MDS revealed that resident #70 was dependent on staff for activities of daily living including bed mobility, transfers, and toileting. The MDS also revealed that resident #70 had an indwelling catheter. Review of the resident #70's current Physician's Orders revealed an order dated 03/27/2025 for a 16French (FR)/10 cubic centimeters (CC) Foley catheter for urine collection related to the presence of a pressure ulcer to the sacrum. Further review of the Physician's Orders revealed that there were no orders for the treatment of a pressure injury to the sacrum for resident #70. Review of resident #70's skin assessment log revealed no documented evidence of the presence of a pressure ulcer to the sacrum. Review of resident #70's current plan of care revealed a plan to address skin conditions. The skin conditions care plan revealed no documented evidence of the presence of a pressure injury to the sacrum. Further review of the care plan addressed the use of a Foley catheter, and the indwelling catheter care plan documented the use of the catheter was due to the presence of a pressure injury to the sacrum. On 04/28/2025 at 9:40 a.m., resident #70 voiced that the indwelling catheter was in place due to bed sores. On 04/29/2025 at 8:56 a.m., an interview was conducted with resident #70 who confirmed that her wound was healed. On 04/29/2025 at 2:13 p.m., a follow-up interview was conducted with resident #70 who stated that her indwelling catheter is in place because she cannot walk. On 04/29/2025 at 9:16 a.m., an interview was conducted with S3Registered Nurse Wound Care who confirmed that resident #70 did not currently have a pressure ulcer to the sacrum. On 04/30/2025 at 3:41 p.m., S2Director of Nursing (DON) was informed that the indwelling catheter justification for resident #70 was inappropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#70, #76, #120) of 3 (#70, #76, #120) residents reviewed for respiratory care. The facility failed to ensure: 1) water in the humidifier bottle on the oxygen concentrator was changed weekly and oxygen tubing was stored properly for resident #70), 2) nebulizer hand pipe was dated and stored properly for resident #76, and 3) oxygen tubing was dated and oxygen concentrator filter was clean for resident #120. Findings: Review of the facility's undated Oxygen Administration (Concentrator or Tank) Policy revealed that humidifier bottles, cannulas, and Oxygen (O2) tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag. Resident #76 Review of the record for resident #76 revealed diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, bronchitis, extended spectrum beta lactamase (ESBL) resistance, apraxia following cerebral infarction, dysphagia, resistance to multiple antibiotics, and cognitive communication deficit. Review of the resident #76's current Physician's orders revealed an order dated 01/30/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligram (mg)/3 milliliter (ml) 1 vial inhale orally four times a day related to wheezing per handheld nebulizer for the diagnoses of wheezing. Record minutes of nebulizer treatment. Also, listen to resident's lungs with stethoscope for abnormal breath sounds after treatment. 0 = Clear lung sounds 1 = crackles, rales, rhonchi, wheezing or rub. Review of a physician order dated 10/07/2024 revealed to change nebulizer tubing, medication chamber, and mask weekly every night shift every Wednesday. On 04/28/2025 at 03:55 p.m., an observation of the bedside table in resident #76's room revealed the nebulizer hand held pipe was lying on top of the table with no cover and was not dated. On 04/29/2025 at 3:17 p.m., an observation of resident #76's nebulizer hand held pipe with S2Director of Nurses (DON) revealed the date on the nebulizer only read 4/1. S2DON said the rest of the date must have wiped off due to the nebulizer liquid. On 04/30/2025 at 9:10 a.m., an observation again of the nebulizer hand held pipe revealed it was lying on the floor uncovered. On 04/30/2025 at 9:15 a.m., an interview with S2DON confirmed the nebulizer hand held pipe should not be lying on the floor. Resident #120 Review of the record for resident #120 revealed diagnoses in part of dysphagia, aphasia, cognitive communication deficits, hypertension, type 2 diabetes, adult failure to thrive, other nonspecific abnormal finding of lung field, pneumonia on 02/12/2025 and 03/21/2025, and chronic obstructive pulmonary disease. Review of the physician orders revealed an order dated 04/08/2025 for oxygen at 2 liters per minute by nasal cannula as needed for oxygen saturation less than 94%. On 04/28/2025 at 3:53 p.m., an observation of resident #120 revealed she was wearing the oxygen per nasal cannula at 2 liters per minute. Observation of the oxygen tubing revealed there was no date on the tubing, and there was a dust build up on the filter on the back of the oxygen concentrator. Observations of the oxygen concentrator on 04/29/2025 at 11:53 a.m. and 04/29/2025 at 2:15 p.m., again revealed there was no date on the oxygen tubing and a buildup of dust was on the filter on the back of the oxygen concentrator. On 04/29/2025 at 3:16 p.m., observation of resident #120's oxygen tubing and oxygen concentrator with S2DON revealed the oxygen tubing did not have a date and there was a buildup of dust on the filter on the back of the oxygen concentrator. S2DON confirmed at that time there was no date on the oxygen tubing and the filter on the back of the oxygen concentrator had dust particles. Resident #70 Review of the medical record for resident #70 revealed an admission date of 03/27/2025 with diagnoses that included chronic obstructive pulmonary disease, morbid obesity, age-related physical debility, lymphedema, and chronic pain syndrome. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 which indicated that resident #70 was cognitively intact. Further review of the MDS revealed resident #70 had oxygen therapy. Review of the Physician's Orders revealed an order dated 03/27/2025 to change O2 tubing, nasal cannula, humidifier bottle, and clean filter weekly every night shift every Wednesday. Review of the April 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed resident #70's oxygen tubing/humidifier bottle was last changed on 04/23/2025. On 04/29/2025 at 8:56 a.m., resident #70 was observed lying in bed with nasal cannula hanging on the bed rail and the humidifier bottle was dated 04/17/2025. On 04/29/2025 at 2:13 p.m., resident #70 was observed lying in bed, and the humidifier bottle was dated 04/17/2025. On 04/30/2025 at 9:16 a.m., an interview was conducted with S6Licensed Practical Nurse (LPN) regarding nasal cannula storage, and she reported the nasal cannula should be stored in a storage bag when not in use. The surveyor and S6LPN observed resident #70's nasal cannula tubing lying on the floor in her room and she confirmed the nasal cannula tubing was not stored properly. On 04/29/2025 at 2:17 p.m., S2DON was interviewed regarding the facility policy for oxygen tubing, nasal cannula, and humidifier bottle. S2DON confirmed resident #70's respiratory equipment should be changed out every Wednesday night.

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles by failing to put an open date on multidose medications for residents #41, #59, #61, #77, #92 and by failing to ensure there were no expired medications available for resident use that were stored in the stock cabinet. Findings: On 04/30/2025 at 2:17 p.m. observation of medication cart 1 with S4Licensed Practical Nurse (LPN) revealed an opened Fluticasone Propionate nasal spray for resident #41 did not have an open date written on the medication container. Observation of an open bottle of artificial tears for resident 77 revealed there was no open date written on the medication container. Observation of an open bottle of Brimonidine eye drops 0.2%, for resident 92 revealed there was no open date written on the medication container. On 04/30/2025 at 2:20 p.m., an interview with S4LPN confirmed the open medications did not have an open date written on them. On 04/30/2025 at 2:45 p.m. observation of medication cart 4 with S5LPN revealed an opened Fluticasone Propionate nasal spray 50 micrograms (mcg) container for resident 59 that did not have an open date written on the medication container. Observation of an opened Nova log 70/30 flex pen for resident 61 revealed there was no open date written on the medication container. Observation of the medication stock cabinet in the front nurses' station revealed an open bottle of Vitamin D 25 micrograms (mcg) with and expiration date of 01/2025. On 04/30/2025 at 2:50 p.m., an interview with S5LPN confirmed the medications for resident 59 and 61 did not have an open date written on the medication container. S5LPN confirmed the Vitamin D 25 mcg in the stock cabinet was expired and available for resident use. On 4/30/2025 at 3:00 p.m. observation of cart 2 with S6 LPN revealed an open bottle of artificial tears with no open date written on the container. At that time an interview with S6LPN confirmed the artificial tears did not have an open date written on the medication container.

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that food was dated and stored properly. This deficient practice had the potential to affect all residents who received meals served from the kitchen. Findings: On 04/28/2025 at 8:50 a.m., observation revealed three bulk storage containers for sugar, flour, and cornmeal covered with clear plastic lids in the food service area. All three lids had dirt and grime build-up on the lids and the front of the containers were visibly soiled. Additionally, multiple products in the dry food storage room were open and did not have the open date documented. The undated items were: 128 ounces (oz) light corn syrup, a large bottle of blended oil, a large open box with ¼ full bag of rice left open to air and undated. Further observation revealed a dented 6 pound 9oz can of peaches. On 04/30/2025 at 1:30 p.m., an interview with S12Dietary Manager confirmed the above areas should have had an opened date and/or should have been cleaned.

Based on observations and interviews, the facility failed to ensure that essential kitchen equipment was maintained in safe operating condition. This deficient practice had the potential to affect all residents who received meals served from the kitchen. Findings: On 04/28/2025 at 9:05 a.m., there were two large ice chests on rolling stands full of ice. The ice scoops were not stored properly and were observed uncovered on top of the ice inside of the ice chests. The deep fryer was observed to have a large amount of old grease and grime build-up on the lower compartment of the deep fryer. Both of the large capacity ovens were in need of cleaning as evidenced by the food spills and splatters on the inner and outer oven doors. The large can opener had a large amount of old food build-up and there were old food spills and splatters observed inside of the microwave. On 04/30/2025 at 1:30 p.m., an interview with S12Dietary Manager confirmed the above areas should have been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide assistance for a resident who was unable to carry out activities of daily living and received the necessary services to maintain good grooming, and personal hygiene for 1(#75) of 2(#64, 75) residents investigated for ADL (activities of daily living) care. Findings: Resident #75 On 02/28/23 at 08:50 am Resident #75 was observed in her room with long dirty fingernails to both hands. On 02/28/23 at 10:30 am an observation of Resident #75 in her room revealed she had long dirty fingernails to both hands that were in need of nail care. Record review revealed Resident #75 was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included vascular dementia and cerebrovascular accident resulting in paralysis of left side. Record review revealed a completed quarterly MDS (minimum data set) assessment was completed on 02/16/2023. Review of the quarterly MDS assessment revealed in section G - Functional Status revealed Resident #75 had total dependence on staff to maintain personal hygiene. Review of care plans revealed an active care plan acknowledging Resident #75 had a self care deficit related to activities of daily living with an intervention in place that required nursing staff to keep fingernails trimmed and clean. On 02/28/23 at 12:38 pm an observation and interview was conducted with S4 LPN in the room of Resident #75. S4 LPN confirmed Resident #75 had long dirty fingernails to both hands that were in need of nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 (#320) of 4(#97, 322, 1, 320) residents investigated for position/mobility. The failed practice was evidenced by facility staff failing to apply a brace to the right hand of Resident #320 as ordered per the physician. Findings: Resident #320 Record review revealed Resident #320 was a [AGE] year old female admitted to the facility on [DATE] with active diagnosis that included CVA (cerebrovascular accident), muscle wasting and contracture of right hand. Review of the POC (plan of care) revealed Resident #320 was dependent on facility staff for all ADL (activities of daily living) care. The POC also revealed Resident #320 had cognitive impairment and was unable to sit upright, stand or walk. The POC also revealed Resident #320 was dependent on staff for all activities of daily living and mobilization. Review of physician orders revealed the following active order: Apply resting hand splint to right hand for up to 23 hours/day for contracture management. May remove for bathing and to observe skin each shift to ensure integrity is intact. Review of the MAR (medication administration record) revealed the nursing staff had signed the electronic record acknowledging they had placed the splint to the right hand of Resident #320 on 03/01/23 at 05:00 am, 02/28/2023 at 05:00 pm, 02/28/2023 at 05:00 am, 02/27/2023 at 05:00 pm and 02/27/2023 at 05:00 am, 02/26/2023 at 05:00 pm, 02/26/2023 at 05:00 am, 02/25/2023 at 05:00 pm, 02/25/2023 at 05:00 am and 02/24/2023 at 05:00 pm. On 02/27/23 at 01:39 pm Resident #320 was observed in her bed with no splint placed on her right hand. On 02/28/23 at 03:08 pm Resident #320 was observed in her bed with no splint applied to her right hand. On 03/01/23 at 09:00 am Resident #320 was observed in bed with no splint observed to the right hand. On 03/01/23 at 09:45 am an interview with S5Therapy Director was conducted in her office. S5 Therapy director confirmed Resident #320 had a contracture to the right hand and a splint was ordered on 02/24/2023 for the right hand of resident #320. S5Therapy Director revealed a splint for Resident #320 had been stored in the therapy office since 02/24/2023. On 03/01/23 at 11:44 am S5 Therapy Director reported she found a second splint in Resident #320`s room in the drawer of the nightstand of Resident #320`s room. S5 Therapy Director confirmed Resident #320 did not have a splint in place to the right of Resident #320 as ordered. On 03/01/23 at 12:45 pm an interview with S2 DON (director of nursing) confirmed Resident #320 should have had the splint to the right hand in place as ordered.