PRINTED: 06/26/2017 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO (X2) MULTIPLE CONSTRUCTION A.

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1 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 SS=E (a)(3)(4)(c)(1)-(4) INVESTIGATE/REPORT ALLEGATIONS/INDIVUALS (a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if F 225 4/5/17 LABORATORY DIRETOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. 03/31/2017 FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 1 of 66

2 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 1 F 225 the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on record review, interview, and observation conducted during the abbreviated surveys (NY , NY , NY , and NY ), it was determined for 3 of 5 residents reviewed for abuse/neglect (Residents #3, 4, and 5) and one additional incident affecting multiple residents in the facility, including Residents #6 and 7, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated and/or reported to the New York State Department of Health (NYS DOH) when required. Specifically: - Resident #5 made an allegation of FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 2 of 66

3 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 2 F 225 abuse/mistreatment and the investigation was not thorough, complete, or accurate, and did not address all of the resident's concerns. - Resident #3 left the facility undetected/unauthorized and the incident was not reported to NYS DOH as required. - The facility did not report to the NYS DOH when an intruder entered the facility, had access to all residents, including Residents #6 and 7, damaged property, and intervention by law enforcement was required. - Resident #4 sustained a fracture of unknown origin that was not reported to the NYS DOH as required. Findings include: 1) Resident #5 was admitted to the facility on 11/9/2016 with diagnoses including diabetes and legal blindness. The Minimum Data Set (MDS) assessment dated 2/13/2017 documented the resident had highly impaired vision, moderately impaired cognition, and did not exhibit behaviors. The comprehensive care plan (P), printed 2/23/2017, documented the resident had an ADL (activities of daily living) self-care deficit and impaired visual function. Interventions included 2 caregivers at all times, and explain all procedures before starting and allow the resident (5-10 minutes) to adjust to changes. On 2/16/2017 at 4:47 PM, the facility reported to the NYS DOH that on 2/15/2017 at 7:00 PM, a family member of the resident called the facility and alleged the resident was inappropriately touched by a male certified nurse aide (NA). The facility reported the resident's roommate was FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 3 of 66

4 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 3 F 225 present and stated no incident occurred. The facility reported the resident was visually impaired, the staff were to be educated on how to communicate with the resident when entering her room, and 2 staff members were to be present at all times for care. The incident report initiated by the Assistant Director of Nursing (ADON) documented: - On 2/17/2017 at 7:00 PM, a family member of the resident called the facility and said the resident reported a male staff member slapped her. - The ADON immediately assessed the resident, who reported she was slapped by a male staff member and yelled out when it happened. - The ADON documented she interviewed the resident's roommate (Resident #8) on 2/17/2017, who said the male staff member was not inappropriate when he answered the call bell and she did not hear the resident yell out. - The ADON also wrote statements documenting she interviewed licensed practical nurse (LPN) #28 and NA #29 (both male staff members), which documented they had no negative interactions with the resident on 2/17/ The attached Investigation Summary Form, written by the Director of Nursing (DON), documented a family member of the resident alleged she was touched inappropriately on 2/17/2017. The form documented the staff member placed the call bell on the resident and did not touch her inappropriately, it was witnessed by the roommate, and abuse/neglect was ruled out. On 2/21/2017, the DON reported to the NYS DOH triage center that the NA placed the call bell over the resident's groin area and the FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 4 of 66

5 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 4 F 225 resident thought it was a hand. During an interview on 2/23/2017 at 1:30 PM, a family member of the resident stated the resident was blind and kept her call bell in her hand at all times for security. The family member stated, as a result, the resident pressed the call bell a lot without knowing it and when she did that, staff sometimes took her call bell away. The family member stated the resident alleged last week that a male staff member took her call bell away and slapped her on the arm. The family member called the facility and spoke to a male LPN, who stated he was already in the room talking to the resident as she was upset and alleged someone took her call bell away and slapped her. The family member stated there was not an allegation that the resident was touched inappropriately. During an interview on 2/23/2017 at 2:05 PM, the ADON stated she received a message from the receptionist that the resident's family member called and said the resident was slapped in the arm. The ADON immediately assessed the resident and interviewed the resident, her roommate, and the staff on the unit. She stated the date on the incident report did not match the date the incident occurred because when she called the DON she was told to hold off on completing the investigation until they received further direction from the Administrator. She stated the next day, the DON told her to do the investigation and she dated the incident report and investigation at the time that she documented it. During an interview on 2/23/2017 at 4:05 PM, the DON stated she did not know why the date of the incident report was incorrect and said it must FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 5 of 66

6 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 5 F 225 have been an error. She sated to her knowledge, the incident resort was completed on the day the incident occurred. She stated she thought the ADON told her the resident alleged being inappropriately touched and that was why she documented that in her investigation. During an interview on 2/27/2017 at 11:40 AM, the resident stated she called her family because the staff were mad that she kept ringing her call bell, and the male staff member slapped her in the arm and called her "stupid." The resident stated he also took her call bell away, and she wanted to hold it as she could not see it and she felt more secure holding it. During an interview on 3/1/2017 at 11:00 AM, LPN #28 stated he received a call from the resident's family member, who said a male NA took the resident's call bell away and slapped her in the arm. He stated he talked to the resident and the NA, and the NA said he took the call bell out of her hand and pinned it on her clothes as she was ringing it without knowing. He stated he relayed the daughter's concerns to the Supervisor and could not remember who that was. The surveyor showed him the statement written by the ADON regarding his interaction with the resident, and he stated he never saw the statement and was not asked to write one. During an interview on 3/1/2017 at 12:30 PM, NA #29 stated the resident was blind, held her call bell in her hand, and rang it often without knowing it. He stated he took the call bell from her hand and pinned it to her clothing, did not slap her, and did not yell at her or call her names. He stated he had not seen the statement written by the ADON prior to being shown it during the FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 6 of 66

7 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 6 F 225 interview with the surveyor, but said the next day someone asked him to write a statement and he did and provided it to the Supervisor. During an interview on 3/6/2017 at 9:50 AM, the ADON stated she was not aware the resident alleged someone took her call bell away. She stated she normally had staff write their own statements, but because this investigation was not completed at the time of the incident, she wrote the interviews later. During an interview on 3/6/2017 at 10:06 AM, the Administrator stated incident reports/investigations should be started at the time of the incident. Also during the interview, the Administrator was asked for a statement written by NA #29. In a follow-up interview at 11:55 AM, the Administrator stated the ADON wrote the statements for the staff. The Administrator stated staff did not write their own statements for this incident, and that was not the usual practice. 2) Resident #3 was admitted to the facility on 5/3/2015 with diagnoses including dementia. The initial comprehensive care plan (P) dated 5/4/2015 (and current at the time of the on-site investigation) documented the resident needed limited assistance from 1 person with a rolling walker when ambulating more than 100 feet, and was at risk for elopement related to poor safety awareness. Interventions included a WanderGuard (alarming device), and the goal was for him not to leave the facility unattended. The Minimum Data Set (MDS) assessment dated 12/22/2016 documented the resident had moderately impaired cognition and disorganized FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 7 of 66

8 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 7 F 225 thinking. The 12/23/2016 wandering risk assessment initiated by MDS licensed practical nurse #20 and signed by MDS registered nurse (RN) #16 documented the resident was at moderate risk for wandering related to being forgetful with a short attention span, exhibiting/expressing fear and/or anxiety, being independently mobile, having a diagnoses of early dementia, and having a known history of wandering. The 1/2017 Treatment Administration Record (TAR) documented the resident had an order to check the WanderGuard at the alarmed doors every shift. The order was initiated on 8/6/2015. A nursing progress note dated 1/11/2017 documented the resident no longer had a WanderGuard. The 1/15/2017 wandering risk assessment completed by RN Supervisor #21 documented the resident was at low risk for wandering. The assessment documented the resident was no longer forgetful with a short attention span, did not exhibit/express fear and/or anxiety, did not have a dementia diagnosis, and did not have a known history of wandering. The resident was observed on 1/30/2017 at 12:00 PM, lying in bed, with a WanderGuard on his left ankle. He stated he went out a few days ago because the doctor discharged him. He stated he went and got some lunch and drank a few beers, and when he came back, they put a WanderGuard on his ankle. He stated he had one before, and because he hated it, they removed it. FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 8 of 66

9 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 8 F 225 During an interview on 1/30/2017 at 1:02 PM, certified nurse aide (NA) #25 stated when she was coming into work on 1/28/2017 at 2:00 PM, she was met outside by a staff member who was looking for the resident. She stated the resident was missing, and the police were called. The resident came back at around 4:30 PM or 5 PM. She stated it was very cold that day and the resident had a heavy jacket on, but was wearing slippers on his feet and did not have his walker. NA #25 stated the resident said he walked to a restaurant, had lunch and a few beers, had his hair cut, and got a ride back to the facility. During an interview on 1/30/2017 at 1:20 PM, LPN #24 stated the NA told her at around 11 AM on 1/28/2017 that she had not seen the resident. When the resident did not return after lunch, they called a code yellow (missing resident code) at around 2 or 3 PM. She stated the resident went out wearing slippers on his feet. During an interview on 1/31/2017 at 3:00 PM, RN Supervisor #21 stated the unit called her at around 1:30 PM on 1/28/2017, and told her the resident was missing. She stated they called a code yellow, and she learned from the staff that he told a few people that day that he was being discharged. She stated after the resident was missing for a while, the NAs told her he was confused so she called the police and the Director of Nursing (DON). She stated the resident came back on his own, she assessed him, and she was told he drank a few beers. During an interview on 2/27/2017 at 4:05 PM, the DON stated she was called on 1/28/2017 by RN #21 about the resident. When she called the Administrator, they deemed the incident not an FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 9 of 66

10 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 9 F 225 elopement as RN #21 recently determined the resident was alert and oriented. She stated the incident was not reported to the NYS DOH, as it was not an elopement. During an interview on 2/28/2017 at 1:00 PM, the Medical Director stated the DON called her on 1/28/2017 to tell her the resident left on his own and was wearing slippers, and he did later return on his own. The Medical Director stated she recommended a WanderGuard be re-applied when he returned, and she did a cognitive exam on him. She stated the resident had a weakness in judgement, could get lost, and did not make the best decisions. During an interview on 3/6/2017 at 10:07 AM, the Administrator stated he was called by the DON on 1/28/2017 about the resident. They deemed the event not to be an elopement because an RN said the resident was alert and oriented, and therefore it was not reported to the NYS DOH. 3) During an interview on 2/14/2017 at 9:40 AM, registered nurse (RN) Supervisor #30 stated in the fall of 2016, the sliding doors were removed from the front of the building due to renovations and as a result, there was not an alarm at the front entrance at night. She stated in the middle of the night, an intruder entered the facility, got on the first set of elevators and went to one of the nursing units. She stated she chased the intruder as he entered 3 residents' rooms and broke a window with his hand and his head. She stated there was broken glass in a resident's room, blood on the floor, and the intruder left a trail of blood around the unit. She stated when the police arrived, they apprehended the intruder. She stated the Administrator and Director of Nursing FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 10 of 66

11 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 225 ontinued From page 10 F 225 (DON) were notified and two of the residents were moved to different rooms at their request (Residents #7 and 8). On 2/23/2017, the surveyor obtained a police report that documented they responded to the facility on 9/26/2016 at 2:35 AM following reports of a trespassing complaint. Review of medical records on 2/27/2017 revealed: - On 9/26/2016 at 4:51 AM, RN #30 documented in Resident #7's medical record that an intruder entered her room at 2:50 AM and attempted to jump out the window. No harm came to the resident, but she was in shock and asked to be moved to another unit. The Administrator agreed with the move. - On 9/26/2016 at 5:01 AM, RN #30 documented in Resident #6's medical record that a man entered her room at 3:00 AM and tried to jump out of her window. The intruder broke the window with his head and hand. The resident was upset, and once it was safe, she was moved to a different room. During an interview with the Administrator on 3/6/2017 at 10:06 AM, he stated he did not recall why the incident was not reported to the NYS DOH. F 279 SS=D 10NYRR 415.4(b)(1)(ii) (d);483.21(b)(1) DEVELOP OMPREHENSIVE ARE PLANS (d) Use. A facility must maintain all resident assessments completed within the previous 15 F 279 4/5/17 FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 11 of 66

12 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 11 F 279 months in the resident s active record and use the results of the assessments to develop, review and revise the resident s comprehensive care plan (b) omprehensive are Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at (c)(2) and (c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under , or ; and (ii) Any services that would otherwise be required under , or but are not provided due to the resident's exercise of rights under , including the right to refuse treatment under (c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident s medical record. (iv)in consultation with the resident and the FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 12 of 66

13 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 12 F 279 resident s representative (s)- (A) The resident s goals for admission and desired outcomes. (B) The resident s preference and potential for future discharge. Facilities must document whether the resident s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. () Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on record review and interview conducted during the abbreviated survey (NY ), it was determined for 1 of 5 residents (Resident #2) reviewed for comprehensiev care plans (P), the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, Resident #2 was not provided with timely care per a specified plan, resulting in her attempting to self-transfer and falling. Resident #2's comprehensive care plan (P) was not individualized with care needs, the resident was not assessed when she returned from the hospital, and skin issues were not addressed timely. Findings include: Resident #2 was re-admitted to the facility on 10/10/2016 with diagnoses including blindness. The Minimum Data Set (MDS) assessment dated 12/12/2016 documented the resident had FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 13 of 66

14 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 13 F 279 moderately impaired cognition and severely impaired vision. She needed extensive assistance from 2 persons with transferring, and had 1 fall with injury since the last assessment. The resident was at risk for pressure ulcers, did not have current pressure ulcers, and had pressure-relieving devices in place. are not provided timely and care needs not specified: The comprehensive care plan (P) initiated on 10/10/2016 documented: - The resident had a self-care deficit related to a past femur fracture. - The P did not document the level of assistance the resident needed with transferring. The P documented to "specify what assistance" the resident needed, and that was not specified. - The P documented the resident: "specify high, moderate, low risk for falls" related to gait disturbance and vision/hearing problems. Interventions included anticipating and meeting needs, and providing access to the call bell. The 12/15/2016 fall risk scale initiated by MDS licensed practical nurse (LPN) #15 and signed off by MDS registered nurse (RN) #16 documented the resident was at high risk for falls related to previous falls, diagnoses, impaired gait, and due to overestimating or forgetting limits. There was no documented evidence the resident's P was updated or individualized with specific care needs following completion of the fall risk scale. The facility's incident report dated 1/15/2017 FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 14 of 66

15 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 14 F 279 documented: - The resident had an unwitnessed fall at 12:10 PM, as she was ambulating without assistance. - RN #14 assessed the resident and documented the resident was found on the ground underneath her bed, had attempted to transfer from the wheelchair to bed on her own, hit her face, had a 2 centimeter (cm) laceration on the left eyebrow, and was sent to the emergency room. - The attached statement from LPN #12 documented she was working that day, but did not witness anything. - NA #13's attached statement documented the resident had asked to go back to bed and she asked RN #14 to talk to the resident. - RN #14's attached statement documented the resident wanted to go back to bed so she tried to put herself back to bed and landed on her face. Per the hospital emergency room discharge summary, the resident was discharged from the emergency room back to the facility on 1/15/2017 at 5:51 PM. There was no documented evidence the resident's P was updated with individualized interventions for fall prevention or for providing care after the resident returned from the emergency room. Per the nursing progress notes, the resident passed away on 1/21/2017. During an interview on 2/15/2017 at 1:30 PM, LPN #12 stated she was working when the resident fell, she heard a scream, and ran to the room. She stated the resident sustained a very large hematoma (bruise) on her face. She stated prior to the fall, the resident was at risk for falls, FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 15 of 66

16 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 15 F 279 and she did not remember the resident having any devices for fall prevention. During an interview on 2/15/2017 at 2:06 PM, RN Supervisor #14 stated that prior to the resident's fall, the NA asked her to talk to the resident as she wanted to go back to bed. She stated she could not do that because she was in the process of sending another resident to the hospital. She stated if she was not busy she would have helped transfer the resident back to bed, and she did not know why the NA did not do so. During an interview on 2/17/2017 at 10:15 AM, MDS LPN #15 stated she completed the fall risk scale, it was signed off by MDS RN #16, and she did not know how the information made it to the resident's P. During an interview on 2/23/2017 at 9:58 AM, MDS RN #16 stated she reviewed the fall risk scale completed by MDS LPN #15 and signed it. She stated the MDS nurses did not transfer the information over to residents' Ps. She stated in the case of a comprehensive assessment, she checked the Ps to ensure the resident had one for each trigger area and then gave a list to RN #17. She stated on 12/19/2016, she gave RN #17 the resident's name and asked her to write some Ps, but fall risk was not one of them. She stated her review of the Ps included looking to see if there was a P, and she did not look to see if the P in place was appropriate. Untimely assessment and treatment: The P, initially implemented on 8/5/2016, documented the resident was at risk for skin FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 16 of 66

17 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 16 F 279 breakdown and had pressure-relieving devices in place. The facility's incident report dated 1/15/2017 documented the resident had an unwitnessed fall at 12:10 PM, sustained a laceration on the head, and was sent to the emergency room. The hospital discharge instructions dated 1/15/2017 at 5:51 PM documented the resident was evaluated for a fall with head injury and facial or scalp contusion, and was also treated for RSV (respiratory syncytial virus). There was no documented evidence the resident was assessed by a qualified person when she returned from the hospital. Nurse practitioner (NP) #18's progress note dated 1/16/2017 at 4:34 PM documented the resident returned yesterday following a fall and she was asked to see her today. NP #18 documented the resident was diagnosed with RSV in the hospital, had an elevated temperature, and she planned to do a work-up and start IV (intravenous) fluids. In a second note at 6:11 PM, NP #18 documented the resident had a Stage II (partial thickness skin loss) pressure ulcer with a surrounding DTI (deep tissue injury) on her coccyx (tailbone), and an air mattress was ordered. RN Supervisor #4's progress note dated 1/17/2017 at 12:00 PM documented the resident's family requested her skin be assessed, as they saw a pressure ulcer on her sacrum (base of spine). She documented she saw the resident's skin with the attending physician, and the Wound Nurse also saw the resident. FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 17 of 66

18 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 17 F 279 The Wound Weekly Observation Tool completed by wound LPN #19 on 1/17/2017 at 4:23 PM documented the resident's family notified the facility the resident had a pressure ulcer, and she was observed with a 7 centimeter (cm) x 4 cm DTI. The plan was to treat with DuoDerm (gel dressing) every 3 days. On 1/17/2017 at 8:51 PM, an order was entered into the resident's medical record for a DuoDerm dressing to be applied to the sacrum every 3 days and as needed. There was no documented evidence the treatment was applied on 1/17/2017. The 1/2017 Treatment Administration Record (TAR) documented the DuoDerm treatment was administered on 1/18/2017 by LPN #12. During an interview on 2/15/2017 at 4:00 PM, the resident's family member stated that after the resident fell and came back from the hospital, family helped toilet the resident and saw a large pressure ulcer on her backside and they asked for someone to assess it. During an interview on 2/15/2017 at 12:40 PM, NP #18 stated she saw the resident on 1/16/2017 and at that time the resident had RSV and a Stage II pressure ulcer with a surrounding DTI. She stated at that time she did not want to put pressure on the wound and cover it, so she ordered an air mattress. She stated when the resident returned from the emergency room, she should have been assessed by an RN. During an interview on 2/15/2017 at 1:30 PM, LPN #12 stated she remembered the resident FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 18 of 66

19 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 18 F 279 developing a pressure ulcer after she came back from the hospital. She stated she did not recall doing the treatment on the pressure ulcer on 1/18/2017, but if she signed for it she must have done it. During an interview on 2/15/2017 at 2:06 PM, RN Supervisor #14 stated the resident's family wanted her skin assessed on 1/17/2017 and she went in with the physician to see her. She stated because the Wound LPN and Director of Nursing (DON) were also present, they would have applied the dressing. During an interview on 2/15/2017 at 3:05 PM, Wound LPN #19 stated she saw the resident on 1/17/2017 with the DON, and the resident's sacrum was red, and she also had a black and blue area that looked like a DTI. She stated the DON recommended a DuoDerm, and when they left the room, the DON was on the phone obtaining the order. She stated she did not apply the DuoDerm at the time of the DON's assessment, as they did not have an order for it. She stated she did not remember applying it later that day. During an interview on 2/28/2017 at 1:00 PM, the attending physician stated she saw the resident's skin on 1/17/2017 because a family member provided her with incontinence care and saw the area. She stated the NP saw her on 1/16/2017 and it was a Stage II, and when she saw it the area had progressed very quickly. She stated that was the first time she became aware the resident had a pressure ulcer. The attending physician also stated residents should be assessed by an RN when they were re-admitted from the hospital. FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 19 of 66

20 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 279 ontinued From page 19 F 279 The facility identified RN #17 as the Supervisor who was working when the resident was re-admitted from the hospital. During an interview on 3/1/2017 at 7:40 AM, RN #17 stated she was not the Supervisor when the resident returned from the hospital. During an interview on 3/6/2017 at 8:10 AM, the DON stated when the resident returned from the hospital, she should have been assessed by an RN. She stated she assessed the resident's skin on 1/17/2017 after the family reported a concern, and she did not recall who applied the dressing or when it was applied. She stated if the treatment was documented as completed on 1/18/2017, then that was when it was done. F 281 SS=D 10NYRR (c)(1) (b)(3)(i) SERVIES PROVED MEET PROFESSIONAL STANDARDS (b)(3) omprehensive are Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on record review and interview conducted during the abbreviated surveys (NY and NY ), it was determined for 2 of 5 residents (Residents #1 and 4) reviewed for quality of care, the facility did not ensure services provided met professional standards of quality. Specifically, for Resident #1 who had multiple occurrences where his feeding tube was clogged, F 281 4/5/17 FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 20 of 66

21 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 281 ontinued From page 20 F 281 staff members attempted to unclog the feeding tube using means not consistent with acceptable professional standards of quality, and there was no documented evidence the facility provided ongoing training/education to the nurses providing care to the resident. Resident #4 complained of leg pain and was assessed by a licensed practical nurse who was not qualified to perform an assessment. In addition, the LPN did not communicate the resident's complaints of pain to the next shift. Findings include: 1) Resident #1 was admitted to the facility on 7/10/2014 with diagnoses including protein-calorie malnutrition and dementia, and received all food, fluids, and medications via a feeding tube. The resident had a G-J tube (gastrostomy-jejunostomy tube, one port in the stomach and the second port into the small intestine) inserted through the abdominal wall. He received medications via the G portion of the tube, and feedings via the J portion of the tube. The comprehensive care plan (P), printed 2/9/2017, documented the resident had an ADL (activities of daily living) deficit related to dementia, and was totally dependent on 2 staff for ADL care, including extensive assistance of 2 for turning and positioning every 2-3 hours and as needed. Review of records from interventional radiology (IR) revealed in 2016, the resident's feeding tube was changed 13 times related to it being clogged/occluded at the facility (1/2/2016, 1/14/2016, 2/1/2016, 2/3/2016, 3/10/2016, 3/28/2016, 5/30/2016, 6/29/2016, 7/10/2016, 7/20/2016, 8/8/2016, 10/31/2016, and FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 21 of 66

22 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 281 ontinued From page 21 F /18/2016). The facility's accident and incident report dated 6/28/2016 documented registered nurse (RN) Supervisor #31 was called related to the resident's feeding tube being clogged. The RN attempted to flush the tube with 10 cc (cubic centimeters) of water, and then placed a Q-tip into the tube in an attempt to unclog it. A portion of the Q-tip broke off in the tube and the RN attempted to retrieve the Q-tip with a paperclip, unsuccessfully. The resident was sent out from the facility to have his tube replaced at that time. The incident report documented all staff would be re-educated on feeding tubes. A copy of this training was not provided with the incident report. Review of IR records documented the resident's feeding tube was changed related to it being clogged/occluded: - On 1/24/2017, and the consultation report documented the facility should not be putting pills in the J tube and should be flushing the tube vigorously. - On 1/31/2017, and the consultation report documented "a cotton swab was found in the J tube plugging the tube in addition to concretious (indigestible material) of feeding distally in the tube. This is very poor tube management." The facility's incident report dated 1/31/2017 documented the facility was unable to determine who used a Q-tip in an attempt to unclog the resident's feeding tube. The report documented that staff education would be provided to all nurses on feeding tubes. The IR consultation report dated 2/7/2017 documented the resident's feeding tube was FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 22 of 66

23 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 281 ontinued From page 22 F 281 replaced, as it was clogged/occluded. The report documented "plugged by misuse again. Solid food in tube." During an interview on 2/9/2017 at 11:10 AM, RN Educator #32 stated she did not recall the incident in 6/2016 when a Q-tip was found in the resident's feeding tube. She could not recall if she did staff education at that time, and stated education could also have been done by the Director of Nursing (DON) or Assistant Director of Nursing (ADON), as it was in response to a specific incident. She stated some of the nurses completed competencies on feeding tubes in 12/2016 at the facility's skills fair. She stated she had a mannequin with a feeding tube and competencies were done using that. She stated when they did the competency, they used a G tube and she did not have a G-J tube for the mannequin. RN Educator #32 stated she did education throughout the facility on feeding tubes last week, in response to the resident's most recent incident with a Q-tip being found in his tube on 1/31/2017. RN Educator #32 was asked for documentation of all staff training on feeding tubes done in 2016 and Review of the facility's education documentation on tube feedings provided by RN Educator #32 revealed: - When the 12/2016 competencies on tube feedings were compared to the resident's 1/2017 Medication Administration Record (MAR), it was revealed that 15 different nurses signed for providing feedings, flushes, or medications to the resident via the feeding tube in 1/2017, and 3 of those 15 nurses signed had completed a competency in 12/ When the 1/31/2017 training record "are and FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 23 of 66

24 DEPARTMENT OF HEALTH AND HUMAN SERVIES ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X2) MULTIPLE ONSTRUTION (X3) SURVEY OMPLETED STREET ADDRESS, ITY, STATE, ZIP ODE SYRAUSE, NY (X4) PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS-REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETION F 281 ontinued From page 23 F 281 Management of G/J Tubes" was compared to the resident's 1/2017 MAR, it was revealed that 15 different nurses signed for providing feedings, flushes, or medications to the resident via the feeding tube, and 2 of those 15 nurses signed that they attended the 1/31/2017 training. One of the 2 nurses was also one of the 3 nurses who completed a competency in 12/2016. In total, 4 of the 15 nurses who provided feeding tube care to the resident in 1/2017 had completed a competency in 12/2016 or 1/2017. In a follow-up interview with RN Educator #32 on 2/10/2017 at 11:32 AM, the surveyor asked if any other education was completed with the facility's nurses in regard to the resident's care. She stated on one occasion, the resident's family member complained about a specific nurse (LPN #33) so RN #32 went to the unit, observed her providing tube feeding care, and documented a statement regarding her skills. She stated she talked with staff a little bit about the medications that were ordered to unclog the resident's tube, but did not spend a lot of time on it. She stated she had not observed any nurses administering those medications to the resident when his tube was clogged. During an interview on 2/10/2017 at 12:08 PM, the DON stated that RN Educator #32 went to the unit and checked on specific nurses when asked. She did not know if RN #32 observed other nurses providing care, and the DON stated she personally had not. She stated many nurses had education in 12/2016 at the skills fair, and RN #21 did that competency with the staff. The DON stated someone gave the medication to unclog the feeding tube via the G tube instead of the J tube a few weeks ago, and they would also have FORM MS-2567(02-99) Previous Versions Obsolete Event : M34Z11 Facility : 0656 If continuation sheet Page 24 of 66