Every finding on record at Windsor Park Rehab & Nursing Center

Based on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. This was evident in 1 (West Side) of 2 units observed. Specifically, 1.) A resident's wheelchair has been observed with torn cushion on the left arm rest, 2.) The Hoyer lift was rusty with dark yellow and blackish stains on the metal frame, 3.) The wooden door frame on the whirlpool room had chipped paint, and 4.) The elevator was observed with layers of mismatched black colored paint. The findings are: The facility's policy titled Maintenance Service with a revision date of 01/2024 stated that it is the policy of the facility to provide maintenance services to all areas of the building, grounds, and equipment. The functions of maintenance personnel include maintaining the building in good repair and establish priorities in providing repair service. The following were observed during multiple observations conducted from 09/26/2024 to 10/03/2024 on the [NAME] Side unit: 1.) Resident #54's wheelchair was observed with a torn cushion on the left arm rest. 2.) The Hoyer lift being used on the [NAME] Side unit was observed with rust and had a large area of dark yellow and blackish stain on the metal frame. 3.) The wooden door frame in the whirlpool room was observed with chipped paint. 4.) The elevator door was observed with layers of mismatched paint. A review of the [NAME] Side unit Maintenance Workbook from 01/2024 through 09/2024 revealed no documentation of the concerns noted during the State Surveyor's observation. During an interview on 10/01/2024 at 10:41 AM, Resident #54 stated that the cushion on their wheelchair arm rest has been torn since they were admitted . They stated that the staff replaced their wheelchair yesterday and gave them another one that has no rip. During an interview on 10/03/2024 at 12:05 AM, the Director of Rehabilitation stated they were responsible for inspecting and repairing the wheelchairs and might have missed the torn arm rest on Resident #54's wheelchair. During an interview on 10/02/2024 at 10:43 AM, the Director of Maintenance stated they were responsible for maintaining the walls and other equipment including the Hoyer lift. The Director stated they make their rounds every morning and missed some areas that need to be repainted. 10 NYCRR 415.5(h)(2)

Based on observations, record review, and interviews conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident in 3 (Resident #159,#35, and #22) of 18 total sampled residents. Specifically, Licensed Practical Nurse #1 was observed using the same blood pressure cuff for Residents #159 and #22 without cleaning and disinfecting the blood pressure cuff in between each resident use. Licensed Practical Nurse #1 also failed to clean and disinfect the blood pressure machine after each usage. The findings are: The facility's policy titled Cleaning and Disinfection of Non -Critical Resident Care Equipment with a revision date of 01/2024 documented that shared equipment including transport equipment, will be cleaned, and disinfected after use by each patient/resident and as needed. On 10/01/2024 at 09:45AM, Licensed Practical Nurse #1 was observed going into Resident #159's room, removed the blue blood pressure cuff from the blood pressure machine and took Resident's # 159 blood pressure. Licensed Practical Nurse #1 did not sanitize the blood pressure cuff prior to placing the cuff on Resident #159's arm. Licensed Practical Nurse #1 then rolled the blood pressure machine out of the room, into the hallway, then logged the blood pressure results. Licensed Practical Nurse #1 without sanitizing the blood pressure cuff, then proceeded to take the blood pressure machine into Resident #22's room. Licensed Practical Nurse #1 washed their hands and applied the same blue blood pressure cuff on Resident's #22's left arm without sanitizing the blood pressure cuff or machine prior to use. Licensed Practical Nurse #1 then washed their hands, rolled the blood pressure machine in the hallway, and continued to prepare the medications to be administered for Resident #22. Licensed Practical Nurse did not sanitize the blood pressure cuff nor the blood pressure machine. After administering Resident #22's medications, Licensed Practical Nurse #1 washed their hands and without sanitizing the blood pressure machine or the blood pressure cuff, took the blood pressure machine into Resident #35's room . Licensed Practical Nurse #1 then took Resident #35's blood pressure using a red cuff. Licensed Practical Nurse#1 administered Resident's #35's medication, washed their hands, and rolled the blood pressure machine next to the medication cart. Licensed Practical Nurse #1 did not cleaning or sanitize the blood pressure machine and the blood pressure cuff after use. On 10/01/2024 at 10:22 AM, immediately following Resident #35's medication administration, Licensed Practical Nurse#1 was interviewed and stated that they had cleaned the blood pressure machine prior to the start of their daily medication administration, and that they are aware that they are to clean the blood pressure machine and blood pressure cuffs between residents' usage. They stated they forgot to clean the blood pressure machine and cuffs between each residents. On 10/01/2024 at 11:07 AM, the Director of Nursing was interviewed and stated that the licensed nurses were given in-service on cleaning the blood pressure cuffs and the blood pressure machine between residents' usage. The Director of Nursing stated that the Licensed Practical Nurse #1 should have cleaned the blood pressure machine between each residents' usage. 10 NYCRR 415.19 (a)(1-3)

Based on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Specifically, there was no available posting of daily nurse staffing information. The findings are: The facility policy titled Staffing with a reviewed date of 01/2024 stated that the facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Direct care staffing information per day is submitted to the Centers for Medicaid and Medicare Services payroll based journal system on the schedule specified but no less than once a quarter. The policy did not contain information on posting of the daily nurse staffing information. During multiple observations conducted on 09/26/2024 and 09/30/2024, the State Surveyor was unable to locate the postings of the daily nurse staffing data for each shift or any signage instructing residents or visitors where it was located. During an interview on 09/27/2024 at 02:10 PM, the Staffing Coordinator stated they only post the names of the staff and their assigned units. The Staffing Coordinator stated they do not post the actual hours worked by the nursing staff or the resident census. During an interview on 09/30/2024 at 01:30 PM, the Director of Nursing stated that they were not aware of the regulation that the nurse staffing information must be posted daily. During an interview on 10/01/2024 at 10:45 AM, the Administrator stated it was the Staffing Coordinator's responsibility to post the nurse staffing information. 10 NYCRR 415.13

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 dated 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 dated 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)

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 dated 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 dated 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)

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 dated 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 dated 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)

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 dated 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 dated 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)

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 dated 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)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (Complaint Intake #NY00342374), the facility failed to ensure that resident assessment accurately reflected the residents' status. This was evident for 13 of 13 Justice Involved Residents who were sampled (Residents 1-13). Specifically, observations made on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during various times through the day revealed 12 Justice Involved Residents wearing two-foot-long restraints around their ankles, one resident left wrist cuffed to their bed rail. Review of Section P of the residents' Minimum Data Set (MDS, an assessment tool) did not identify that Justice Involved Residents (1-13) had restraints in use. The facility did not assess the residents properly and also violated the rights of the Justice Involved Residents allowing the use of restraints while at the facility. The findings are: A Policy titled Minimum Data Set, dated dated dated ,d+[DATE], states it is the facility's policy to follow the guidelines of the most current State-specified Long Term Care Resident Assessment Instrument manual correctly and effectively according to Centers for Medicare and Medicaid Services. The policy further documented that each discipline is responsible for obtaining an accurate assessment of the resident's status. The Minimum Data Set 3.0 Section P0100 titled Physical Restraints describes restraints. It documents: Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. A 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. 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 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. Section P under Physical Restraints was blank, the code for limb restraints was blank, indicating the Justice Involved Resident #4 did not have physical restraints in use and the facility did not assess the use of restraints on the residents. A document in Justice Involved Resident #4's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of skin integrity. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal (a small depression in the center of the macula that contains only cones and constitutes the area of maximum visual acuity) Involvement, Urinary Tract Infection, and Dermatophytosis (mycotic infections). 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 dated dated [DATE], documented that Resident #6 had a Brief Interview of Mental Status and scored 12 associated with moderately impaired cognition. Section P under Physical Restraints was blank, the code for limb restraints was blank. indicating that the Justice Involved Resident did not have physical restraints in use and the facility did not assess the use of restraints on the residents. A document in Justice Involved Resident #6's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of 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 (information 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 dated dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. Section P under Physical Restraints was blank, the code for limb restraints was blank, indicating that the Justice Involved Resident did not have physical restraints in use and the facility did not assess the use of restraints on the residents. A document in Justice Involved Resident #6's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of skin integrity. There was no documented evidence restraint care plans were developed for Justice Involved Residents (1-13). During an interview on 06/26/24 at 3:17 PM, the Director of Nursing stated that they informed the Federal Bureau of Prison that the facility is a restraint free facility, but the Federal Bureau of Prison stated that they enforce the restraints for security reasons. The Director of Nursing stated that they admitted Justice Involved Residents who must be shackled. The Director of Nursing stated that the Minimum Data Set was not coded for restraints because the facility was not imposing the restraints, and that the Federal Bureau of Prison was. During a telephone interview on 06/27/24 at 2:18PM, Minimum Data Set Coordinator stated the Justice Involved Residents are under the Department of Correction and that the shackles and cuffs are not considered a restraint, therefore, the Minimum Data Set was not coded to identify residents wearing a restraint. 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. 10 NYCRR 415.11(b)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (Complaint Intake #NY00342374), the facility failed to ensure that resident assessment accurately reflected the residents' status. This was evident for 13 of 13 Justice Involved Residents who were sampled (Residents 1-13). Specifically, observations made on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during various times through the day revealed 12 Justice Involved Residents wearing two-foot-long restraints around their ankles, 1 resident left wrist cuffed to their bed rail. Review of Section P of the residents' Minimum Data Set (MDS, an assessment tool) did not identify that Justice Involved Residents (1-13) had restraints in use. The facility did not assess the residents properly and also violated the rights of the Justice Involved Residents by allowing the restraints while at the facility. The findings are: A Policy titled Minimum Data Set, dated dated dated ,d+[DATE], states it is the facility's policy to follow the guidelines of the most current State-specified Long Term Care Resident Assessment Instrument manual correctly and effectively according to Centers for Medicare and Medicaid Services. The policy further documented that each discipline is responsible for obtaining an accurate assessment of the resident's status. The Minimum Data Set 3.0 Section P0100 titled Physical Restraints describes restraints. It documents: Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. A 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. 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 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. Section P under Physical Restraints was blank, the code for limb restraints was blank. The facility did not assess the use of restraints on the resident. A document in Justice Involved Resident #4's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of skin integrity. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal (a small depression in the center of the macula that contains only cones and constitutes the area of maximum visual acuity) Involvement, Urinary Tract Infection, and Dermatophytosis (mycotic infections). 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 dated dated [DATE], documented that Resident #6 had a Brief Interview of Mental Status and scored 12 associated with moderately impaired cognition. Section P under Physical Restraints was blank, the code for limb restraints was blank. The facility did not assess the use of restraints on the resident. A document in Justice Involved Resident #6's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of 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 (information 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 dated dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. Section P under Physical Restraints was blank, the code for limb restraints was blank. The facility did not assess the use of restraints on the resident. A document in Justice Involved Resident #12's medical record titled, care plan for special restrictive intervention not facility policy rather court order in maintaining incarceration protocol dated 06/06/24 document interventions to check skin under cuffs to prevent skin breakdown and maintenance of skin integrity. There was no documented evidence restraint care plans were developed for Justice Involved Residents (1-13). During an interview on 06/26/24 at 3:17 PM, the Director of Nursing stated that they informed the Federal Bureau of Prison that the facility is a restraint free facility, but the Federal Bureau of Prison stated that they enforce the restraints for security reasons. The Director of Nursing stated that they admitted Justice Involved Residents who must be shackled. The Director of Nursing stated that the Minimum Data Set was not coded for restraints because the facility was not imposing the restraint, and that the Federal Bureau of Prison was. During a telephone interview on 06/27/24 at 2:18 PM, Minimum Data Set Coordinator stated the Justice Involved Residents are under the Department of Correction and that the shackles and cuffs are not considered a restraint, therefore, the Minimum Data Set was not coded to identify residents wearing a restraint. 10 NYCRR 415.11(b)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (NY00342374), the Medical Director failed to ensure resident care policies were implemented and the rights of individual were respected. This was evident for 13 Justice Involved Residents sampled (Justice Involved Residents #1-13). Specifically, on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during observations made various times throughout the day 11 Justice Involved Residents were observed wearing shackles around their ankles and 1 Justice Involved Residents were observed with their left wrist cuffed to the bed. During observations on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 confirmed all Justice Involved Residents eating in their room. They were not allowed to participate in group activities, community dining, communicate freely with visitors, leave their rooms freely and receive mail that were not opened by the representatives of the Federal Bureau of Prison Services. The findings are: The facility's Policy titled Resident Rights dated 01/2024, stated that a 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 stated the incarcerated individual's rights are honored and met unless otherwise determined by the Federal Court System. 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. Observations made on 06/06/2024, 06/26/2024, and 06/27/2024 during various times throughout each day revealed 11 Justice Involved Residents wearing two-foot-long shackles around their ankles. All observations on 06/06/2024 and 06/26/2024, 06/27/2024-06/28/2024 confirmed all Justice Involved Residents eating only in their room and did not participate in facility activities. 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 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. Justice Involved Resident #6 was admitted to the facility with diagnoses including Advance Atrophic (age-related Macular degeneration) without Sub foveal (a small depression in the center of the macula that contains only cones and constitutes the area of maximum visual acuity) Involvement, Urinary Tract Infection, and Dermatophytosis (mycotic infections). 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 dated dated [DATE], documented that 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, and Enterocolitis (information 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 dated dated [DATE], documented that Resident #12 had a Brief Interview of Mental Status and scored 14 associated with intact cognition. 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 a telephone interview on 06/27/2024 at 2:34 pm, the Medical Director stated that they participate in the Quality Assurance Meetings, oversee, and coordinate care of the residents. The Medical Director stated they review the policies but that they were not involved in development of the policies. The Medical Director stated that they are aware that the facility is a restraint free facility and that the Justice Involved Residents are being restraint under the Federal Bureau of Prison. The Medical Director also stated that they were aware that the Justice Involved Residents were restricted to their room. The Medical Director stated that they do not have any control over the Federal Bureau of Prison and that they believed it was normal because the Justice Involved Residents are incarcerated. 10 NYCRR 415.15(a)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00324912), the facility failed to protect resident's rights to be free from physical abuse. The facility did not ensure that each resident was free from physical abuse. This was evident for 1 out of 6 residents (Resident #4) sampled for Abuse. Specifically, the facility surveillance camera, dated 09/26/23, showed Resident #4 hit Certified Nursing Assistant (CNA) #4 as CNA #4 was escorting Resident #4 from the dining room to Resident #4's room. CNA #4 then pulled Resident #4's hair. The findings are: The facility's Policy and Procedure dated 01/09/23, titled Abuse and Neglect states that it is the policy of the facility to assure residents are free from abuse and neglect, including involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, family members, legal guardians, or outside members of the community. Resident #4 was admitted to the facility on [DATE] with diagnosis of Mild Intellectual Disabilities and Schizoaffective Disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 09/08/23 documented that Resident #4 had moderately impaired cognition. A Psychosocial Well-being Care Plan dated 09/12/23, documented that Resident #4 has the potential to be victimized and the potential to abuse others. The interventions included providing early interventions, setting limits on inappropriate behaviors, and remove Resident #4 form area of aggressor. An Investigation Summary dated 09/26/23 documented that Registered Nurse Supervisor (RNS) #2 notified the Director of Nursing (DON) at approximately 11:07 PM (on 09/25/23) that Resident #4 was aggressive towards staff and scratched RNS #2. The medical doctor (MD) #1 was notified with instructions to monitor Resident #4's behavior and to transfer Resident #1 to the hospital if behavior continues. Resident #4 was assessed and had no recollection of the incident and outburst. The investigation also states that based on camera review; Resident #1 was aggressive, and CNA #4 used physical force to redirect Resident #4. The Surveillance Camera Recording dated 09/25/23 was reviewed on 10/04/23: the recording showed on 09/25/23 at 10:25PM, Resident #4 walked into the dining room with their rolling walking. At 10:27PM, Resident #4 began coloring in a book. At 10:32PM, CNA #3 and CNA #5 approached Resident #4 and was talking to Resident #4. At 10:33PM Resident #4 was shaking both their hands at CNA #3 and CNA #5. Resident #4 also threw their walker to the floor. At 10:34 PM, Licensed Practical Nurse (LPN) #2 arrived in the dining area along with CNA #3, #5, #6 and all four staff members were observed talking to Resident #4. At 10:35PM, CNA #4 approached Resident #4, tapped Resident #4 on their right shoulder and Resident #4 stood up and began walking out of the dining room with CNA #4. CNA #4 pulled Resident #4's chair back after Resident #4 stood up from their chair. At 10:35 to 10:36PM, CNA #4 was walking next to Resident #4 and LPN #2 walking behind them in the hallway. Resident #4 began hitting CNA #4. CNA #4 put both their hands up in the air pulled on Resident #4's hair then let go of Resident #4's hair. CNA #3 appeared in the hallway and assisted CNA #4 to escort Resident #4 back to their room. At 10:37:36 PM, RNS #2 approached LPN #2 in the hallway and was talking to LPN #2. At 10:38PM, RNS #2 and LPN #2 walked towards Resident #4's room. A Nursing Progress Note dated 09/25/23 at 10:24PM, by LPN #2 documented that Resident #4 was observed with non-compliance behavior, not staying in their room. Resident #4 was walking on the floor with their rolling walker and without assistance. Resident #4 became very aggressive, hitting themselves and staff. A Nursing Progress Note dated 09/26/23 at 12:29AM, by Registered Nurse (RN) #2, documented that at 10:40PM Resident #4 was observed to be agitated. Staff reported that Resident #4 was observed pacing in the hallway with their walker. Staff was not able to redirect Resident #4. Resident #4 became physically aggressive, towards staff. Resident #4 was observed banging their hands on the table and hit themselves in the face. During a telephone interview on 10/04/23 at 1:04PM, CNA #4 stated that at 10:40PM on 09/25/23, LPN #2 screamed at CNA #4 to get Resident #4 out of the dining room. CNA #4 said that they went to the dining room and observed that Resident #4 was agitated but they persisted on taking Resident #4 to their room because LPN #2 instructed them to do so. CNA #4 stated that while they were escorting Resident #4 to their room Resident #4 began hitting CNA #4. CNA #4 stated that they put their hands up in the air to block Resident #4 from hitting them and in the process their hand must have touched Resident #4's hair. CNA #4 stated that they did not pull Resident #4's hair. CNA #4 stated that LPN #2 was waking behind in the hallway. During an interview on 10/04/23 at 4:17PM, LPN #2 stated that Resident #4 went to the dining room and was coloring. LPN #2 stated that they informed CNA #4, who Resident #4 was familiar with and who was assigned to Resident #4, that Resident #4 was in the dining room. LPN #2 stated that CNA #4 approached Resident #4 in the dining room and encouraged Resident #4 to go back to their room. LPN #2 stated that Resident #4 willing got up and followed CNA #4 out of the dining room. LPN #2 stated that while CNA #4 was walking with Resident #4 in the hallway, they observed Resident #4 hit CNA #4. LPN #2 stated that they encouraged Resident #4 to stop hitting CNA #4 and informed CNA #4 to leave Resident #1. LPN #2 stated that CNA #4 did not walk away from Resident #4 because Resident #4's gait was unsteady. LPN #2 stated that CNA #3 came and assisted CNA #4 to escort Resident #4 to their room. LPN #2 stated that they were walking behind Resident #4 and CNA #4 and did not see when CNA #4 pulled on Resident #1's hair. During an interview on 10/04/23 at 5:21PM, RNS #2 stated that they arrived on the unit at approximately 10:35PM and LPN #2 notify them that Resident #4 was physically aggressive as CNA #4 attempted to escort Resident #4 to their room. RNS #2 stated that a body assessment was done on 09/25/23 and there was no redness, no bruising, no discoloration no injuries. RNS #2 stated that they called the Medical Doctor and received a telephone order to monitor Resident #4 for any further behavior and if the behavior escalate, Resident #4 should be sent to the hospital for further evaluation. RNS #2 stated that Resident #4 calmed down at 11:30PM and went back to the dining room to color in their book. RNS #2 stated that they became aware on 09/26/23, after reviewing the surveillance camera, that CNA #4 pulled on Resident #4's hair. RNS #2 said that there was no injury to Resident #4's scalp on 09/26/23. During an interview on 10/06/23 at 3:33PM, the DON stated that RNS #2 did not inform them of any altercation between Resident #4 and CNA #4. The DON stated that on 09/26/23 at 12:30PM during an Interdisciplinary Team (IDT) meeting a discussion led them to review the surveillance camera. The DON stated that the camera footage showed that CNA #4 pulled on Resident #4's hair. The DON stated that CNA #4 was called immediately and was removed from the schedule. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00324912), the facility failed to ensure that a reasonable suspicion of a crime against a resident or an individual receiving care from the facility was reported to the local law enforcement. This was evident for 1 out of 6 residents (Resident #4) sampled. Specifically, the facility surveillance camera dated 09/26/2023 showed Resident #4 hit Certified Nursing Assistant (CNA) #4 as CNA #4 was escorting Resident #4 from the dining room to Resident #4's room. CNA #4 then pulled on Resident #4's hair. The facility did not report the alleged allegation of abuse within 2 hours on 09/25/23 to local law enforcement. The facility reported the abuse to local law enforcement on 10/04/23 while the Department of Health (DOH) surveyors were onsite investigating the allegation of abuse. The findings are: The facility's Policy and Procedure title Reporting of Crime states that it is the policy of the facility to assure all alleged/suspected violations and all substantiated incident of abuse, or a crime has been committed will be promptly reported to appropriate state agencies and other entities or individuals as required by law and CMS expectations. An Investigation Summary dated 09/26/23 documented that RNS #2 notified the Director of Nursing (DON) at approximately 11:07 PM (on 09/25/23) that Resident #4 was aggressive towards staff and scratched RNS #2. The medical doctor (MD) #1 was notified with instructions to monitor Resident #4's behavior and to transfer Resident #4 to the hospital if behavior continues. Resident #4 was assessed and had no recollection of the incident and outburst. The investigation also states that based on camera review; it was evident that CNA #4 violated redirection of Resident #4 while the Resident was agitated. CNA #4 also used physical force on Resident #4. The Surveillance Camera Recording dated 09/25/23 was reviewed on 10/04/23: the recording showed on 09/25/23 at 10:25PM, Resident #4 walked into the dining room with their rolling walking. At 10:27PM, Resident #4 began coloring in a book. At 10:32PM, CNA #3 and CNA #5 approached Resident #4 and was talking to Resident #4. At 10:33PM Resident #4 was shaking both their hands at CNA #3 and CNA #5. Resident #1 also threw their walker to the floor. At 10:34 PM, Licensed Practical Nurse (LPN) #2 arrived in the dining area along with CNA #3, #5, #6, and all four staff members were observed talking to Resident #4. At 10:35PM, CNA #4 approached Resident #4, tapped Resident #4 on their right shoulder and Resident #4 stood up and began walking out of the dining room with CNA #4. CNA #4 pulled Resident #4's chair back after Resident #4 stood up from the chair. At 10:35 to 10:36PM, The camera footage showed CNA #4 was walking next to Resident #4 and LPN #2 walking behind them in the hallway. While they were walking in the hallway to Resident #4's room, Resident #4 began hitting CNA #4. CNA #4 put both their hands up in the air pulled on Resident #4's hair then let go of Resident #4's hair. CNA #3 appeared in the hallway and assisted CNA #4 to escort Resident #4 back to their room. At 10:37:36 PM, Registered Nurse Supervisor (RNS) #2 approached LPN #2 in the hallway and was talking to LPN #2. At 10:38PM RNS #2 and LPN #2 walked towards Resident #4's room. During an interview on 10/06/23 at 3:33PM, the DON stated that on 09/26/23 at 12:30PM during an Interdisciplinary Team (IDT) meeting a discussion led them to review the surveillance camera footage which CNA #4 pulled on Resident #4's hair. The DON stated Resident #1's family stated that they did not want the incident to be reported to local law enforcement. The DON stated that they did not call local law enforcement to honor Resident #4's family's request. During an interview on 10/6/23 at 3:51PM, the Administrator stated that the incident was reported to local law enforcement on 10/04/2023 at 7:00PM. 10NYCRR 415.4(b)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00321418), the facility did not ensure that a resident drug regimen was free from unnecessary medication. This was evident for one out of six residents (Resident #1) reviewed for antipsychotic medication. Specifically, Resident #1, who was not initially receiving an antipsychotic medication, was administered Haloperidol (an antipsychotic medication use used to treat certain mental/mood disorder such as schizophrenia, schizoaffective disorder) 2miligrams (mg) as a onetime dose on 08/02/23 for diagnosis of Anxiety. There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the anti-psychotic medication. The findings are: Review of the Antipsychotic Medication Use Policy, revision date of 12/2016, states that Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Diagnoses alone do not warrant the use of antipsychotic medication. Resident #1 was admitted to the facility with diagnosis including Pneumonia, Arthritis and Anxiety disorder. A Minimum Data Set (MDS, a resident assessment tool) was not done as Resident #1 had been just admitted to the facility. A Nursing Progress Note dated 08/02/2023 at 9:29PM, by Registered Nurse (RNS #1) documented That Resident #1 was observed to be anxious and was talking to themselves several times during the shift. Resident #1 was constantly yelling and talking to self. Resident #1 appeared alert and oriented times four. After a few hours, Resident #1 start yelling again. The Medical Doctor (MD) #1 was notified and ordered one dose of Haloperidol 2mg. Resident #1 will be seen by psychiatrist as well. Monitoring continues. A Physician Order Report dated 08/02/2023 - 09/08/2023 documented Haloperidol 2mg, orally STAT for diagnosis of Anxiety disorder due to known physiological condition. There was no documented evidence in Resident #1's medical record that non-pharmacological interventions were completed prior to the administration of the anti-psychotic medication. There was no documented evidence in Resident #2's medical record that Resident #2 was assessed or monitored for the effectiveness of the medication and potential adverse consequences. During an interview on 10/04/2023 at 3:04PM, Certified Nursing Assistant (CNA) #1, who assisted CNA #2 with caring for Resident #2 on 08/02/2023 on the evening shift stated that during care Resident #1 was not physically abusive and was not aggressive and they provided incontinent care without any issues. CNA #1 stated that they returned to Resident #2 a second time during the shift and Resident #1 was being picky (very specific with what Resident #1 wanted) and was switching topics and was not concentrating. During an interview on 10/04/2023 at 3:35PM, Licensed Practical Nurse (LPN) #2 stated that Resident #1 was upset and was demanding everything to be done the way Resident #1 wanted it. LPN #2 stated that Resident #1 yelled when the CNAs (CNA #1, CNA #2) tried to change Resident #2's incontinence brief. LPN #2 stated that Haloperidol one tablet 2mg was administered to Resident #1 by oral route as per the physician's order. During a subsequent telephone interview on 10/24/2023 at 4:08PM, LPN #2 stated that they do not recall attempting any non-pharmacological interventions prior to administering the Haloperidol medication. LPN #2 stated that they went to Resident #1 's room and informed the Resident #1 that he MD #1 ordered a onetime dose of Haloperidol 2mg and Resident #1 took the medication. LPN #2 stated that they monitored Resident #1 but could not recall documenting. During an interview on 10/04/2023 at 4:04PM, RNS #1 stated that they admitted Resident #1 to the unit on 08/02/2023 and that Resident #1 was alert and oriented times four. RNS #1 stated that Resident #1 was very emotional, very specific about all aspects of care, especially food preferences. RNS #1 stated that Resident #1 was not confused but had difficulty to focusing on topics when they were discussing preferences of care. RN #1 stated that Resident #1 was cooperative during admission and did not demonstrate any behavioral problems. RNS #1 stated that later in the shift Resident #1 had outbursts of yelling. RNS #1 stated that they went to Resident #1 's room and talked to Resident #1, but Resident #1 did not have any complaints. RN #1 stated that after RN #1 left Resident #1's room, Resident #1 started yelling and was disturbing other Residents. RN #1 stated that they called MD #1 and MD #1 ordered Haloperidol 2mg to be administered orally STAT. During a subsequent telephone interview on 10/24/2023 at 3:50PM, RNS #1 stated that Resident #1 was monitored after the medication was administered and that Resident #1 was observed relaxed and calmer. RNS #1 stated that they were not sure if they had documented in the medical record. RNS #1 stated that no one forced Resident #1 to take the medication and that Resident #1 was aware of what Resident #1 was taking. During a telephonic interview on 10/04/2023 at 4:43, MD #1 stated Resident #1 was a newly admitted Resident and was not yet evaluated. MD #1 stated that they were notified about Resident #1 's erratic aggressive behavior of yelling and disturbing the piece of other residents. MD #1 stated that prescribing an antipsychotic medication for Anxiety induced psychosis cause by chronic opioid intake. MD #1 stated that a non-pharmacological intervention like trying to talk, trying to calm down Resident #1, and calling the family were not effective. MD #1 stated that the Haloperidol 2mg was ordered 08/02/2023 as a STAT order oral medication. MD #1 stated that they did not document in Resident #1's medical record. During an interview on 10/04/2023 at 5:12PM, the Director of Nursing (DON) stated that they met Resident #1 the next day after admission on 8/03/2023. DON stated that there should have been more documentation on the reason for the STAT order of Haldol. The DON stated that the nurse documented that Resident #1 was yelling as the indicator for the STAT order, but yelling is not an acceptable indicator for the use of Haldol. 10 NYCRR 415.12(1)(2)(i)

Based on observation and staff interview, the facility did not ensure that an infection prevention and control program designed to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This was observed and inspection of the medication room specifically: 1) On two occasions during a medication pass observation LPN #1 (Licensed Practical Nurse) did not clean and disinfect the glucose Resident # 38 2) The medication room was also being used as storage for urine and stool specimens. The facility policy on Glucose Meter cleaning states: to maintain glucose testing meters in a clean, sanitary condition and ready for resident use. The glucose testing meter is to be inspected for signs of blood, debris, dust or lint anywhere in or around the test strip carrier prior to each use and the outside of the glucose testing meter is to be cleansed after each use with an EPA approved disinfectant (Sani- cloth - purple top canister). The facility policy on Storage of Laboratory Specimens states that laboratory specimens are store in a manner to ensure that the quality of the laboratory specimens are maintained - in a specimen refrigerator. During a medication pass observation on 03/22/2018 at 4:20 PM LPN #1 who is the medication nurse was observed doing a finger stick on resident # 38. She washed her hands, introduced herself to the resident and identify her. She then proceeded cleaning the blood glucose machine with Sani cloth (germicidal -disposable wipe) and did the finger stick. The machine was not registering the reading and she then put it back in its case and stated I will get the other machine on the other side (east side). Taking the second machine, she disinfected and cleansed it with the use of Sani- cloth and proceeded to do the finger stick of the resident. This time the reading registered. After using the machine she put it back in its case without disinfecting it. LPN #1 was interviewed on 3/22/18 at approximately 4:45 PM. LPN # 1 stated that she is supposed to clean and disinfect the glucose meter before and after use. She stated that she was nervous as she was being observed by surveyor. LPN #1 accompanied the Surveyor during the inspection of the the medication room. Two (2) refrigerators were observed in the medication room. The top refrigerator was used for medications storage and the bottom refrigerator was used for storage of laboratory specimens. LPN #1 was interviewed stated that when they collect urine or stool for the laboratory and it needs to be refrigerated they store it in the specimen refrigerator in the medication room. She clarified that the specimen refrigerator was the one at the bottom. 415.19 (a)(1-3)

Based on observations and staff interviews, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the dumpster's were not covered and litter was observed around and underneath the dumpster's. This was evident during observations conducted for the Kitchen Tour. The findings are: On 5/11/2017 at 9:33 AM, five dumpster's located outside, at the back of the building, were observed not covered. Each of the lids were up and garbage bags were on top of the dumpster's. The ground was heavily soiled and the area around and underneath the dumpster's were littered with disposable gloves, used plastic cups and cardboard boxes. On 05/12/2017 at 11:43 AM, six dumpster's were observed filled garbage bags and the top of the dumpster's remained open with the covers flush against the wall. The Food Service Director was immediately interviewed and stated that garbage pick-up was scheduled for 6:00 am, but the company did not come. On 05/11/2017 9:33 AM, the early shift cook was interviewed and stated that it is the responsibility of the maintenance and housekeeping departments to keep the area clean. An interview was conducted with the Maintenance Supervisor on 5/11/17. The supervisor stated that the housekeeping department is responsible for maintaining the cleanliness of the dumpster area including sweeping every morning. There was no documented evidence in the facility policy and procedure for Kitchen Garbage and Refusal Disposal for keeping the dumpster site clean and the dumpster's covered. The Policy and Procedure indicated that the maintenance director maintains a log regarding collections, twice a week. 415.14(h)

Based on record review and interviews of facility staff during the recertification survey the facility did not ensure that adequate monitoring was conducted for a resident receiving anticoagulant medication. Specifically, Resident #10 was diagnosed with [REDACTED]. The resident's comprehensive care plan and physicians orders instructed instructed that a PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) test was to be conducted on a weekly basis. The resident had abnormal high PT/INR lab values, which resulted in the physician ordering more frequent labs at the end of March into April. The standing order for weekly PT/INR was discontinued. Once the resident's lab values were stable, a new dose of [MEDICATION NAME] was started, but no new order for PT/INR was made. There was no documented evidence in the medical record that the PT/INR was done after 4/7/17. This deficient practice was was evident for 1 of 5 residents reviewed for Unnecessary Medication Use out of a Sample of 30 (Resident #10). The finding is: Resident #10 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident had [DIAGNOSES REDACTED]. The MDS documented the resident received anticoagulant medication for 7 days. The resident's CCP (Comprehensive Care Plan) dated 5/21/16 identified Potential for Bleeding secondary to use of anticoagulant as potential problem. Interventions included the monitoring of lab values such as CBC, PT/INR and report abnormal values to physician. There was no specific intervals noted for the PT/INR to be done at this time. The physician's orders [REDACTED]. The resident's medical record indicates that monitoring was being performed up until The Lab Report dated 3/28/17 documented the resident's PT 62.9 seconds (Reference range 9.8 - 11.9) and INR 5.9 (Reference range 1.0-2.0). The physician (MD) signed the report and noted instructions for [MEDICATION NAME] to be held on 3/28 and 3/29 and repeat the PT/INR on 3/30. The Lab Report dated 3/30/17 documented PT 58.4 and INR 5.2 . The MD signed the report and wrote instructions to discontinue the [MEDICATION NAME] and repeat the PT/INR on Monday. The Lab Report dated 4/3/17 documented PT 23.2 and INR 2.1. The MD signed the report and wrote instructions for [MEDICATION NAME] 2 mg to be started, and the PT/INR to be done on 4/7/17. The Lab Report dated 4/7/17 documented PT/INR done 4/7/17 with result PT 14.7, INR 1.4. The physician signed the report and documented that [MEDICATION NAME] would be increased to 2.5 mg HS. The MD Orders dated 4/8/17 documented [MEDICATION NAME] 2.5 mg at bedtime was ordered. The Physician order [REDACTED]. The standing order for PT/INR to be done weekly on Tuesdays was discontinued on 3/31/17. There was no documented evidence in the medical record that the physician ordered any PT/INRs to be done after the new dosage of [MEDICATION NAME] was ordered on [DATE]. The MD Monthly Note dated 4/20/17 documented the resident was on [MEDICATION NAME] and there was a plan in place for PT/INR labs to be done on Tuesdays. The MD Monthly renewal orders dated 4/20/17 documented orders for [MEDICATION NAME] 2.5 mg at bedtime. The orders did not contain an order for [REDACTED].>There was no documented evidence in the medical record that the PT/INR was done after 4/7/17. This is a time period of more than 4 weeks. An annual CCP note dated 5/7/17 documented the resident was on [MEDICATION NAME] therapy, and the PT ([MEDICATION NAME] Time)/INR was to be done weekly. The manufacturer's medication guide for [MEDICATION NAME] dated 9/2016 documented anticoagulation must be monitored carefully with INR labs. The manufacturer instructs that for new doses of [MEDICATION NAME], the INR should be done daily until the results stabilize, and after stabilization the dosage can be maintained with periodic INR every 1 to 4 weeks. On 5/16/17 at 9:43:19 AM the day shift Registered Nurse Supervisor #1 was interviewed and stated that at the time of the monthly renewal, the nurse reviews the orders to make sure all orders are there. She stated that any standing lab orders should appear on the printed monthly orders, but one-time lab orders will not be generated on the monthly orders. The RN stated she reviewed the monthly renewal orders in April, and at the time, she did not realize there for no lab orders for PT/INR monitoring. She stated that maybe she figured there could have been a separate one time order for PT/INR labs. One-time lab orders are entered into the computer and printed out. They are called into the lab by the nurse so they can send a technician. RN Supervisor #2 usually checks the lab results weekly because she is the evening shift supervisor. On 5/15/17 at 3:08 PM, RN Supervisor #2 was interviewed and stated the PT/INR was missed for 4 weeks. The standing order was discontinued when the resident had a high PT/INR in March and more frequent PT/INR labs were ordered. She stated the standing order for PT/INR was discontinued in error. She further stated weekly labs for PT/INR are done Tuesdays, and reviews them every week. The RN stated that if she was off and another nurse reviewed the lab results, it is possible they would not notice the resident has no labs. During the monthly renewal, they should have noticed there were no lab orders. She stated that usually the LPNs ask about the labs on Tuesdays and Thursdays before giving [MEDICATION NAME], but it is possible there was confusion because the resident is on comfort care. On 5/15/17 at 11:52 AM, the Physician (MD) was interviewed and stated the resident is [MEDICATION NAME] for Chronic [MEDICAL CONDITION], and the therapeutic goal is for the INR to be 1.8. The MD stated that he believed the PT/INRs are being done weekly, and the facility calls him with the results so the dosage can be adjusted as needed. He stated he would review the chart in order to provide additional information. On and 5/16/17 at 10:20 AM, the MD was interviewed again and stated that the INR was high in March so the [MEDICATION NAME] was held for a few days and then restarted at a lower dose. He stated that he did not know what happened with the INR monitoring, and he could not recall looking for the INR results during the monthly renewal in April. The MD stated the INR is usually monitored every week in order to monitor the [MEDICATION NAME] level, and he could not recall if he noticed that the labs were not being done. The MD did not realize there were no PT/INR labs done until the SA (State Agency) informed him. He stated that due to the resident being on comfort care, he has implemented a plan to lower the [MEDICATION NAME] dose so that labs will not be required. 415.12(l)(1)

Based on record review and interview, the facility did not ensure the physician reviewed the resident's total plan of care. Specifically, Resident #10 was diagnosed with [REDACTED]. The resident's comprehensive care plan and physicians orders instructed instructed that a PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) test was to be conducted on a weekly basis. The resident had abnormal high PT/INR lab values, which resulted in the physician ordering more frequent labs at the end of March into April. The standing order for weekly PT/INR was discontinued. Once the resident's lab values were stable, a new dose of [MEDICATION NAME] was started, but no new order for PT/INR was made by the physician. There was no documented evidence in the medical record that the PT/INR was done after 4/7/17. The physician did a monthly evaluation and orders 4/20/17 and did not order PT/INR labs to be done at that time. This deficient practice was was evident for 1 of 5 residents reviewed for Unnecessary Medication Use out of a Sample of 30 (Resident #10). The finding is: Resident #10 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident had [DIAGNOSES REDACTED]. The MDS documented the resident received anticoagulant medication for 7 days. The resident's CCP (Comprehensive Care Plan) dated 5/21/16 identified Potential for Bleeding secondary to use of anticoagulant as potential problem. Interventions included the monitoring of lab values such as CBC, PT/INR and report abnormal values to physician. There was no specific intervals noted for the PT/INR to be done at this time. The Physician's Orders dated 3/23/17 documented orders for the resident to receive [MEDICATION NAME] 3 mg (milligrams) - 1 tab at bedtime and PT/INR to be done weekly every Tuesday. The resident's medical record indicates that monitoring was being performed up until The Lab Report dated 3/28/17 documented the resident's PT 62.9 seconds (Reference range 9.8 - 11.9) and INR 5.9 (Reference range 1.0-2.0). The physician (MD) signed the report and noted instructions for [MEDICATION NAME] to be held on 3/28 and 3/29 and repeat the PT/INR on 3/30. The Lab Report dated 3/30/17 documented PT 58.4 and INR 5.2 . The MD signed the report and wrote instructions to discontinue the [MEDICATION NAME] and repeat the PT/INR on Monday. The Lab Report dated 4/3/17 documented PT 23.2 and INR 2.1. The MD signed the report and wrote instructions for [MEDICATION NAME] 2 mg to be started, and the PT/INR to be done on 4/7/17. The Lab Report dated 4/7/17 documented PT/INR done 4/7/17 with result PT 14.7, INR 1.4. The physician signed the report and documented that [MEDICATION NAME] would be increased to 2.5 mg HS. The MD Orders dated 4/8/17 documented [MEDICATION NAME] 2.5 mg at bedtime was ordered. The Physician Order Report documented that one time lab orders for PT/INR were entered on 3/30/17, 4/3/17 and 4/7/17. The standing order for PT/INR to be done weekly on Tuesdays was discontinued on 3/31/17. There was no documented evidence in the medical record that the physician ordered any PT/INRs to be done after the new dosage of [MEDICATION NAME] was ordered on [DATE]. The MD Monthly Note dated 4/20/17 documented the resident was on [MEDICATION NAME] and there was a plan in place for PT/INR labs to be done on Tuesdays. The MD Monthly renewal orders dated 4/20/17 documented orders for [MEDICATION NAME] 2.5 mg at bedtime. The orders did not contain an order for [REDACTED].>There was no documented evidence in the medical record that the PT/INR was done after 4/7/17. This is a time period of more than 4 weeks. An annual CCP note dated 5/7/17 documented the resident was on [MEDICATION NAME] therapy, and the PT ([MEDICATION NAME] Time)/INR was to be done weekly. The manufacturer's medication guide for [MEDICATION NAME] dated 9/2016 documented anticoagulation must be monitored carefully with INR labs. The manufacturer instructs that for new doses of [MEDICATION NAME], the INR should be done daily until the results stabilize, and after stabilization the dosage can be maintained with periodic INR every 1 to 4 weeks. On 5/15/17 at 11:52 AM, the Physician (MD) was interviewed and stated the resident is [MEDICATION NAME] for Chronic [MEDICAL CONDITION], and the therapeutic goal is for the INR to be 1.8. The MD stated that he believed the PT/INRs are being done weekly, and the facility calls him with the results so the dosage can be adjusted as needed. He stated he would review the chart in order to provide additional information. On and 5/16/17 at 10:20 AM, the MD was interviewed again and stated that the INR was high in March so the [MEDICATION NAME] was held for a few days and then restarted at a lower dose. He stated that he did not know what happened with the INR monitoring, and he could not recall looking for the INR results during the monthly renewal in April. The MD stated the INR is usually monitored every week in order to monitor the [MEDICATION NAME] level, and he could not recall if he noticed that the labs were not being done. The MD did not realize there were no PT/INR labs done until the SA (State Agency) informed him. He stated that due to the resident being on comfort care, he has implemented a plan to lower the [MEDICATION NAME] dose so that labs will not be required. 415.15(b)(2)(iii)

Based on observation, record review and interview the facility did not ensure that a physician's order [REDACTED]. This resulted in no harm to the resident with the potential for more than minimal harm. The finding is: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/22/13 during a medication pass at approximately 10 AM the Licensed Practical Nurse (LPN) was observed to remove the [MEDICATION NAME] 5% from the wrapper it was sealed in. The LPN proceeded to the resident ' s bedside and prepared to apply the [MEDICATION NAME] to the residents back. At that time, the LPN observed that a [MEDICATION NAME] dated 4/22/13 was on the resident ' s back. The LPN removed the patch and proceeded to apply the new [MEDICATION NAME] 5% to the resident ' s back. A review of the physician's order [REDACTED]. The nursing supervisor informed the surveyor that the LPN medication nurse reported to her and the physician that the [MEDICATION NAME] 5% ordered to be removed at 10:00 pm for the resident was observed to be in place on the residents back this morning. It had not been removed at 10 pm as ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nursing supervisor informed the surveyor that after being informed that the 10 PM [MEDICATION NAME] was removed at 10 AM the physician wrote a new order for the [MEDICATION NAME]: D/C current [MEDICATION NAME] restart [MEDICATION NAME] 10 PM x 12 hours on 10 PM patch off 10 AM. The LPN medication nurse was interviewed on 4/22/13 as to why she administered the [MEDICATION NAME] to the resident after she observed that the 10 PM patch was not removed the evening before as ordered. She could not provide an explanation. The evening (LPN) nurse who did not remove the [MEDICATION NAME] at 10 PM was interviewed on 4/22/13 at 3:35 PM. She explained that she as she prepared to remove the [MEDICATION NAME] from the resident, a medical emergency occurred with another resident. This medical emergency resulted in the resident being transferred to the hospital. She stated that she should not have signed that she removed the [MEDICATION NAME] before actually removing the patch from the resident's back. 415.11(c)(3)(ii) Based on observation, record review and interview, the facility did not follow a orders by a physician as required by state and federal regulations. Specifically, 1) The nursing staff did provided Resident #1 with nectar thickened liquid instead of honey thickened as ordered by the physician. 2) The nursing staff did not follow physician's orders [REDACTED]. This was evident for 2 out 16 sampled residents. This resulted in no harm with the potential for more than minimal harm. The findings are: 1) Resident # 1 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ((MDS) dated [DATE] assessed the resident with a BIMS score of 3 representing that the resident is alert but confused. on section K0510 documented the following: "Nutritional approaches..Mechanically altered diet - require change in texture of food or liquids (pureed food, thickened liquids)." On 4/22/13 during the lunch observation, it was observed that 4 oz. orange juice nectar consistency was on the resident's tray. The diet ticket with the resident's name dated 4/22/13 documented the following diet "2-3g Na, Pureed Honey-like. " The ticket also documented "Juice (Honey-like), " consistency. The resident did not receive honey thickened liquid juice on her lunch tray. On 4/23/13 during the lunch observation, it was observed that 4 oz. orange juice nectar consistency was on the resident's tray. The diet ticket with the resident's name dated 4/23/13 documented 2-3 g Na, Pureed Honey-like diet consistency. The diet ticket also documented " Juice ( Honey-like), " consistency. The resident did not receive honey thickened liquid juice on her lunch tray. Review of Mount Sinai Hospital transfer records dated 3/8/13 documented the following: " Dysphagia with honey thickened liquids. " Nutritional Risk assessment dated [DATE] documented the following: "Diet order..Pureed, Honey like liquid ...Provide diet as prescribed by MD (Medical Doctor). " Speech and Swallow evaluation dated 3/14/13 documented the following: Swallow reflex declined ... " Recommendations: Continue Pureed diet and honey thickened liquids. " Multidisciplinary Care Plan dated 3/8/13 documented the following: "Problem: Resident at increased risk for alterations in nutritional status secondary to ...Potential for aspiration ...Provide current diet..Honey like consistency." The Physician's monthly order dated 3/31/13 up to the last day of survey 4/24/13 documented the following: "Puree with Honey Thick Liquids." On 4/22/13 at 1pm, the Food Service Director was interviewed and stated that "it was a mistake in the tray line." He added that the resident should be receiving honey thickened liquids on her tray. On 4/22/13 at 1:45pm, the Medical Director was interviewed. He read the speech pathologist notes and stated: " The resident is too weak and the swallow test cannot be done, so she recommends the safest diet as possible, Honey thickened liquids. " On 4/23/13 at 1pm, the Food Service Director and Dietitian were both interviewed and stated that " there was a mistake again on the tray line. " They added that in service was provided to the kitchen staff to ensure that appropriate diet order are provided to the residents.

Based on observation, record review and staff interview, the facility did not ensure that the residents ' furnishings were in good repair. Specifically, 1) Overbed tables were found to have rough edges, chipping, scratches and missing paint. 2) Two (2) dresser drawers were scratched with missing handles. 3) One dresser was observed with the outer covering missing on the top left corner. 4) The left armrest of a wheelchair was torn exposing the foam padding underneath. This was evident for 25 of the 31 resident rooms on the east and west wings and the main dining area. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: On 7/22/11 at approximately10am, during an environmental tours of the facility, the following observations were made: (1) The edges of the top ledges of 35 overbed tables observed in 25 of 31 resident rooms on the east and west wings of the facility and main dining area had rough edges, chipping, scratches, missing paint, and were in general disrepair. (2) The 3rd dresser drawer in room 6 east was scratched and had a broken handle. The opposite dresser in the same room had all 4 dresser handles missing. (3) The dresser in room 26 west was scratched, scraped, and dented with a 4" x 3" portion of the outer covering missing on the top left corner. (4) The left armrest of a wheelchair in room 26 west had a 5" x 2" leather covering missing, exposing the foam padding underneath. On 7/25/11 at approximately 10AM, all rooms were again checked for disrepair of overbed tables and dresser drawers. Drawer handles in room 6 east were repaired and fully intact. All overbed tables remained unchanged. A review of the packing slip dated 5/19/11 documented that an order for [REDACTED]. There was no maintenance log book available for review. On 7/22/11 at 10AM, the Maintenance Director was interviewed and stated that he was aware that the overbed tables were in disrepair and needed to be replaced. He further stated that the Administrator had placed an order for [REDACTED]. He stated that when the tables arrived, a few of them were found to be malfunctioning and were returned, and they were now waiting for the replacement order to arrive. He did not have any explanation for why the drawer handles were broken and missing. On 7/25/11 at 11:50AM, the Administrator was interviewed. He stated that he had placed an order for [REDACTED]. When the shipment arrived, a few of the overbed tables were found to have malfunctioning parts and were sent back to the manufacturer. The remaining tables were unloaded and placed about the nursing home. On 7/25/11 at 1:15PM, the Certified Nursing Assistant (CNA) working on the east side of the floor was interviewed. She stated that if an item needed to be repaired in a resident's room, she would report it to the Assistant Director of Nursing (ADN) or tell the maintenance worker directly if she were to see him. She also stated that the ADN would then follow up with the maintenance director and he would fix it immediately. On 7/25/11 at approximately 1:20pm, the Licensed Practical Nurse (LPN) on the east side of the floor was interviewed. She stated that she would either tell the ADN or the Maintenance Director if any repairs were needed on the floor. On 7/25/11 at 1:25PM, the ADN was interviewed. She stated that she would tell the Maintenance Director verbally if any item was found broken in a resident's room. The Maintenance Director would then log it in his maintenance book to be fixed. If it could be repaired, he would fix it right away. If not, a replacement item would be ordered. She also stated that new overbed tables were needed in May of this year to replace older, worn tables. The Administrator promptly ordered them upon hearing that they were needed. She stated that the order came quickly, but a few of the tables were malfunctioning and sent back. The overbed tables were put into the dining room, where they were needed most. On 7/25/11 at 1:30 PM as part of the QA (Quality Assurance) interview, the DNS stated that staff complained about the overbed tables, and a QA study was done in April 2011 to address this issue. The study identified that the overbed tables were chipped. A couple of weeks ago, they received 20 overbed tables, and 5 of them were returned to the company due to malfunctioning parts. She further stated that the tables are not made of good quality material and can break easily. They are replaced as needed. 415.5(h)(2)