**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a splint was in place to prevent worsening of contractures for 1 resident (Resident #42) of 4 residents reviewed for splints. The findings include: Review of the facility policy titled, .Brace/Immobilizers/Splints .date revised 2/1/2022 revealed .Apply brace/immobilizer/splint to appropriate extremity per MD [medical doctor] order/Therapist instructions . Resident #42 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease, Dysphagia Following Cerebral Infarction, and Major Depressive Disorder. Medical record review of the Active Orders Report revealed an order dated 8/10/2021, for OT (occupational therapist) splint order resident to wear LT (left) resting hand splint day time hours on day shift. Medical record review of an OT discharge order dated 1/28/2022, revealed discharge recommendations splint/brace .restorative program established/ trained . Observation on 2/14/2022 at 3:05 PM, 2/15/2022 at 7:50 AM, and 9:35 AM, revealed resident resting in bed without the LT splint in place. Continued observation and interview on 2/15/2022 at 9:38 AM, with Certified Nursing Assistant (CNA) #1, in the resident room, revealed the splint on a bookcase and not on the resident. Continued interview with CNA #1 revealed the therapy staff were responsible for ensuring splints were on. Interview on 2/15/2022 at 9:40 AM, with Charge Nurse #1, on the 300 hall revealed therapy staff placed the splint for Resident #42. Interview on 2/15/2022 at 9:45 AM, with the OT, in the therapy room, revealed the OT discharged the resident 3 weeks ago and was being seen by Restorative Nursing currently. Interview with the Restorative Aid on 2/15/2022 at 9:50 AM, outside the therapy room, revealed the Restorative Aid was responsible for ensuring the splint for Resident #42 was in place. Continued interview confirmed the Restorative Aid failed to put the splint in place yesterday (2/14/2022) until 5:30 PM and failed to put the splint in place today (2/15/2022) . Interview with the Director of Nursing (DON) on 2/16/2022 at 11:10 AM, in the conference room, confirmed the facility policy on splints was not followed for Resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to prevent a fall for 1 resident (Resident #20) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, .Fall Prevention Program . dated 10/1/2021, revealed .The Fall Prevention Program is designed to ensure a safe environment for all Residents. Each Resident is evaluated by an RN [Registered Nurse]/ LPN [Licensed Practical Nurse] to assess his/her individual level of risk . Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Heart Failure, and History of Falling. Continued medical record review of the resident Plan of Care original date 2/20/2018 revealed .fall risk .I may fall because of muscle weakness, fall history . Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 required extensive assist of 2 staff for transfer. Review of a facility investigation dated 12/8/2021, revealed .CNA [Certified Nursing Assistant] was attempting to transfer resident .with 1 assist when resident became weak and fall [fell] .nurse assessment noted no visible injuries and resident had no complaints of pain . Interview with the Assistant Director of Nursing (ADON) on 2/16/2022 at 8:17 AM, in the ADON office, confirmed the CNA transferred resident without assistance resulting in the fall. Interview with CNA #2 on 2/16/2022 at 10:02 AM, by phone, confirmed the CNA had attempted to transfer resident without assistance and the resident fell. Interview with the Director of Nursing (DON) on 2/16/2022 at 11:08 AM, in the conference room, confirmed the facility policy on falls was not followed.