PRINTED: 10/13/2017 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO (X2) MULTIPLE CONSTRUCTION A.

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1 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 279 SS=D (d);483.21(b)(1) DEVELOP OMPREHENSIVE ARE PLANS F (d) Use. A facility must maintain all resident assessments completed within the previous 15 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 LABORATORY DIRETOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) 08/10/2017 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. Event : 3RN11 Facility : 0656 If continuation sheet Page 1 of 16

2 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 279 ontinued From page 1 F 279 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 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 surveys (NY and NY ), it was determined for 1 of 3 residents reviewed for accidents (Resident #1), the facility did not develop and implement a comprehensive care plan (P) for each resident that addressed their needs. Specifically, Resident #1 had a decline in functioning, was not able to transfer as care planned, and the resident was not evaluated to determine the appropriate method of transfer nor was the resident's P and care instructions updated to reflect her transfer status. Findings include: Event : 3RN11 Facility : 0656 If continuation sheet Page 2 of 16

3 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 279 ontinued From page 2 F 279 Resident #1 was admitted to the facility on 12/28/2016 with diagnoses including dementia and anxiety. The comprehensive care plan (P) initiated on 12/29/2016, documented the resident transferred with supervision from 1 staff person and a rolling walker. The physical therapy (PT) progress reports dated 5/16/2017 and 5/21/2017 documented the resident transferred with supervision. The documentation of care provided by certified nurse aide (NAs) specified the resident was provided with extensive assistance for transferring on 5/23/2017 and 5/24/2017. The 5/24/2017 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and needed extensive assistance for transferring. The 5/25/2017 MDS licensed practical nurse (LPN) #24's progress note documented the resident needed extensive assistance for transferring. The documentation of care provided by NAs specified the resident needed extensive assistance for transferring on 5/25/2017, 5/26/2017, and 5/27/2017. On the evening shift of 5/27/2017 and 5/28/2017, the resident needed total assistance for transferring. The NA care instructions printed on 5/31/2017 documented the resident transferred with supervision from 1 staff member and a rolling Event : 3RN11 Facility : 0656 If continuation sheet Page 3 of 16

4 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 279 ontinued From page 3 F 279 walker. The instructions did not document whether the resident needed a gait belt for transfers. On 6/12/2017 at 11 AM, NA #21 stated in an interview, at about 8:45 PM on 5/28/2017, the resident wanted a shower and she could not give her one because she could not stand on her own or transfer. She stated this was unusual as the resident normally transferred on her own with a rolling walker. She stated she did not tell anyone because the nurses knew the resident was not transferring well and was weak with a decline in condition. She stated she could not recall what the resident's care instructions documented for transfer instructions. On 6/12/2017 at 2:40 PM, LPN #23 stated in an interview, around 5-5:30 AM on 5/30/2017, she tried to cue the resident to move to her chair. She stated the resident was not able to self transfer so NA #22 transferred her by placing her arms under the resident's arms and moving her. She stated the resident's legs buckled during the transfer and NA #22 swiftly put her into the chair. RN Manager #25 stated in an interview on 6/15/2017 at 9:55 AM, the resident was declining and was not as responsive as her usual. The resident normally transferred with 1 assist and she learned that the staff had been transferring her with 2 assist. She stated she did not know the change was made as they did not obtain a PT evaluation and she did not update the P or NA instructions as she was not aware of the change in status. Event : 3RN11 Facility : 0656 If continuation sheet Page 4 of 16

5 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 279 ontinued From page 4 F 279 MDS RN #26 stated in an interview 6/28/2017 at 12:56 PM, she signed off on the resident's 5/24/2017 MDS when it was complete. She stated the RN Manager was responsible for taking the MDS to the care plan meeting ensuring the MDS and P matched in regards to the resident's status. On 6/30/2017 at 11:18 AM, NA #27 stated in an interview, the resident was very self-sufficient and transferred with 1 assist. She stated over the weekend of 5/27 and 5/28/2017, the resident was confused and weak and on 5/27/2017, she needed physical assistance for transferring and NA #27 also had the LPN help her transfer the resident on that day. F 323 SS=G 10NYRR (c)(1)(ii)(2)(i) (d)(1)(2)(n)(1)-(3) FREE OF AENT HAZARDS/SUPERVISION/DEVIES F 323 (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment Event : 3RN11 Facility : 0656 If continuation sheet Page 5 of 16

6 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 5 F 323 from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed s dimensions are appropriate for the resident s size and weight. This REQUIREMENT is not met as evidenced by: Based on record review, interview, and observation conducted during the abbreviated surveys (NY and NY ), it was determined for 2 of 3 residents reviewed for accidents (Residents #4 and 5), the facility did not provide adequate supervision and assistance devices to prevent accidents. Specifically, - For Resident #5, who was locked out of the facility by a staff member, the resident was not provided with adequate supervision when he was left outside alone; when the assigned care givers did not account for his whereabouts for an entire shift, and the resident was not provided with a safe plan for re-entering the facility. This resulted in actual harm for Resident #5 as he sustained a head laceration requiring 6 sutures. - For Resident #4, who was a new admission, the facility did not ensure adequate supervision was provided when the resident was wandering and actively exit-seeking. 1) Resident #5 was admitted to the facility on 5/30/2015 with diagnoses including a past cerebrovascular accident (VA, stroke) and encephalopathy. The resident was cognitively intact per the 4/17/2017 Minimum Data Set (MDS) assessment. Event : 3RN11 Facility : 0656 If continuation sheet Page 6 of 16

7 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 6 F 323 The 6/1/2017 ambulance report documented the resident was picked up at 9:31 PM, in front of a public building on the opposite side of the street as the nursing facility. The resident hit his head on the sidewalk and had a laceration that required suturing. The resident told the EMTs he was locked out of the facility; banged on the door and could not get in, and then fell when he crossed the street. The 6/1/2017 emergency room progress note documented the resident presented with a 2.5 centimeter (cm) laceration above the left eye, 1 cm abrasion to the forehead, and a bruise to the left thigh with complaints of tenderness. Sutures were applied to the laceration. The 6/2/2017 incident report initiated at 1:43 AM, documented the resident was last seen on the unit at around 6 PM and was known to wander the facility. At 11:45 PM, staff called the Supervisor and a code yellow (missing person) and law enforcement were called. Local law enforcement informed the facility the resident was taken to the hospital. Statements attached to the incident report included: - The resident's statement documented he went out the front door to wait for his family member and was told the doors were locked at 8:30 PM. He did not want to come inside so the staff person told him to use the side door. The side door was locked so he walked down the street, his walker caught the curb, and he fell. He stated a passerby called an ambulance. - ertified nurse aide (NA) #17's statement documented the resident was not in room at 8 PM and was not there later in the shift either. She asked other staff members if they knew where he Event : 3RN11 Facility : 0656 If continuation sheet Page 7 of 16

8 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 7 F 323 was and was told he liked to walk around the building. - Licensed practical nurse (LPN) #18's statement documented the resident was not in his room at 8 PM when he went to give him medications and it was normal for him to be off the unit. At 10:45 PM, a NA asked him where the resident was and when they could not find him, he called the Supervisor. - Receptionist #19's statement documented at 8:20 PM, the resident was outside and she told him the doors were locked at 8:30 PM. At 8:30 PM, the resident did not want to come in, and he was told to use the side doors when he was ready to come inside. - Maintenance Staff #20's statement documented when he went to lock the doors at 8:30 PM, the resident was sitting outside and did not want to come in. He told the resident use the side door when he was ready to come inside and he locked the front doors. The 6/2/2017 nurse practitioner (NP) #15's progress note documented the resident was seen following a fall and return from the emergency room. The note further documented details surrounding the fall were uncertain at the time of the note and what she did know was that the resident was found to be missing from the facility at 1:00 AM on 6/2/2017 and was found at a local hospital. The resident sustained a laceration above his left eyebrow from a fall that was closed with 6 sutures. On 7/3/2017 at 10:29 AM, Receptionist #19 stated in an interview, at 8:30 PM, the front doors to the facility were locked and if someone wanted to get into the building after 8:30 PM, they Event : 3RN11 Facility : 0656 If continuation sheet Page 8 of 16

9 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 8 F 323 needed to go to the side door, pick up the phone, and call the 1S Unit. She stated on 6/1/2017, the resident was told to use the side door when he wanted to come in as he did not want to come in at 8:30 PM. She stated she did not think anything of it as the resident often sat outside and seemed reliable. She stated she left shortly after 8:30 PM and did not let anyone know the resident was outside when she left. On 7/3/2017 at 11:40 AM, the resident stated in an interview, the night he fell, he was sitting outside and the staff told him they were locking the doors. He said he was told to go to the side door when he wanted to come in but when he did, the doors were locked. He stated he banged on the door and when no one came, he left. He stated he fell and hit his head on the curb and someone called an ambulance. On 7/5/2017 at 4:11 PM, Maintenance Staff #20 stated in an interview, on 6/1/2017, he went to lock the doors at 8:30 PM and the resident said he was not ready to come inside. He stated he told the resident to use the side door when he was ready to come in and he thought the resident knew how to pick up the phone and call the 1S Unit. He stated he did not tell anyone the resident was outside after he locked the doors at 8:30 PM. On 7/6/2017 at 2:22 PM, NA #17 stated in an interview, when she started her shift at 3 PM on 6/1/2017, the resident was in his room. She stated when she went to pick up dinner trays she noticed his meal was in his room untouched. She was told by other NAs who were regulars on the unit to leave the meal as he would come back Event : 3RN11 Facility : 0656 If continuation sheet Page 9 of 16

10 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 9 F 323 and eat it later. She stated between 8 and 9 PM, she passed linens and the resident was not back so she asked other NAs again and they told her he walked around the building. She did not report her concerns to a nurse as the LPN was a float. NA #17 stated when she left that night, he had not returned. On 7/6/2017 at 2:35 PM, LPN #18 stated in an interview, the resident was not in his room at 8 PM when he had a medication due but he did not think much of it as it was the norm for the resident to be off the unit for an entire shift visiting a resident on another unit. He stated after the 8 PM medication pass, he did his work and at 11 PM a NA asked him where the resident was. He stated that at that time, they started looking for the resident. On 7/7/2017 at 12:30 PM, the Director of Nursing (DON) stated in an interview, the resident's cognition was okay but he had poor judgement. She stated the facility's front door was locked at 8:30 PM and the resident should not have been locked out. She stated if he refused to come inside, the staff should have called the Supervisor for assistance. She stated no residents should be using the facility's side doors as you had to walk through the parking lot to get there and it was not a safe area. She stated the NAs and LPN on the unit also should have known the resident's whereabouts on their shift. She stated even though he walked around the building, they should be verifying his whereabouts during their shift. On 7/13/2017 at 10 AM, NP #15 stated in an interview, she saw the resident on 6/2/2017 when Event : 3RN11 Facility : 0656 If continuation sheet Page 10 of 16

11 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 10 F 323 he returned from the hospital and he had sutures to the laceration above his eyebrow at that time. She stated she had been working with the facility's team and the resident on improving his accountability for his whereabouts and did hear that he was locked out of the building the night that he fell. 2) Resident #4 was admitted to the facility on 6/14/2017 with diagnoses including advanced dementia and falls. The resident's palliative care consultation (completed in the hospital) dated 6/7/2017 documented the resident could not explain why he was in the hospital and did not know what year it was. The hospital discharge summary, dated 6/13/2017, documented the resident's diagnoses included advanced dementia. The resident was discharged from the hospital on two medications used to treat memory impairment and Zoloft (anti-depressant). The initial elopement risk assessment completed on 6/14/2017 at 4:51 PM, by registered nurse (RN) #8 documented the resident's risk factors for elopement included: disorientation; lack of understanding of his surroundings; newly admitted, and ambulating with one assist. The assessment did not identify the resident as having dementia and did not document he took an antidepressant. The resident scored at low risk for wandering/elopement based on this assessment. The initial nursing assessment dated 6/14/2017 Event : 3RN11 Facility : 0656 If continuation sheet Page 11 of 16

12 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 11 F 323 at 4:53 PM and completed by RN #8 documented the resident did not know why he was at the facility, was confused, and was oriented to person and not to place or time. The incident report dated 6/14/2017 documented the resident was admitted to the facility at 4:40 PM and was noted to be missing at 6 PM. A code yellow was called and local law enforcement returned the resident to the facility. The investigation summary documented the resident was assessed for wandering risk, was a new admission, and was assessed to be at low risk for wandering at admission. The 6/14/2017 physician's orders documented the resident's medications for memory impairment and Zoloft were ordered at the facility. After the resident was returned to the facility, RN #8 completed a second elopement risk assessment dated 6/14/2017 at 7:22 PM. The assessment documented the resident's risk factors for elopement included: disorientation; lack of understanding of his surroundings; newly admitted; experiencing a change in staff/caregiver; independent with ambulation; a diagnosis of dementia with psychosis, and a known history of wandering. The use of an antidepressant medication was not checked. The resident scored at high risk for elopement on this assessment. The 6/15/2017 social worker's progress note documented the resident had severely impaired cognition. Event : 3RN11 Facility : 0656 If continuation sheet Page 12 of 16

13 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 12 F 323 On 6/28/2017 at 1:15 PM, RN #8 stated in an interview, when the resident was admitted he completed the initial nursing assessment and elopement risk assessment by examining the resident and reviewing the information from the hospital. He stated when he was done, he left the unit to call the physician and obtain the admission orders. He stated he did not know why he did not check that the resident had dementia on the initial elopement risk assessment and he did not check that the resident was on an antidepressant as he was not sure whether the facility physician would continue that order from the hospital. On 7/3/2017 at 4 PM, certified nurse aide (NA) #10 stated in an interview, after the resident was admitted to the facility, he was wandering the unit, walking in and out of other residents' rooms, trying to leave, was confused, and they tried to keep an eye on him. She stated at around 5:30 PM, the resident was sitting near the nurse's station, the staff left the area to pass meal trays, and the resident left the unit at that time. On 7/3/2017 at 4:10 PM, NA #11 stated in an interview, after the resident was admitted, he was wandering the unit asking where he was. She stated the staff re-directed him but when they were busy passing meal trays, he left the unit. On 7/5/2017 at 2:05 PM, licensed practical nurse (LPN) #12 stated in an interview, after the resident was admitted, they tried to get him to sit at the tables near the nurse's station so they could watch him because he was wandering the unit. She stated another nurse (LPN #13) stopped by the facility and even though she was Event : 3RN11 Facility : 0656 If continuation sheet Page 13 of 16

14 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 13 F 323 not on duty, she stayed with the resident because herself and the other LPN on duty (LPN #14) were busy. She stated the resident kept saying that his car was at the facility and he needed to get to his car and go home. She stated when LPN #13 left, the NAs were busy passing dinner trays, she was administering insulin, and LPN #14 was administering a tube feeding, and that was when the resident left the unit. She stated LPN #14 was the resident's assigned nurse and she thought LPN #14 called the Supervisor and asked for a wanderguard and was told they did not have any available. LPN #12 stated when the resident was returned to the unit, he said he checked every car in the parking lot for his car and when he did not find his car, he started walking home. On 7/5/2017 at 3:30 PM, LPN #14 stated in an interview, after the resident was admitted, he was wandering the unit, going in and out of other residents' rooms, and asked for the way out as he said his car was in the parking lot and he needed to get to his car and leave. She stated it was difficult to keep track of the resident and because he asked her to show him the way out, she called the Supervisor and asked for a wanderguard. She stated the Supervisor stated they would bring one but they did not receive it prior to him being found to be missing. On 7/6/2017 at 10:30 AM, QA RN #7 stated in an interview, she completed the investigation into the resident's elopement and considered the elopement risk assessment. She stated she questioned whether the resident's medications were checked if that would have made him high risk for elopement but she did not look into why Event : 3RN11 Facility : 0656 If continuation sheet Page 14 of 16

15 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 14 F 323 the RN did not check that the resident had a dementia diagnosis on the assessment. She stated the facility planned to train all the RNs on the admission process and admission assessments and stated the DON would have more details. In a follow-up interview with RN #8 on 7/6/2017 at 1:55 PM, he stated when he assessed the resident, the resident was lying in bed and was not wandering the unit. He stated when he left the unit, he told the staff he was going to call the physician to obtain admission orders and about 30 to 45 minutes later, he was notified the resident was missing. He stated the unit staff did not call him to ask for a wanderguard prior to the resident's elopement and he was not notified the resident was wandering or that they were having difficulty keeping track of him. He stated the resident was found a few streets away, he did not know the exact location, and when the resident returned, he mentioned he was looking for his car. On 7/10/2017 at 12:30 PM, the DON stated in an interview, that at the end of 7/2017, the VP of linical Services planned to provide education to the nurses on the admission process including admission assessments. She stated she was not aware RN #8 did not check that the resident had dementia on the initial elopement risk assessment and stated she would not have expected him to check the medications as risk factors until he was aware whether the physician was going to continue the hospital medication orders. She stated she was not told that LPN #13 was watching the resident when she was not on duty and was not aware the staff on the unit were Event : 3RN11 Facility : 0656 If continuation sheet Page 15 of 16

16 ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES SQUARE NURSING AND REHAB ENTRE (X4) SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) (X3) SURVEY OMPLETED F 323 ontinued From page 15 F 323 having difficulty keeping an eye on the resident prior to his elopement. She stated there were many RNs in the building at that time, and the unit staff should have called for help if they needed it. The surveyor attempted to contact LPN #13 via the telephone and no response was received. 10NYRR (h)(1&2) Event : 3RN11 Facility : 0656 If continuation sheet Page 16 of 16