**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain, improve, or prevent avoidable decline in range of motion and mobility. This was evident in 1 (Resident #18) of 3 residents reviewed for Limited Range of Motion, out of 25 sampled residents. Specifically, Resident #18 who had a physician's order to apply bilateral wrist cock-up splints was observed on multiple occasions without the splint applied. The findings are: The facility's policy titled Osteopenia with a revised date of 06/2024 documented that the facility will screen and provide assessments upon admission and at least quarterly of all residents with potential/actual diagnosis of osteopenia. Safe handling guidelines, as outlined, should be always practiced. The policy documented that appropriate physical and occupational therapy evaluation will be ordered. The Rehabilitation Services Department will make recommendations regarding orthotic and/or positioning devices such as splints, braces, supine stander, wedges and followed by physician's orders. Nursing will ensure that appropriate care plans are identified, and interventions are implemented. Resident #18 had diagnoses which include Spastic Quadriplegic Cerebral Palsy, Epilepsy, and Encounter for Attention to Tracheostomy. The Minimum Data Set assessment dated [DATE] documented that Resident #18's cognitive status was severely impaired. The Minimum Data Set assessment also documented that Resident #18 had impairments on both sides of upper extremity and required total assistance with grooming. A Comprehensive Care Plan for Musculoskeletal Care dated 06/25/2023 with a last reviewed date of 12/22/2024 documented the following interventions: perform musculoskeletal assessment every shift, implement osteopenia protocol, assess for sign and symptom of functional weakness/paralysis, and perform restorative nursing care, such as the use of assistive devices. A physician's order dated 08/09/2024 documented orders for right and left wrist cock-up splints to apply all daytime, from 8:00 AM to 8:00 PM. During observations made on 02/05/2025, 02/06/2025, 02/07/2025 and 02/10/2025, between the hours of 09:45 AM to 12:00 PM. Resident #18 was observed in bed, alert and awake. The Resident was confused and nonverbal, was observed with weakness to bilateral wrists. There was no bilateral wrist cock-up splints applied. On 02/10/2025 at 11:15 AM, an interview was conducted with Certified Nursing Assistant #1 who was assigned to Resident #18. Certified Nursing Assistant #1 stated they were aware of the order for the wrist splint and that it was not applied because it was communicated by the Rehabilitation Services Department to only apply the wrist splint when Resident #18 is out of bed. On 02/10/2025 at 11:21 AM, an interview was conducted with Registered Nurse #1 who stated they are responsible for clinical aspects of resident care. Registered Nurse #1 stated that Resident #18's wrist cock-up splint is normally applied when the Resident is out of bed. They stated that Resident #18 cannot have the splint for 12 hours because their skin was too fragile. On 02/10/2025 at 11:45 AM, an interview was conducted with Occupational Therapist #1. They stated they recommend splint devices after conducting assessments. Occupational Therapist #1 stated that the cock-up splints are to be applied to the resident's wrist to maintain joint integrity and to prevent further contractures. On 02/11/2025 at 10:10 AM, an interview was conducted with the Director of Nursing who stated that the Rehabilitation Service Department and physicians are responsible for the assessment and recommendation of splint devices and nursing staff implements them. The Director of Nursing stated if a resident cannot tolerate the splint, it needs to be communicated with the physician so the order can be adjusted. The Director of Nursing stated that the wrist cock-up splints order for Resident #18 has to be applied all day from 8:00 AM - 8:00 PM as stated in the physician's order. 10 NYCRR 415.12 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey conducted from 11/8/2023 to 11/16/2023, the facility did not ensure each resident received preadmission screening for a mental disorder or intellectual disability. This was evident for 1 (Resident #99) of 27 total sampled residents. Specifically, Resident #99 did not have a Level 1 Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility. The findings are: The facility policy titled PASRR Screen dated 12/2022 documented the PASARR Screen for all residents will be reviewed prior to their admission to protect their rights and ensure the identification and delivery of specialized developmental and mental health services. Resident #99 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and ventilator dependence. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #99 was severely cognitively impaired and admitted from an acute hospital on 8/3/2023. There was no documented evidence a Level 1 PASARR was completed prior to Resident #99 being admitted to the facility. On 11/10/2023 at 12:57 PM, the admission Director (AD) was interviewed and stated that Resident #99 was admitted to the facility without a Level 1 PASARR because they were admitted from a hospital in New Jersey. On 11/16/2023 at 2:03 PM, the Director of Patient/Family Services (DPS) was interviewed and stated Level 1 PASARRs were completed by referring facilities and received prior to a resident's admission to the facility. The DPS was unable to obtain a Level 1 PASARR for Resident #99 prior to their admission to the facility because the PASARR is not required in New Jersey. 10 NYCRR 415.11(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Ileostomy drainage bag and tubing were observed several times uncovered and exposed to public view in the hallway. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 28 residents (Resident #106). The finding is: The facility policy dated Colostomy/Ileostomy Care dated 10/2019 documented the following: It is the policy of the facility that the licensed nurse is responsible for the care of the resident who has an ostomy. The Policy also documented that the licensed nurse would provide stoma care while changing the ostomy pouch and provide privacy. Resident #106 had diagnoses which include Ileostomy, GI Dysmotility, and Hereditary and Idiopathic Neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an impaired cognition and required total assistance with Activities of Daily Living (ADLs). On 09/02/21, between the hours of 11:43 AM and 12:45 PM, Resident #106 was observed sitting in a wheelchair (w/c) in the hallway, in front of the nurse's station. The resident's Ileostomy drainage bag and tubing were uncovered and visible. There were feces along the tubing and in the drainage bag attached to lower side of the w/c. On 09/03/21, between the hours of at 10:42 AM and 11:57 AM, Resident #106 was observed being fed by a Certified Nursing Assistant (CNA #1) while sitting in a w/c, in the hallway, in front of the nurse's station. The resident's Ileostomy drainage bag and tubing were uncovered and visible. There were feces along the tubing and in the drainage bag attached to lower side of the w/c. On 09/07/21 at 09:49 AM, Resident #106 was observed in front of the nursing station,with an unidentified staff member. The Ileostomy bag was uncovered with feces inside. The Comprehensive Care Plan (CCP) for Bowel Elimination Alteration dated 08/12/21 documented Resident #106 required actual maintenance of any gastrointestinal diversional device attached to the child's body for elimination of waste related to medical diagnoses (ileostomy, GI dysmotility, intestinal malabsorption). The CCP interventions included the following: Perform bowel assessment and abdominal palpation for distention every shift, identify location of gastrointestinal diversion, perform skin assessment every shift, monitor output and frequency, change devices as ordered and PRN (as needed). The Physician's order dated 07/30/21, renewed on 09/09/21, documented the following: Ostomy care: Change ostomy daily and as needed (PRN). Cleanse with normal saline and dry well. The Physician's note dated 8/27/21 documented the following: Resident has a long history of dysmotility. Ileostomy was placed 2 years ago. There is a red rubber catheter placed within the ostomy to promote drainage. A series of 8-10 slits made along the length of the catheter to promote drainage and prevent clogging with stool. Catheter is inserted to 75% of its length. Typical drainage is less than 300 ml per shift (q12 h) but if the output is greater than this, it should be replaced 1:1 with lactated ringers' solution. On 09/07/21 at 10:44 AM, an interview was conducted with CNA #1. CNA #1 stated that the nurse takes care of the ostomy bag. The CNAs make sure the ileostomy bag is cleaned properly and not clogged, and the nurse drains it and measures and documents the output. CNA #1 stated she was never aware of the privacy issues related to the ostomy bag being exposed to the public view. CNA #1 concluded by saying I never received such training that the ostomy or catheter bags have to be covered in public. ] On 09/07/21 at 10:25 AM, an interview was conducted with the Unit Registered Nurse (RN#1) who stated she was not aware of the need for a privacy bag for the ileostomy. RN #1 stated that Resident #106 always sits in the hallway, and no one has said anything about the ileostomy drainage bag being exposed. On 09/07/21 at 10:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility does not have privacy bags for the ostomy. The DON stated the facility has a few residents with an ostomy bag. The DON stated that the staff were not trained on the use of a privacy bag to conceal the ostomy from public view. The DON concluded by saying we will work on it. 415.5(a)