**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This was evident for 13 out of 13 Justice Involved Residents. Specifically, 13 Justice Involved Residents were not allowed to exercise their rights while residing in the facility. Based on interviews with facility staff, residents and representatives of the Federal Bureau of Prison Services while residing in the facility, the residents remain in the custody and under the authority of the Bureau of Prisons. The Justice Involved Residents were not allowed to choose their own physician, make phone calls, formulate their own advance directives, receive visitors at the time of their choosing, receive their mail unopened, or communicate with other residents in the facility. Additionally, the Justice Involved Residents were assigned 2 Federal Bureau of Prisons guards, placed in restraints, and secluded in their rooms for most of the day. Furthermore, the facility does not have any evaluation or order for the restraints used on the residents. This was an immediate jeopardy with the likelihood of harm for 13 Justice Involved Residents. The findings are: The facility's Policy titled Resident Rights dated 01/2024, documented resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and participation in resident groups. The policy further documented the justice involved residents' individual rights are honored and met unless otherwise determined by the Federal Court System. The facility's Policy titled Visitation dated 01/2024, documented the facility permits residents to receive visitors subject to resident's wishes and the protection of the rights of other residents in the facility. The policy further documented that the resident may visit with non-relative visitors who are visiting with the consent of the resident at any time. Observations made on 06/06/2024, 06/26/2024, and 06/27/2024 during various times throughout the day revealed 11 Justice Involved Residents wearing two-foot-long shackles around their ankles. Observations on 06/06/2024 and 06/27/2024 confirmed all Justice Involved Residents were eating only in their room and did not participate in facility activities. The justice involved residents do not have the right to privacy as a security guard remains in the room with the justice involved resident at all times except for showering and personal hygiene care. Justice Involved Resident #4 was admitted to the facility with diagnoses including Nontraumatic Compartment Syndrome (a buildup of pressure around the muscles) of the right upper extremity, Chronic multifocal Osteomyelitis (an autoimmune disease in which the immune system attacks healthy tissue and organs causing inflammation) of the right hand and an Antiviral infection. Justice Involved Resident #4 required intravenous antibiotics therapy for a wrist wound via Peripherally Inserted Central Catheter and restorative therapy and was expected to be discharged to another institution as per discharged care plan. The Minimum Data Set (an assessment tool), dated 05/03/2024, documented that Justice Involved Resident #4 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored of 15 associated with intact cognition. An Activities Care Plan - Resident is an Inmate, dated 02/07/2024 documented interventions to observe and report functional changes that impact the resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by guards. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal Involvement (an eye disorder that may affect vision) Involvement, Urinary Tract Infection, and Dermatophytosis (fungal infection). Justice Involved Resident #6 required wound treatment to the left abdominal fold and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented that Resident #6 had a Brief Interview of Mental Status and scored 12 associated with moderately impaired cognition. An Activities Care Plan - Resident is an Inmate dated 11/28/2023 documented interventions to observe and report functional changes that impact resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by guards. Justice Involved Resident #12 was admitted to the facility with diagnoses including Diverticulitis (infection in one or more small pouches in the digestive tract) of the Intestine, Anxiety disorder, and Enterocolitis (inflammation that occurs throughout your intestines). Justice Involved Resident #12 required intravenous antibiotic treatment and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. An Activities Care Plan - Resident is an Inmate dated 11/28/2023 documented interventions to observe and report functional changes that impact resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by Security Officer Specialists (guards). During interviews on 06/26/2024 with Justice Involved Residents #4, #6, and #12 on 06/26/2024, they all stated they are not allowed to participate in group activities and community dining. They stated they are not allowed to have visitors, make, or receive phone calls unless it is approved by the Bureau of Prison. Justice Involved Residents #4, #6, and #12, also stated they only eat in their rooms and receive their mail opened. During an interview on 06/26/2024 at 10:07 AM, Senior Officer Specialist #1 stated they are the voices for the Justice Involved Residents and that most of the residents' questions should be directed to the Officers. During an interview on 06/26/24 at 10:07 AM, Senior Officer Specialist #2 stated the Justice Involved Residents receive their phone call after the calls are screened by the Federal Bureau of Prison. Senior Officer Specialist #2 stated the residents' phone conversations are recorded and the Officers must be present during phone and face-to-face conversations. During an interview on 06/26/24 at 12:43 PM, the Director of Recreation stated the Justice Involved Residents do not have the autonomy to participate in group activities. The Director of Recreation stated the Justice Involved Residents receive individual activity in their rooms. All activities must first be approved by the Senior Officer Specialist before the residents can receive their activities. The Director of Recreation stated the Senior Officer Specialists do not allow the residents to leave their room, walk around the general population, or participate in any functions being held for the other population of residents. The Director of Recreation stated they do not receive or handle the Justice Involved Residents mail; the Senior Officer Specialists are responsible for the handling of the Justice Involved Residents' mail. During an interview on 06/26/2024 at 5:45 PM, the facility Psychologist stated they evaluated approximately 6 Justice Involved Residents in the facility and a Senior Officer Specialist was present during each evaluation. The Psychologist stated when they asked the Officer for privacy, they are told an Officer must be in the room. During an interview on 06/27/2024 at 10:21 AM, according to the Administrator, they are not restricting the Justice Involved Residents from eating in the dining room with other residents or to participating in group activities outside of their rooms. The Administrator stated the Senior Officer Specialist team are the ones who refuse the residents the freedom to participate. The Administrator stated the Justice Involved Residents stay in their room unless they are visiting with family or participating in physical therapy. 10 NYCRR 483.10 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, conducted during an abbreviated survey (NY00342374), the facility failed to ensure that thirteen Justice Involved Residents (Residents 1-13) had the right to, and that the facility promoted and facilitated the residents self-determination through support of residents choices. The facility did not ensure that Justice Involved Residents had the right to make choices about aspects of their life that were significant to them. This was evident in 13 of 13 Justice Involved Residents sampled for self-determination. Specifically, observations made on 06/06/2024, 06/26/2024 and 06/27/2024, during various times throughout the day revealed 13 Justice Involved Residents wearing two-foot-long shackles around their ankles which limited their movement throughout the facility. The Justice Involved Residents were under the supervision of Federal Bureau of Prison guards 24 hours a day. All observations on 06/06/2024 and 06/27/2024 confirmed all Justice Involved Residents were eating only in their room and not participate in facility group activities or choose activities of their choice such as types of music. Justice Involved Residents were not permitted to receive visitors at any time or at the time of their choosing, they were not allowed. to make or receive phone calls at the time of their choosing. The Federal Bureau of Prison guards, remained in the room with the Justice Involved Resident at all times, thereby restricting privacy. This resulted in an Immediate Jeopardy with the likelihood of harm for the 13 Justice Involved Residents. The findings are: The facility's Policy titled Resident Self Determination and Participation dated 01/2024, documented the facility respects and promotes the right of each resident to exercise their autonomy regarding what the resident considers to be important facets of their life. The policy further documented that each resident is allowed to choose activities, schedules and health care that are consistent with their interests, values, assessments, plans of care, and provided assistance as needed to engage in their preferred activities on a routine basis. The facility's Policy titled Resident Rights dated 01/2024, documented resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and participation in resident groups. The policy further documented the Justice Involved Residents individual rights are honored and met unless otherwise determined by the Federal Court System. Observations made on 06/06/2024, 06/26/2024, and 06/27/2024 during various times throughout the day revealed 11 Justice Involved Residents wearing two-foot-long shackles around their ankles. Observations on 06/06/2024 and 06/27/2024 confirmed all Justice Involved Residents were eating only in their room and did not participate in facility activities. The residents do not have the right to privacy as a security guard was stationed in their room, outside of their room door, present during activities, and rehabilitation therapy sessions. Justice Involved Resident #4 was admitted to the facility with diagnoses including Nontraumatic Compartment Syndrome (a buildup of pressure around your muscles) of the right upper extremity, Chronic multifocal Osteomyelitis (an autoimmune disease in which the immune system attacks healthy tissue and organs causing inflammation) of the right hand and an Antiviral infection. Justice Involved Resident #4 required intravenous antibiotics therapy for wrist wound via Peripherally Inserted Central Catheter and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set (an assessment tool), dated 05/03/2024, documented Justice Involved Resident #4 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored of 15 associated with intact cognition. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal Involvement (an eye disorder that may affect vision) Involvement, Urinary Tract Infection, and Dermatophytosis (fungal infection). Justice Involved Resident #6 required wound treatment to the left abdominal fold and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented Resident #6 had a Brief Interview of Mental Status and scored 12 associated with moderately impaired cognition. Justice Involved Resident #12 was admitted to the facility with diagnoses including Diverticulitis (infection in one or more small pouches in the digestive tract) of Intestine, Anxiety disorder, Enterocolitis (inflammation that occurs throughout your intestines). Justice Involved Resident #12 required intravenous antibiotic treatment and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. During an interview with Justice Involved Resident's #4, #6, and #12 on 06/26/2024, they all stated they are not allowed to have visitors unless approved by the Federal Bureau of Prison. Justice Involved Residents #4, #6, and #12, also stated they are not allowed to participate in group activities and community dining. Justice Involved Residents # 4, # 6 and # 12 stated they have never heard of an Ombudsman and did not know how to contact them or file a complaint. During an interview on 06/26/24 at 12:43 pm, the Director of Recreation stated they provide the Justice Involved Residents with MP3 player (an electronic device that can play digital music) and download music of their choice. However, an Officer must approve the music. The Director of Recreation went on to say the Senior Officer Specialist does not allow the Justice Involved Residents to leave their room and they are not allowed to walk around the general population. During an interview on 06/27/2024 at 9:56 am, the Director of Social Worker stated the Justice Involved Residents are not restricted from visitation and phone calls, however, visitation and phone calls must be approved by a court order, then the Justice Involved Resident can get visitation and phone calls. 10 NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to ensure residents were afforded the right to formulate advance directives while residing in the skilled nursing facility. This was evident for 13 out of 13 Justice Involved Residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) sampled. Specifically, a review of the medical record revealed that 13 Justice Involved Residents were designated as Full Code. The medical record did not document that the residents were provided written information that included their right to formulate advance directives in accordance with their wishes. During interviews with the Director of Social Work it was revealed the Justice Involved Residents were assigned full code status by the Federal Bureau of Prisons. The Director of Social Work further confirmed the facility did not advise Justice Involved Residents they had the right to formulate advance directives in accordance with their wishes. Interviews with Justice Involved Residents #4, #6 and #12 confirmed they were not afforded the right to formulate their own advance directives while residing in the facility. This resulted in Immediate Jeopardy with the likelihood of harm for the 13 Justice Involved Residents. The findings are: The facility's Policy titled Advanced Directives, with the last reviewed date 01/2024, documented that in accordance with Federal (Title 42 section 483.10) and State (Title10 section 41S.3), Regulations recognize each Resident's right to formulate Advance Directives. Compliance with these regulations is demonstrated by honoring existent Resident Advance Directives and by providing education and opportunities for Residents, Family Members, or Surrogates to exercise this right by formulating Advance Directives. Justice Involved Resident #4 was admitted to the facility with diagnoses including Nontraumatic Compartment Syndrome (a buildup of pressure around the muscles) of the right upper extremity, Chronic multifocal Osteomyelitis (an autoimmune disease in which the immune system attacks healthy tissue and organs causing inflammation) of the right hand and an Antiviral infection. Justice Involved Resident #4 required intravenous antibiotics therapy for wrist wound via Peripherally Inserted Central Catheter and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set (an assessment tool), dated 05/03/2024, documented Justice Involved Resident #4 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 15, which is associated with intact cognition. A Baseline Care Plan dated 02/02/2024 documented an Advance Directive was reviewed and verified with Justice Involved Resident #4/representative. After a thorough discussion with the Residents/Representatives, Full Code was elected. A Psychosocial History and Initial Assessment for Justice Involved Resident #4 dated 02/05/2024 documented that a directive was given for Full Code. A Quarterly Care Plan Meeting dated 05/22/2024 documented that Justice Involved Resident #4 remained Full Code. Physician's Order for Justice Involved Resident #4 dated 03/06/2024 documented Code Status Full Code Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal Involvement (an eye disorder that may affect vision) Involvement, Urinary Tract Infection, and Dermatophytosis (fungal infection). The Minimum Data Set, dated [DATE], documented Justice Involved Resident #6 had a Brief Interview of Mental Status and scored 12, which is associated with moderately impaired cognition. Justice Involved Resident #6 required wound treatment to the left abdominal fold and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. A Baseline Care Plan dated 11/22/2023 documented that an Advance Directive was reviewed and verified with Justice Involved Resident #6/representative. After a thorough discussion with the Residents/Representatives, Full Code was elected. A Physician's Order for Justice Involved Resident #6 dated 11/22/2023 documented Code Status Full Code. A Psychosocial History and Initial Assessment for Justice Involved Resident #6 dated 11/27/2023 documented that a directive was given for Full Code. A Social Service Quarterly Note, written by Director of Social Service, dated 05/20/2024 documented Resident #6 continues to be Full Code. Justice Involved Resident #12 was admitted to the facility with diagnoses including Diverticulitis (infection in one or more small pouches in the digestive tract) of Intestine, Anxiety disorder, and Enterocolitis (inflammation that occurs throughout your intestines). Justice Involved Resident #12 required intravenous antibiotic treatment and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. A Baseline Care Plan dated 03/18/2024 documented that an Advance Directive was reviewed and verified with Justice Involved Resident #12/representative. After a thorough discussion with the Residents/Representatives, Full Code was elected. A Physician's Order for Justice Involved Resident #12 dated 03/18/2024 documented Full Code status. A Psychosocial History and Initial Assessment for Justice Involved Resident #12 dated 03/19/2024 documented that a directive was given for Full Code. A Social Service note, written by the Director of Social Service, dated 05/28/2024, documented Resident #12 returned from the hospital and continues to be Full Code. During an interview on 06/27/2024 at 1:06 PM, Justice Involved Resident #4 stated someone in the facility had explained an Advance Directive to them. Justice Involved Resident #4 stated they were not given the opportunity to choose, and they were told, by Bureau of Prison, they cannot die in prison because they are a convicted felon. Justice Involved Resident #4 stated they were aware they cannot change their Full Code status. During the interview with Justice Involved Resident #4, Senior Officer Specialist #2 consistently interrupted the interview, and stated the Bureau of Prison is responsible for the Advanced Directives for Justice-Involved individuals. During an interview on 06/27/2024 at 1:08 PM, Justice Involved Resident #6 stated that their transferring facility explained Advanced Directives to them. Justice Involved Resident #6 stated they do not recall current facility discussing their Advance Directive with them or ever being given the opportunity to choose. During an interview on 06/27/2024 at 1:11 PM, Justice Involved Resident #12 stated they do not know what an Advance Directive was. Resident #12 stated that no one in the facility had ever discussed an Advance Directive with them. Justice Involved Resident #12 stated they do not recall anyone telling them they have the right to formulate their own Advance Directive. During an interview on 06/27/2024 at 9:56 AM, the Director of Social Service stated Naphcare (the payor source) completed the Advanced Directive prior to the Justice Involved Residents' admission to the facility. The Director of Social Service stated they explained and educated residents on Advanced Directives. The Director of Social Service stated they informed the Justice Involved Residents they are Full Code, but they did not ask the Justice Involved Residents if they wanted to change their code status or formulate other advance directives. During an interview on 06/27/24 at 10:21 AM, the Administrator stated they admitted the Justice Involved Residents with the same rights as the regular resident population. The Administrator stated they do not act as an agent regarding Justice Involved Residents and law enforcement is in charge. The Administrator went on to say the Justice Involved Residents' rights were not violated. 10 NYCRR 415.3 (e) (2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for 13 out of 13 Justice Involved Residents. Specifically, 13 Justice Involved Residents were not allowed to exercise their rights while residing in the facility. Based on interviews with facility staff, residents and representatives of the Federal Bureau of Prison Services while residing in the facility, the residents remain in the custody and under the authority of the Bureau of Prisons. The residents were not allowed to choose their own physician, make phone calls, formulate their own advance directives, receive visitors at the time of their choosing, receive their mail unopened, or communicate with other residents in the facility. Additionally, the residents were placed in restraints and secluded in their rooms for most of the day. This resulted in an Immediate Jeopardy with the likelihood of harm for the 13 Justice Involved Residents. The findings are: The facility's Policy titled Resident Rights dated 01/2024, documented resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and participation in resident groups. The policy further documented the Justice Involved Residents' individual rights are honored and met unless otherwise determined by the Federal Court System. The facility's Policy titled Visitation dated 01/2024, documented the facility permits residents to receive visitors subject to resident's wishes and the protection of the rights of other residents in the facility. The policy further documented that the resident may visit with non-relative visitors who are visiting with the consent of the resident at any time. Observations made on 06/06/2024, 06/26/2024, and 06/27/2024 during various times throughout the day revealed 11 Justice Involved Residents wearing two-foot-long shackles around their ankles. Observations on 06/06/2024 and 06/27/2024 confirmed all Justice Involved Residents were eating only in their room and did not participate in facility activities. The justice involved residents do not have the right to privacy as a security guard remains in the room with the justice involved resident at all times except for showering and personal hygiene care. Justice Involved Resident #4 was admitted to the facility with diagnoses including Nontraumatic Compartment Syndrome (a buildup of pressure around your muscles) of the right upper extremity, Chronic multifocal Osteomyelitis (an autoimmune disease in which the immune system attacks healthy tissue and organs causing inflammation) of the right hand and an Antiviral infection. Justice Involved Resident #4 required intravenous antibiotics therapy for wrist wound via Peripherally Inserted Central Catheter and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set (an assessment tool), dated 05/03/2024, documented that Justice Involved Resident #4 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored of 15 associated with intact cognition. An Activities Care Plan - Resident is an Inmate, dated 02/07/2024 documented interventions to observe and report functional changes that impact the resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by guards. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal Involvement (an eye disorder that may affect vision) Involvement, Urinary Tract Infection, and Dermatophytosis (fungal infection). The Minimum Data Set, dated [DATE], documented that Resident #6 had a Brief Interview of Mental Status and scored 12 associated with moderately impaired cognition. Justice Involved Resident #6 required wound treatment to the left abdominal fold and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. An Activities Care Plan - Resident is an Inmate dated 11/28/2023 documented interventions to observe and report functional changes that impact resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by guards. Resident #6's rights were denied by being a prisoner while in the nursing home. Justice Involved Resident #12 was admitted to the facility with diagnoses including Diverticulitis (infection in one or more small pouches in the digestive tract) of the Intestine, Anxiety disorder, and Enterocolitis (inflammation that occurs throughout your intestines). Justice Involved Resident #12 required intravenous antibiotic treatment and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. An Activities Care Plan - Resident is an Inmate dated 11/28/2023 documented interventions to observe and report functional changes that impact resident quality of life, offer, and assist resident/family with alternative forms of communication as requested by guards. Provide materials needed for independent leisure pursuits as allowed by security officer specialists (guards). During interviews on 06/26/2024 with Justice Involved Residents #4, #6, and #12 on 06/26/2024, they all stated they are not allowed to; have visitors, make, or receive phone calls unless it was approved by the Bureau of Prison. Justice Involved Residents #4, #6, and #12, also stated they are not allowed to participate in group activities, and they only receive activities in their rooms. The Justice Involved Residents also stated they have never participated in community dining, and they only eat in their rooms. The Justice Involved Residents also stated, they receive their mail opened. During an interview on 06/26/2024 at 10:07 AM, Senior Officer Specialist #1 stated they are the voices for the Justice Involved Residents and that most of their questions should be directed to the Officers. During an interview on 06/26/24 at 10:07 AM, Senior Officer Specialist #2 stated the Justice Involved Residents receive their phone call after the calls are screened by the Federal Bureau of Prison. Senior Officer Specialist #2 stated the residents' phone conversations are recorded and the Officers must be present during phone and face-to-face conversations. During an interview on 06/26/24 at 12:43 PM, the Director of Recreation stated the Justice Involved Residents do not have the autonomy to participate in group activities. The Director of Recreation stated the Justice Involved Residents receive individual activity in their rooms. All activities must first be approved by the Senior Officer Specialist before the Justice Involved Residents can receive their activities. The Director of Recreation stated the Senior Officer Specialists do not allow the Justice Involved Residents to leave their room, walk around the general population, or participate in any functions being held for the other population of facility's residents. The Director of Recreation stated they do not receive or handle the Justice Involved Residents mail; the Senior Officer Specialists are responsible for the handling of their mail. During an interview on 06/26/2024 at 5:45 PM, the facility Psychologist stated they evaluated approximately 6 Justice Involved Residents in the facility and a Senior Officer Specialist was present during each evaluation. The Psychologist stated when they asked the Officer for privacy, they were told an Officer must be in the room. During an interview on 06/27/2024 at 10:21 AM, according to the Administrator, they are not restricting the Justice Involved Residents from eating in the dining room with other residents or to participating in group activities outside of their rooms. The Administrator stated the Senior Officer Specialist team are the ones who refuse the residents the freedom to participate. The Administrator stated the Justice Involved Residents stay in their room unless they are visiting with family or participating in physical therapy. 10 NYCRR 483.10 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to ensure the residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This was evident for 13 out of 13 (Residents 1-13) sampled residents. Specifically, observations made at various times throughout the days on 06/06/2024, 06/26/2024, and 06/27/2024-06/28/2024 revealed that 11 Justice Involved Residents were wearing two-foot-long shackles around their ankles. One resident with a right leg amputation had their left wrist constantly handcuffed to the bedside rail. Each of the 11 residents was chained to their respective beds via a four-foot-long chain that was clipped to the middle of the shackles with handcuffs. The chains limit the distance residents could walk in their room (approximately 4-5 feet from the bed to the chair). This resulted in Immediate Jeopardy with the likelihood of harm for the 13 Justice Involved Residents for restraints that were not ordered or evaluated by the facility. Findings are: The facility's Policy titled Use of Restraints, dated 01/2024 documented restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The policy further documented that prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician. Observations on 06/26/2024 and 06/26/024-06/28/2024 during various times throughout the day revealed 11 Justice Involved Residents wearing shackles around their ankles (two-feet-long) and one resident (right leg amputated) always had their left wrist hand-cuffed to the bedside rail. They were either sitting up in their bed or lying on their bed. Additionally, while Justice Involved Residents remained in their room, they were chained to their beds via a chain approximately four-foot-long that was clipped to the middle of the shackles with handcuffs. The chains limited residents' distance to walk in the room. The chain goes off when the residents go to the bathroom or to Physical Therapy. The Minimum Data Set did not identify shackles being used on Justice Involved residents for 13 out of the 13 Justice-Involved Residents reviewed for restraints. There were no Physician's Orders or justification for the restraint use or restraint assessment. There was no documented evidence revealing the restraints were medically necessary, nor that alternatives were attempted prior to implementing shackles. A review of the care plans for 13 Justice Involved Residents revealed no care plans for restraint were developed. Justice Involved Resident #4 was admitted to the facility with diagnoses including Nontraumatic Compartment Syndrome (a buildup of pressure around the muscles) of the right upper extremity, Chronic multifocal Osteomyelitis of the right hand (a disease that causes pain and damage in bones due to inflammation) and an Antiviral infection. Justice Involved Resident #4 required intravenous antibiotics therapy for wrist wound via Peripherally Inserted Central Catheter and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set (an assessment tool), dated 05/03/2024, documented that Justice Involved Resident #4 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 15, which is associated with intact cognition. A Physician's Order dated 03/06/2024 documented Special Restrictive Intervention: check skin under cuffs to make sure there is no skin breakdown and maintenance of skin integrity. Monitor skin integrity every shift. A document titled Care Plan Restrictive Device dated 06/06/24 documented Special Restrictive Interventions, not facility policy, but rather a court order to maintain incarceration protocol with interventions to check skin under cuffs to ensure there were no skin breakdown and maintained skin integrity. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal Involvement (an eye disorder that may affect vision) Involvement, Urinary Tract Infection, and Dermatophytosis (fungal infection). Justice Involved Resident #6 required wound treatment to the left abdominal fold and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set, dated [DATE], documented Resident #6 had a Brief Interview of Mental Status and scored 12, which is associated with moderately impaired cognition. There were no Physician's Orders or justification for restraint use or restraint assessment. No alternatives were attempted prior to implementing shackles. A document titled Care Plan Restrictive Device dated 06/06/24 documented Special Restrictive Interventions, not facility policy, but rather a court order to maintain incarceration protocol with interventions to check skin under cuffs to ensure there were no skin breakdown and maintained skin integrity. Justice Involved Resident #12 was admitted to the facility with diagnoses including Diverticulitis (infection in one or more small pouches in the digestive tract) of Intestine, Anxiety disorder, and Enterocolitis (inflammation that occurs throughout your intestines). Justice Involved Resident #12 required intravenous antibiotic treatment and restorative therapy. They were expected to be discharged to another institution as per discharged care plan. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #12 had intact cognition. Section P did not identify shackles being used on the Justice Involved Resident. A Physician's Order dated 03/18/2024 documented Special Restrictive intervention: check skin under cuffs to make sure there are no skin breakdown and maintenance of skin integrity. Monitor skin integrity every shift. There were no Physician's Orders or justification for restraint use or restraint assessment. There was no documented evidence revealing the restraints were medically necessary, nor that alternatives were attempted prior to implementing shackles. A document titled Care Plan Restrictive Device dated 06/06/24 documented Special Restrictive Interventions, not facility policy, but rather a court order to maintain incarceration protocol with interventions to check skin under cuffs to ensure there were no skin breakdown and maintained skin integrity. During an interview on 06/26/2024 at 1:30 PM, 06/27/2024, and 06/28/2024 at 5:30 PM, the Medical Director stated the Medical Doctor from the Bureau of Prison communicated with the Director of Nursing about the Justice Involved Residents who will be admitted to the facility. The Medical Director stated they are aware the facility is restraint-free, and the Justice Involved Residents are restrained under the Bureau of Prison. The Medical Director stated they are responsible for overseeing the care of the residents and are aware the Justice Involved Residents are chained all the time, but the facility does not have any control over that. The Medical Director stated they participated in the Quality Assurance Meetings but did not think to address the Justice Involved Residents wearing restraints. According to the Medical Director, the residents came from prison wearing shackles and they thought it was normal. During an interview on 06/26/2024 at 3:17 PM and 06/27/2024 at 3:55 PM, the Director of Nursing stated they reviewed the Patient Review Instruments for the Justice Involved Residents and approved them for admissions into the facility. The Director of Nursing stated they told the detention center that the facility does not use restraints, but they said the Bureau of Prison enforced the restraints for security reasons. The Director of Nursing stated the Bureau of Prison doctors informed them the residents were inmates and they explained to the Bureau of Prison doctor the facility is restraint-free, but they kept the Justice Involved Residents restrained. The Director of Nursing stated they understood the conflict of the facility being restraint free and they admitted the Justice Involved Residents are in shackles all the time. The Director of Nursing stated the residents do not wear shackles during shower and Physical Therapy. The Director of Nursing stated it is a Federal Regulation to restrain Justice Involved Residents even though the facility is a restraint free facility. The Director of Nursing stated Federal Jurisdiction was enforcing the restraint. During an interview on 06/27/24 at 10:21 AM, the Administrator stated they do not act as the agent regarding the use of restraint for the Justice Involved Residents and that law enforcement is in charge. The Administrator stated the facility was free from restraint, but an outside agency came in and enforced restrictions and restraints. The Administrator stated they are aware of the guidance and once the facility is not acting as an agent to enforce restrictions, they are not liable. The Administrator also stated they admit all residents with the same rights. The Administrator further stated they told Bureau of Prison the facility is restraint-free but were told they should not get involved. The Administrator Stated the Justice Involved Residents' rights were not violated. 10 NYCRR 415.4(a) (2-7)