Based on observations, interviews, and record review conducted during a Standard survey completed on 6/14/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #58) of three residents reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #58's right hand splint was worn at all times as ordered and care planned. The finding is: The policy and procedures titled Assistive Devices and Equipment, revised on 1/2024, documented that devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to wheelchairs (manual and powered), walkers, canes, adaptive devices etc. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Resident #58 had diagnoses of cellulitis (a bacterial skin infection), urinary tract infection, and adult failure to thrive (a state of decline that is multifactorial). The Minimum Data Set (a resident assessment tool) dated 4/4/24, documented Resident #58 had severe cognitive impairment and could not understand others or was not understood by others, and had a right upper extremity functional limitation in range of motion. The Comprehensive Care Plan dated 6/1/24, documented that a right functional hand splint was to be worn at all times during the day and at bedtime. It could be removed for hygiene, range of motion or functional tasks. The staff were to monitor for signs of discomfort every shift. Review of Resident Orders dated 2/2/24, documented a right functional hand splint was to be worn at all times during the day and bedtime. It could be removed for hygiene and range of motion or functional tasks. Staff were to monitor for signs of discomfort every shift, day, evenings, and overnights. During an observation and interview on 6/10/24 at 11:55 AM, Resident #58 was observed in their wheelchair in the hallway with a family member. Resident #58 did not have their functional hand splint on. The family member stated that Resident #58 should wear a splint on their right hand. During an observation on 6/12/24 at 10:47 AM, Resident #58 was in the common area resting in their wheelchair and did not have their functional hand and splint on. The Resident demonstrated the inability to extend their right hand all of the way. During an observation and an interview on 6/14/24 8:47 AM, Resident #58 was in the television room without their functional hand split on. The device was attached to their wheelchair. When asked why they did not have their splint on they stated they never had it on. During an interview on 6/14/24 at 9:37 AM, Registered Nurse #1 stated that Resident #58 should wear a right-hand splint. Registered Nurse #1 observed the resident and stated they were not wearing their hand splint. Registered Nurse #1 checked the residents care plan and stated the resident was care planned to wear the functional splint at all times. Registered Nurse #1 stated this was important because it was a therapy recommendation, and they may have a contracture. During an interview on 6/14/24 9:49 AM, Certified Nursing Assistant #3 stated that Resident #58 was compliant with their plan of care. They looked at the resident's care plan to verify if the resident was care planned for a functional hand splint. They stated that they did see the splint in the resident's chart. They stated the resident once wore a functional splint and but did not think they did anymore. During an interview on 6/14/24 10:09 AM with Certified Nursing Assistant #2, they stated Resident #58 normally wore a wrist splint. Certified Nursing Assistant #2 observed Resident #58 and stated they did not have it on. Certified Nursing Assistant #2 stated they were not familiar with the new kiosk system to look if the Resident had was care planned for a functional hand splint. They stated that they did not think that Resident #58 normally wore the splint. Certified Nursing Assistant #2 stated that it was important to check residents care plans and that the splint should be worn to so that the resident's hand does not further contract. During an interview on 6/14/24 at 10:32 AM with Occupational Therapist #1, they stated that Resident # 58 should be wearing a splint on their right hand and was care planned for this. They stated that Resident #58 could be confused but was compliant with wearing the splint and it was important to make sure they wore their splint to reduce contractures and stop them from getting worse. They stated it was important to not let the contracture get to the point where it closed and would become painful, and the splint was to help preserve the joints. They stated it was the nurse's responsibility to make sure they are following plan of care orders. During an interview on 6/14/24 at 10:57 AM, the Director of Nursing stated they expected that Resident #58 would wear the splint if they should and have staff put it on. They stated that it was the responsibility of the Unit Manager, but it was everyone's responsibility to make sure the resident's care plan was followed. They stated it was important to make sure splints were worn to prevent contractures and to prevent further decline in residents. During an interview on 6/14/24 at 11:04 AM, the Administrator stated staff should be well informed about the care plan of each resident and it was on the kiosk with the resident's profile. They stated all staff have received training on how to find information and utilize the electronic medical record and how to document and chart properly. They stated this was important to ensure that the residents care plan was being met. 10NYCRR 415.12(e)(2)

Based on interview and record review conducted during a Standard survey completed 6/14/24, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services or other clinically qualified nutrition professional. The finding is: The policy and procedure titled Food and Nutrition Services revised 1/2024 did not include qualifications and skills sets for clinically qualified nutrition professionals. Review of the undated job description job title Nutrition Service Director revealed the candidate must provide documentation of registry/certificate upon application for the position, must have training in cost control, food management, and diet therapy. Review of the undated job description job title Diet Tech revealed the purpose of the job position is to oversee nutritional well-being of residents by conducting nutrition assessments, identifying patients at risk, and creating diet plans. Qualifications listed included a two-year associate degree in Dietetics Education or related field. Review of the Facility Survey Report signed and dated 6/13/24 revealed Dietitian #1 was not the full-time dietetic service supervisor and Dietary Supervisor #2 (Food Service Director) was listed as the full-time dietetic service supervisor. Review of timecards dated 3/12/24 through 6/12/24 revealed Dietitian #1, a registered dietician, worked less than 35 hours per week at the facility. During an interview on 6/11/24 at 10:45 AM, Dietary Supervisor #2 stated they were hired as the Food Service Director for the facility this past September. They stated they were the full-time Food Service Director for the facility. They stated they did not have a certificate as a Certified Dietary Manager or a Certified Food Service Manager. They stated they had not completed any course of study in food safety and management. During an interview on 6/11/24 at 10:50 AM, Dietary Supervisor #1 stated they were the full-time Diet Tech at the facility. They stated they did not have any certification in food service management or nutrition and hospitality and had been hired as a Diet Tech three years ago after having been a Certified Nurse Aide at the facility. During an interview on 6/13/24 at 10:28 AM, Dietician #1 stated they did not work full time at the facility and that they worked there two days a week. During an interview on 6/13/24 at 3:41 PM, the Administrator stated the Dietician was available in the building a minimum of 2 days per week. They stated they thought Dietary Supervisor #2 (Food Service Director) and Dietary Supervisor #1 (Diet Tech) were qualified for their positions. The qualifications of the regulations were reviewed with the Administrator, and they stated the Food Service Director was not qualified for the position per the regulations. They stated it was important for Food Service Directors and/or Diet Techs to have the proper certifications, so the residents will receive safe and nutritious food and there will be not food related illnesses. 10NYCRR 415.14(a)(1)

Based on observation, interview and record review conducted during a Standard survey completed 6/14/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for one (Resident #307) of two residents reviewed for infection control practices during pressure ulcer care. Specifically, staff did not maintain proper hand hygiene during wound care and the resident was not on enhanced barrier precautions (infection control interventions including gown and glove use for high contact resident care activities designed to reduce transmission of multidrug-resistant organisms). The finding is: Review of the policy and procedure titled Hand Washing/hygiene dated 1/24 documented that all personal should follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. The use of alcohol-based hand rub or soap and water should be used for the following situations: before handling clean or soiled dressings, gauze pads; before moving from a contaminated body site to a clean body site during care; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment; after contact with objects in the immediate vicinity of the resident; and after removing gloves. The use of gloves does not replace hand washing/hygiene and integration of glove use along with routine hand hygiene was the best practice for preventing healthcare-associated infections. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with wounds even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Examples of wounds included chronic pressure ulcers. Enhanced barrier precautions were to be used when staff performed wound care for any skin opening that required a dressing. Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/24 documented that it was the policy of the facility to adhere to the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services guidelines as related to enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms. Enhanced barrier precautions were a Centers for Disease Control and Prevention recommendation to provide guidance for the use of personal protective equipment in facilities for preventing the spread of multi-drug resistant organisms. The facility would implement enhanced barrier precautions for any resident that had a chronic wound and would remain in effect until the resolution of the wound. Appropriate signage for the type of precaution would be posted on the resident's room door. Gown and gloves would only be needed when providing high-contact resident care activities. Resident #307 diagnoses included pressure ulcer of the sacrum (area above the tail bone on right and left buttocks), adult failure to thrive (a state of decline that is multifactorial) and diabetes mellitus type II. The Minimum Data Set (a resident assessment tool) dated 4/24/24 documented the resident was cognitively intact, had one stage II (shallow open wound when the top layer of skin breaks down and extends into the deeper layer of skin) pressure ulcer upon admission and two stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers upon admission. Review of the Comprehensive Care Plan with problem start date 4/19/24 and resolved on 5/30/24 documented that Resident #307 may have enhanced barrier precautions applied. Interventions included for signage on doors and gowns and gloves to be worn with high contact with affected source. The Comprehensive Care Plan with problem start date of 5/4/24 documented that Resident #307 was admitted with a stage IV pressure ulcer on their coccyx (tail bone). Interventions did not include enhanced barrier precautions. Review of the Physician Order Report dated 6/1/24-6/14/24 documented on 5/7/24, Resident #307 had an order to cleanse the pressure ulcer on their coccyx with soap and water, pat dry, apply hydrogel to wound bed, cover with bordered gauze daily and as needed. The order report documented on 6/13/24, Resident #307 was to have enhanced barrier precautions every shift due to their wound. Review of the Wound Physician Services notes dated 5/9/24-6/13/24, Medical Doctor #2 documented weekly that Resident #307 had a healing stage IV pressure injury to their sacrum. Review of Resident Progress Notes dated 5/30/24 at 3:28 PM, Registered Nurse #3 documented that Resident #307's enhanced barrier precautions were discontinued because the resident's wound was no longer draining. During intermittent observations on 6/10/24 at 12:09 PM and 6/11/24 at 10:04 AM, Resident #307 did not have enhanced barrier precaution signage on their room door. During an observation and interview on 6/12/24 at 1:15 PM, Certified Nursing Assistant #3 stated they wore a gown and gloves while providing incontinent care because Resident #307 was on contact precautions. Certified Nursing Assistant #3 stated they were unsure what Resident #307 was on precautions for, but they knew when a resident was on precautions because the name placard was marked with a green dot and there would be a precaution sign above that. Certified Nursing Assistant #3 observed Resident #307's door did not have a precautions sign and the name placard did not have a green dot. Certified Nursing Assistant #3 stated that Resident #307 was on contact precautions at one point during their stay and was unsure why there was not a green dot or precaution sign now. During a wound care observation on 6/12/24 at 1:41 PM, Licensed Practical Nurse #1 performed hand hygiene and entered Resident #307's room, there was no enhanced barrier precaution signage on the door. They cleansed Resident #307's overbed table with an antibacterial wipe, placed a barrier towel on the table and turned on the hot water in the bathroom. Without performing hand hygiene, Licensed Practical Nurse #1 donned two pairs of gloves and moved the resident's overbed table, wheelchair and rolling walker. Then they placed the dressing change supplies on the table with their gloved hands. Licensed Practical Nurse #1 wet a washcloth with the running sink water and put the washcloth on top of the supplies on the overbed table. Licensed Practical Nurse #1 then grabbed their scissors out of their pocket and cleansed them with an antibacterial wipe. Without changing their gloves or performing hand hygiene, Licensed Practical Nurse #1 applied soap to the washcloth then proceeded to wash, rinse and dry Resident #307's open wound on their coccyx. Licensed Practical Nurse #1 then removed their top layer of gloves, packed the wound with the dressing and covered it with border gauze. Licensed Practical Nurse #1 removed their gloves and placed the dressing wrappers into a garbage bag. They then applied new gloves without performing hand hygiene, repositioned the resident in the bed and then doffed their gloves. Licensed Practical Nurse #1 then donned one glove, picked up the garbage bag with their gloved hand, and exited the room. They applied antibacterial hand rub to their ungloved hand and walked down the hallway to the dirty utility room. Licensed Practical Nurse #1 entered the dirty utility room, threw the garbage bag into the garbage, doffed the one glove, and then performed antibacterial hand hygiene to both hands. Licensed Practical Nurse #1 did not wear a gown during wound care. During an observation of a televisit Wound Rounds with Medical Doctor #2, on 6/13/24 at 8:01 AM, Resident #307's room did not have enhanced barrier precautions signage on their door. Registered Nurse #3 rolled Resident #307 onto their side while the Director of Nursing was holding a cellular phone for Medical Doctor #2 to visualize the coccyx wound. Neither staff had donned a gown for the televisit. During an interview on 6/13/24 at 7:37 AM, Licensed Practical Nurse #1, stated that they were working as a graduate nurse and have completed Resident #307 treatment in the past. Licensed Practical Nurse #1 stated during wound care observation on 6/12/24 they had missed hand hygiene opportunities. Licensed Practical Nurse #1 stated hand hygiene should always be performed in-between doffing and donning of gloves. Licensed Practical Nurse #1 stated they did not change their gloves prior to cleansing Resident #307 wound. They stated that they should have doffed the dirty gloves after touching items in Resident #307's room, then performed hand hygiene prior to donning new gloves to prevent the possible spread infection to the wound. Licensed Practical Nurse #1 stated that the process of double gloving was not taught in the facility but was a process they learned in nursing school. Licensed Practical Nurse #1 stated that Resident #307 was not on enhanced barrier precautions and would be if they had a history of multiple drug resistant organisms. During an interview on 6/13/24 at 10:39 AM, Registered Nurse #3 stated that Resident #307 had a chronic pressure ulcer. Registered Nurse #3 stated that hand hygiene needed to be performed every time a staff member donned or doffed a pair of gloves. They stated prior to the start of cleansing a wound Licensed Practical Nurse #1 staff member needed to perform hand hygiene and don a new pair of gloves to prevent the possible contamination of the wound. Registered Nurse #3 stated the Director of Nursing discontinued enhanced barrier precautions for Resident #307 on 5/30/24 when the wound was no longer draining. During an interview on 6/13/24 at 2:42 PM, Registered Nurse #2 (Infection Control Nurse) stated that it was not facility practice to double glove and that hand hygiene should be performed prior to/after leaving a resident's room and in between glove changes. Registered Nurse #2 stated that a new pair of gloves should be worn, after staff performed hand hygiene, prior to cleansing an open wound to prevent possible cross contamination. Registered Nurse #2 stated that a resident with an open draining wound should be on enhanced barrier precautions to reduce the spread of multiple drug resistant organisms and staff were to wear a gown and gloves when coming into close contact with the open area or bedding. During an interview on 6/13/24 at 3:07 PM, Registered Nurse #2 stated Resident #307 should have been on enhanced barrier precautions because their wound was open and greater than a stage II. During a telephone interview on 6/14/24 at 11:14 AM, Medical Doctor #1 (Medical Director) stated they have followed Resident #307 since they were residing at their previous nursing facility, and they had a chronic pressure ulcer to their sacrum. Medical Doctor #1 stated that any resident that had skin breakdown or a pressure ulcer needed to be on enhanced barrier precautions due to the new federal regulation that was just released. During an interview on 6/14/24 at 11:23 AM, the Director of Nursing stated staff should be preforming hand hygiene in between glove changes. They stated that Licensed Practical Nurse #1 should have doffed old gloves, performed hand hygiene, and donned new gloves prior to cleansing Resident #307's open wound to their sacrum. They stated that touching items in the room without hand hygiene and a glove change could have possibly contaminated Resident #307 open wound. The Director of Nursing stated that any resident that had open, draining wounds would need to be on enhanced barrier precautions that would consist of staff wearing gown and gloves for care. The Director of Nursing stated Registered Nurse #3 nor themselves wore a gown during wound round observation for Resident #307 on 6/13/24. The Director of Nursing stated they discontinued Resident #307 enhanced barrier precautions at the end of May because the wound was no longer draining. The Director of Nursing stated the precautions should not have been discontinued because stage IV pressure ulcers had a possibility of drainage. The Director of Nursing stated that the purpose of enhanced barrier precaution was to prevent the spread of infection, protect the staff and other residents from the spread of infection and any open wound had a higher risk for infection. During an interview on 6/14/24 at 12:07 PM, the Administrator stated they expected staff performed hand hygiene before and after resident interaction, when they touched soiled surfaces and if their hands were visibly soiled. They stated hand hygiene should be performed in between glove changes to mitigate germs being spread. 10NYCRR 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review completed during the Standard survey conducted 7/18/22 through 7/22/22, the facility did not ensure the providers made actual face to face contact with the residents at required visits for 3 of 9 residents (Resident #s 314, 55, and 82) reviewed. Specifically, provider visits were completed via telehealth (delivery of health care via remote technologies) and not in person (face to face) as required. The findings are: The policy and procedure (P&P) titled Provider Visits with a revised date of 1/22 documented the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The P&P documented the NP (nurse practitioner) may preform required visits by state and federal regulations. Review of a hand written note provided by the Director of Nursing (DON) documented the MD provided in the facility visits on April 29, 2022, April 30, 2022, June 23, 2022, and June 24, 2022. Additionally, it was documented that other visits were completed via telehealth on Thursdays. 1. Resident #314 admitted to the facility with diagnoses including gastrointestinal hemorrhage (bleeding from the intestines), stage three chronic kidney disease and type I diabetes mellitus. The Minimum Data Set (MDS-a resident assessment tool) dated 7/12/22 documented Resident #314 was cognitively intact, understood and understands. The electronic medical record (EMR) documented Patient Encounters on the following dates: 6/10/22 Initial NP visit; 6/16/22 Initial MD visit; 7/6/22 Return from hospital stay visit completed by the NP; and 7/15/22 Initial MD visit. Review of the Facility Activity Report (progress notes) documented on 7/15/22 Resident #314 was assessed by the MD via telehealth. During an interview on 7/21/22 at 1:18 PM, Resident #314 stated they have never seen the MD in person and have had only telehealth visits. Resident #314 stated they would have preferred to see the MD in person because it is more personal, the MD would have heard better, and if they did not understand what the MD said they could have asked the MD to repeat it. During an interview on 7/22/22 at 8:29 AM, Registered Nurse (RN) Unit Manager #1 stated the MD comes into the building monthly for a two-day time span and then will round on weekly on Thursdays via telehealth. RN #1 stated the NP completes telehealth visits Monday through Fridays. RN #1 stated they did not know if Resident #314's initial visits were completed in person by the MD. 2. Resident #55 had diagnoses including type II diabetes mellitus, chronic kidney disease, major depressive disorder. The MDS dated [DATE] documented Resident #55 was understood and understands with severe cognitive impairment. The EMR documented Patient Encounters on the following dates: 5/25/22 60-day visit were completed by the NP. During interviews on 7/21/22 at 8:50 AM and 10:07 AM, RN #3 Unit Manager stated that Resident #55 had a 60-day provider visit on 5/25/22 completed by the NP. The NP does not do in person visits, and completes all their provider visits Monday through Friday via telehealth. RN #3 stated they have no interaction with the MD. 3. Resident #82 admitted to the facility with diagnoses including Alzheimer's disease, hypertension (HTN), and hypercholesterolemia (high cholesterol). The MDS dated [DATE] documented Resident #82 had severe cognitive impairment, the physician (or authorized assistant or practitioner) did not examine the resident in the 14 days prior, and the physician (or authorized assistant or practitioner) changed the residents orders on 4 of the 14 days prior. The EMR documented Patient Encounters on the following dates: 5/11/2022 Initial NP Visit; 5/12/22 Initial MD Visit; and 6/7/22, a 30-day visit completed by the NP. During an interview on 7/21/22 at 9:59 AM, Licensed Practical Nurse (LPN) Assistant Director of Nursing (#1) stated they were responsible for scheduling provider visits. The MD completed telehealth visits on Thursday and would come into the building once or twice a month. LPN #3 stated the MD would have a face-to-face visit with a resident if they were due for their 60-day visit at the time the MD was in house. LPN #1 stated that all NP visits were completed via telehealth Monday through Friday. During a telehealth interview on 7/22/22 at 10:14 AM, the NP stated that all their resident visits (initial, 30-day, 60-day, 90-day and acute visits) were completed via telehealth, and they do not come to the building. The NP stated they were unaware that a resident needed to be seen in-person for a 60-day routine visit. During a telephone interview on 7/22/22 at 10:40 AM, the MD stated that they had to see resident's face-to-face every two months and that initial visits were completed via telehealth. The MD stated the last face-to-face visit for Resident #55 was on 11/23/21 and any further face-to-face MD visits were missed. Resident #314 was seen via telehealth for their initial visits on 6/16/22 and 7/15/22, and Resident #82 was seen via telehealth on May 12, 2022, for their initial visit. During an interview on 7/22/22 at 11:41 AM, the DON stated the NP visits are done via telehealth and the MD visits are done via telehealth unless the MD is in the building. The DON stated they were unsure if a resident's initial visit needed to be completed in person. 415.15 (b)

Based on interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees #4, 5, 6, 7) of eight employees who were subject to the New York State (NYS) Nurse Aide Registry had not been screened through the NYS Nurse Aide Registry prior to their employment. The findings are: Review of the facility policy titled Employee Files dated 11/2016, revealed all applicants, for all departments, must be screened through Prometric (outside contractor that maintains the NYS Nurse Aide Registry) to confirm if the person in question has ever worked as a Certified Nurse Aide (CNA) and/or ever had any disciplinary actions enforced. A copy of the findings to be reviewed for status and placed in the permanent file. 1. Review of Employee #4's (Human Resources (HR) Coordinator) personnel file on 7/29/19 revealed Employee #4 was hired by the facility on 5/13/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #4. 2. Review of Employee #5's (Licensed Practical Nurse) personnel file on 7/30/19 revealed Employee #5 was hired by the facility on 5/14/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #5. 3. Review of Employee #6's (Registered Nurse) personnel file on 7/30/19 revealed Employee #6 was hired by the facility on 5/16/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #6. During an interview on 7/29/19 at 3:30 PM, the HR Coordinator stated the Nurse Aide Registry is checked and the verification sheet is printed for all new employees by the Receptionist. She further stated around mid-May, there was a new Receptionist and a new HR Coordinator, and there was probably a miscommunication in the training at that time. 4. Review of Employee #7's (CNA) personnel file on 7/29/19 revealed Employee #7 was hired by the facility on 6/24/19. Further review of the file revealed it contained a Pennsylvania State Nurse Aide Registry verification, titled Pulse Portal dated 5/22/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #7. During an interview on 7/29/19 at 3:20 PM, the HR Coordinator stated at the time of hire, Employee #7 told her that she was working on getting her Pennsylvania Nurse Aide Certification transferred over to NYS and therefore she only checked the Pennsylvania Nurse Aide Registry for Employee #7. 415.4(b)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed 8/2/19, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for one (Resident #46) of one resident reviewed for dialysis. Specifically, there was no collaboration between the facility and the dialysis center regarding removal of the dialysis dressing post dialysis. The finding is: Review of the facility policy and procedure titled Hemodialysis Documentation with a revision date 5/4/11 revealed under Shunt Care to monitor for bruit (whooshing sound of blood flow) and thrill (a buzzing vibration felt by palpitation) each shift and record in the Medication Administration Record/Treatment Administration Record (MAR/TAR), blood pressure (B/P) readings and blood specimens should not be drawn from the arm with the shunt. Between dialysis treatment, the skin over the internal AV (arteriovenous) fistula access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) requires only routine care with soap and water. Topical dressing will be required as per physicians order only. 1. Resident #46 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD), anxiety and bipolar disorder (a serious mental illness characterized by extreme mood swings). Review of the Minimum Data Set (MDS- a resident assessment tool) dated 5/15/19 documented the resident is understood, understands and is cognitively intact. The MDS further documented under section O the resident is receiving dialysis. During an observation on 7/31/19 at 8:10 AM, the resident was observed sitting outside of his room eating breakfast fully dressed. On the resident's right forearm was a cotton ball covered with approximately two four-inch crossed pieces of see through tape over his AV fistula site. At the time of the observation the resident stated that the taped cotton ball was from dialysis yesterday. During an observation on 7/31/19 at 10:53 AM, the resident was lying in bed sleeping. On his right forearm was a cotton ball covered with approximately two four-inch crossed pieces of see through tape over his AV fistula site. Review of the current Care Plan dated 5/29/19 revealed the resident is on dialysis due to ESRD stage five. The resident is extremely non-compliant with dialysis and diet with interventions including dialysis Tuesday, Thursday, Saturday, fluid restriction 1500 ml (milliliters), no B/P or blood draws in arm with shunt and monitor site (fistula) for complications every shift. Review of the Dialysis Logging form (used to communicate between the facility and the dialysis center) dated 5/11/19 through 5/21/19 documented, Access dressing to come off four hours after treatment. Review of the Physician Order Report dated 7/1/19 through 7/30/19 revealed orders to monitor fistula in right arm every shift for complications, check for bruit and thrill, bruising and bleeding. There was no documented Physician Order for the care of the AV fistula dressing post dialysis. During an observation on 8/2/19 at 7:43 AM, the resident was sitting outside his room with the AV fistula on the site right forearm with a cotton ball covered with approximately two three-inch crossed pieces of see through tape over the AV fistula site. The cotton ball had a moderate amount of red drainage. At the time of the observation the resident stated that the taped cotton ball was from dialysis yesterday. During an observation on 8/2/19 at 10:21 AM, revealed AV fistula dressing remained over the resident's access shunt. During an interview on 7/31/19 at 1:05 PM with the Dialysis Center Registered Nurse (RN) revealed the dressing should be removed after 4 hours of treatment. The Dialysis Center RN stated, I do have to say he has come back for his next treatment with the dressing still on. During an interview on 8/2/19 at 10:29 AM, the Licensed Practical Nurse (LPN) #1 Charge Nurse revealed the Dialysis Logging sheet goes with the resident to dialysis. The nursing home fills out the pre information and the dialysis center fills out the post information. When the resident returns, the aides get his weight the nurse checks his vital signs and his site. LPN #1 stated, I take off the bandage the next day because it's usually falling off by then. She was not sure when the dressing should be removed or if a physician's order to remove the dressing was needed. During an interview on 8/2/19 at 11:08 AM, the Nurse Practitioner stated she would expect the facility to have instructions from the dialysis center on how to care for the dressing and when it should be removed. I would expect the staff to let me or the MD (medical doctor) know what the recommendations are for an order. During an interview on 8/2/19 at 11:28 AM, the Director of Nursing stated she would expect the facility to have instructions from the dialysis center on how to care for the dressing. He's been with us a long time and they've (dialysis center) never told us what to do with the dressing. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that residents who have not used anti-psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use anti-psychotropic drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for one (Resident #75) of five residents reviewed for anti-psychotropic medications. Specifically, there was a lack of behavior documentation that warranted the administration of an antipsychotic medication (Abilify) and a lack of behavior documentation addressing the positive/negative effects of the antipsychotic on the resident. Additionally, there was a delay in acting upon recommendations for a GDR. The finding is: Review of a facility policy titled Antipsychotic Medication Policy dated 2/2018 revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The staff will observe, document, and report to the attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 1. Resident #75 was admitted to the facility on [DATE] with diagnoses which include unspecified psychosis not due to substance or known physiological condition, dementia without behavioral disturbances, diabetes mellitus type 2, and metabolic encephalopathy (disease of the brain and spinal cord). Review of the Minimum Data Set (MDS-a resident assessment tool) dated 6/10/19 revealed the resident had moderately impaired cognition. Review of a hospital Progress Note dated 4/11/19 documented the resident had voiced complaints of depression and was started on Lexapro (antidepressant)10 milligrams (mg) by mouth daily. Review of a Physician's Order dated 4/15/19 revealed an order for Lexapro 10 mg by mouth daily for depression. Review of a Physician Progress Note dated 5/11/19 documented the resident had no complaints. The staff report he just wants to spend time in bed. He will not participate in physical therapy. He does walk okay but gets agitated and paranoid when he is not in bed. Review of Physician's Order dated 5/12/19 revealed an order for Abilify 5 mg by mouth daily. There was no documented evidence for the initiation of the antipsychotic. Review of Facility Activity Report dated 5/1/19 through 5/11/19 revealed documentation that the resident's daily mood was calm and alert; every day through that time frame. There was no documented evidence for the use of the antipsychotic medication. Review of the 24-hour reports dated 5/9/19 through 5/16/19 lacked behavior documentation to support the initiation of the antipsychotic nor had they documented positive/negative effects following administration of the medication except for a Progress Note dated 5/13/19 that indicated no adverse effects. During an interview on 7/31/19 at 10:00 AM, Registered Nurse (RN) #1 stated she believed the Abilify was started for weepiness and depression but that would be a question for the Physician. She did not know why there were no more behavior notes and stated, I would've been the one writing them and don't know why they weren't done. Interview with the Director of Nursing (DON) on 8/1/19 at 8:50 AM revealed she agreed there should have been more documentation on resident's behaviors to support the use of the antipsychotic. The Physician made the decision to start Abilify due to a conversation with resident and staff. The resident wanted to spend all his time in bed and was agitated and paranoid when not in bed. He would not participate in therapy. Interview with Social Work (SW) on 8/1/19 at 11:30 AM revealed there are no other notes identifying any behaviors in the resident's medical record. The SW stated, I voiced to the Physician he (resident) felt edgy and the antipsychotic was ordered. During an interview on 8/1/19 at 1:45 PM, the Physician stated, I did not order Abilify as an antipsychotic but for an adjunct to his depression. He (resident) had good results with Abilify as an adjunct to antidepressant therapy. He had already been on the Lexapro and was still having depressive behaviors. Review of a Full Psychiatric Evaluation dated 5/26/19 revealed the Psychiatrist visited the resident for his depression. Currently treated with Lexapro 10 mg and Abilify 5 mg every day. He presents with rapid pressured speech, flamboyant affect, little off, bipolar verses a bit manicky. Mood is euphoric, affect hyperactive, no paranoia noted, no hallucinations (visual or auditory), and no suicidal ideations. Continue medication regimen. Further review of the Facility Activity Reports dated 5/12/19 through 6/28/19 revealed the resident was calm and alert without behaviors except for 6/3/19 when he commented he is unable to do anything. He needs nursing help and help to get his dead wife to heaven. The Physician ordered a urinalysis (urine test) as this was not a usual behavior for the resident. Recommendations from the Pharmacist dated 6/13/19 revealed recommendations for the Physician to review the use of Abilify 5 mg by mouth daily started 5/12/19 and Lexapro 10 mg by mouth daily started 4/15/19. Review if GDR of the medication would be appropriate. Further review revealed the Physician agreed to the recommendations and signed the form on 6/18/19. During a phone interview on 8/1/19 at 1:48 PM, the Physician stated he would expect the recommendations be acted upon within 7 business days. 415.12(1)(2)(i)