James Square Violations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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03/16/2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
918 JAMES STREET

JAMES SQUARE NURSING AND REHAB CENTRE
SYRACUSE, NY 13203
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
F 225 483.12(a)(3)(4)(c)(1)-(4) INVESTIGATE/REPORT F 225 4/5/17

SS=E ALLEGATIONS/INDIVIDUALS
483.12(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
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
03/31/2017
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M34Z11 Facility ID: 0656 If continuation sheet Page 1 of 66
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F 225 Continued 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 (NY00196103, NY00195410,
NY00195103, and NY00196850), 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
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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 (CCP), 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 (CNA).
The facility reported the resident's roommate was
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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 CNA #29 (both male staff members),
which documented they had no negative
interactions with the resident on 2/17/2017.
- 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 CNA placed the call
bell over the resident's groin area and the
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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.

DON stated she did not know why the date of the
incident report was incorrect and said it must
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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.

LPN #28 stated he received a call from the
resident's family member, who said a male CNA
took the resident's call bell away and slapped her
in the arm. He stated he talked to the resident
and the CNA, and the CNA 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,

CNA #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
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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.

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 CNA #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.

5/3/2015 with diagnoses including dementia.
The initial comprehensive care plan (CCP) 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.

12/22/2016 documented the resident had
moderately impaired cognition and disorganized
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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.

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.
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certified nurse aide (CNA) #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.
CNA #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.

LPN #24 stated the CNA 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 CNAs 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.

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
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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.

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.

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
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(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.
10NYCRR 415.4(b)(1)(ii)
F 279 483.20(d);483.21(b)(1) DEVELOP F 279 4/5/17
SS=D COMPREHENSIVE CARE PLANS
483.20
(d) Use. A facility must maintain all resident
assessments completed within the previous 15
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months in the residents active record and use the
results of the assessments to develop, review
and revise the residents comprehensive care
plan.
483.21
(b) Comprehensive Care 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 483.10(c)(2) and 483.10(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 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required

under 483.24, 483.25 or 483.40 but are not
provided due to the resident's exercise of rights
under 483.10, including the right to refuse
treatment under 483.10(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 residents medical record.
(iv)In consultation with the resident and the
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residents representative (s)-
(A) The residents goals for admission and

desired outcomes.
(B) The residents preference and potential for

future discharge. Facilities must document
whether the residents desire to return to the
community was assessed and any referrals to
local contact agencies and/or other appropriate
entities, for this purpose.
(C) Discharge plans in the comprehensive care

plan, as appropriate, in accordance with the
requirements set forth in paragraph (c) of this
section.
by:
Based on record review and interview conducted
during the abbreviated survey (NY00194344), it
was determined for 1 of 5 residents (Resident #2)
reviewed for comprehensiev care plans (CCP),
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
(CCP) 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.

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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.
Care not provided timely and care needs not

specified:
The comprehensive care plan (CCP) initiated on

10/10/2016 documented:
- The resident had a self-care deficit related to a
past femur fracture.
- The CCP did not document the level of
assistance the resident needed with transferring.
The CCP documented to "specify what
assistance" the resident needed, and that was not
specified.
- The CCP 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 CCP was updated or individualized with
specific care needs following completion of the
fall risk scale.
The facility's incident report dated 1/15/2017

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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.
- CNA #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.

resident's CCP 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.

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,
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and she did not remember the resident having
any devices for fall prevention.

Supervisor #14 stated that prior to the resident's
fall, the CNA 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 CNA did not do so.

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 CCP.

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' CCPs. She stated
in the case of a comprehensive assessment, she
checked the CCPs 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 CCPs, but fall risk was not one of them.
She stated her review of the CCPs included
looking to see if there was a CCP, and she did
not look to see if the CCP in place was
appropriate.
Untimely assessment and treatment:
The CCP, initially implemented on 8/5/2016,

documented the resident was at risk for skin
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breakdown and had pressure-relieving devices in
place.

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.
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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.

treatment was applied on 1/17/2017.

(TAR) documented the DuoDerm treatment was
administered on 1/18/2017 by LPN #12.

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.

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.

LPN #12 stated she remembered the resident
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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.

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.

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.

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.
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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.

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.
10NYCRR 415.11(c)(1)
F 281 483.21(b)(3)(i) SERVICES PROVIDED MEET F 281 4/5/17
SS=D PROFESSIONAL STANDARDS
(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility,

as outlined by the comprehensive care plan,
must-
(i) Meet professional standards of quality.

by:
during the abbreviated surveys (NY00195410 and
NY00195273), 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,
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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:

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.

(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
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11/18/2016).
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."

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
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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 2017.
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 12/2016.
- When the 1/31/2017 training record "Care and
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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.

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
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been trained on that by RN Educator #32. She
stated she did not know if education was provided
in 6/2016 after the incident with the Q-tip, and
stated she would not know as she was not the
DON then.

pharmacist #44 stated he had not provided
training to nursing on using the medications used
to unclog the resident's J tube (sodium
bicarbonate and Creon), and that training would
be done by nursing.

#21 stated she did the competency with nurses at
the skills fair in 12/2016. She stated she taught
how to care for a G tube, check placement, and
how to administer medications to someone with a
G tube. She stated she did not focus on J tubes.


11/9/2016 documented the resident had severely
impaired cognition and was dependent on two
persons for transferring. The resident received
scheduled and as needed pain medications
during the past 5 days and did not report pain
during the assessment interview.
The comprehensive care plan (CCP) revised

12/27/2016 documented the resident had an
activities of daily living (ADL) self-care deficit
related to dementia, fatigue, and limited mobility.
Interventions included: monitoring for as needed
pain medication; providing a clear and concise
explanation prior to starting care/procedures;
assisting the resident with grooming and dressing
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by 8:00 AM daily; providing assistance from 1
person with dressing and personal care; and
providing extensive assistance from 2 persons
with transferring.
The 1/2017 Medication Administration Record

(MAR) documented:
- An order for Tylenol ER (extended release), 650
milligrams (mg), twice a day for pain.
- An order for as needed Tylenol ER, 650 mg,
every 6 hours as needed for pain.
- On 1/28/2017 at 8:00 PM, licensed practical
nurse (LPN) #1 administered the routine Tylenol
to the resident and documented a pain level of 0.
- There was no documentation the resident was
administered the as needed Tylenol on
1/28/2017.
The late entry nursing progress note for

1/28/2017 for the 2:00 PM to 10:00 PM shift
(entered into the medical record on 1/29/207 at
10:22 AM) by LPN #1 documented she was
notified by a certified nurse aide (CNA) that the
resident had leg pain. She "assessed" the
resident who stated her leg hurt a little, but was
not bad. She told the resident that she just
received her routine Tylenol, and told the resident
to let her know if the Tylenol did not help. LPN #1
documented the resident did not complain of pain
the rest of the shift. There was no documented
evidence the resident was assessed by a
qualified professional when she complained of
pain.
The 24-hour nursing report written by LPN #1 on

1/28/2017 documented the resident did not voice
complaints during the evening shift. There was no
documented evidence LPN #1 passed on
information regarding the resident's complaints of
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pain to the oncoming shift.
Registered nurse (RN) #3's progress note dated

1/29/2017 at 8:13 AM documented she was
asked to see the resident, as she complained of
leg pain. RN #3 documented the resident "cried
out when this writer attempted to move or touch
the area of the shin." RN #3 documented the
nurse practitioner (NP) was called, who ordered
an x-ray.
The x-ray report dated 1/29/2017 at 10:25 AM

documented the resident had a spiral fracture of
the left tibia (lower leg bone).

documented early in the morning that day, RN #3
was called to assess the resident for pain in the
left leg, which was reported by LPN #2. LPN #1's
statement documented the CNA told her the
resident's leg hurt on the evening shift of
1/28/2017, so she went and asked the resident
about her leg. The resident stated it hurt a little.
LPN #1 told her she received her routine Tylenol
and if she had any more pain to let her know.

Director of Nursing (DON) stated she was notified
on 1/29/2017 that the resident had pain and had a
fracture. She stated she was not aware the
resident was not assessed when she complained
of pain on 1/28/2017, and was also not aware
LPN #1 documented she assessed the resident.
She stated LPNs could not assess residents.

LPN #1 stated sometime on the evening shift on
1/28/2017, she was told the resident complained
of leg pain. She went into the room and asked the
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resident, who said she was in pain, but it was not
that bad. She stated she told the resident she had
already given her the routine Tylenol and if it did
not work, she should let her know. She stated she
did not hear from the resident again that shift.
She stated she would not have documented the
resident's complaint on 24-hour report. She
stated she might have passed it on verbally to the
next shift, but could not remember if she did.
10NYCRR 415.11(c)(3)(i)
F 309 483.24, 483.25(k)(l) PROVIDE CARE/SERVICES F 309 4/5/17
SS=D FOR HIGHEST WELL BEING
483.24 Quality of life

Quality of life is a fundamental principle that
applies to all care and services provided to facility
residents. Each resident must receive and the
facility must provide the necessary care and
services to attain or maintain the highest
practicable physical, mental, and psychosocial
well-being, consistent with the residents
comprehensive assessment and plan of care.
483.25 Quality of care

Quality of care is a fundamental principle that
applies to all treatment and care provided to
facility residents. Based on the comprehensive
assessment of a resident, the facility must ensure
that residents receive treatment and care in
accordance with professional standards of
practice, the comprehensive person-centered
care plan, and the residents choices, including
but not limited to the following:
(k) Pain Management.

The facility must ensure that pain management is
provided to residents who require such services,
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consistent with professional standards of practice,
the comprehensive person-centered care plan,
and the residents goals and preferences.
(l) Dialysis. The facility must ensure that

residents who require dialysis receive such
services, consistent with professional standards
of practice, the comprehensive person-centered
care plan, and the residents goals and
preferences.
by:
Based on record review, observation, and
interview conducted during the abbreviated
survey (NY00195410), it was determined for 1 of
5 residents reviewed for quality of care (Resident
#4), the facility did not ensure residents received
the necessary care and services to attain or
maintain the highest practicable physical, mental,
and psychosocial well-being. Specifically,
Resident #4 complained of pain and was not
assessed by a qualified professional, and
complaints of pain were not communicated to the
next shift. When Resident #4 complained of pain
on the following shift, the resident was not
assessed timely, staff continued to provide care
without adequate pain control, and the resident
was subsequently diagnosed with a spiral fracture
of the left tibia (lower leg bone).
Findings include:
Resident #4 was admitted to the facility on

The comprehensive care plan (CCP) revised

12/27/2016 documented the resident had an
activities of daily living (ADL) self-care deficit
related to dementia, fatigue, and limited mobility.
Interventions included: monitoring for as needed
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pain medication; providing a clear and concise
explanation prior to starting care/procedures;
assisting the resident with grooming and dressing
by 8:00 AM daily; providing assistance from 1
person with dressing and personal care, and
providing extensive assistance from 2 persons
with transferring.

moderately impaired cognition and was
dependent on 2 persons for transferring. The
resident received scheduled and as needed pain
medications during the past 5 days and did not
report pain during the assessment interview.

(MAR) documented:
- An order for Tylenol ER (extended release), 650
milligrams (mg), twice a day for pain.
- An order for as needed Tylenol ER, 650 mg,
every 6 hours as needed for pain.
- On 1/28/2017 at 8:00 PM, licensed practical
nurse (LPN) #1 administered the routine Tylenol
to the resident and documented a pain level of 0.
- There was no documentation the resident was
administered the as needed Tylenol on
1/28/2017.
The late entry nursing progress note for

1/28/2017 for the 2:00 PM to 10:00 PM shift
(entered into the medical record on 1/29/207 at
10:22 AM) by LPN #1 documented she was
notified by a certified nurse aide (CNA) that the
resident had leg pain. LPN #1 "assessed" the
resident, who stated her leg hurt a little, but was
not bad. LPN #1 told the resident that she just
received her routine Tylenol, and told the resident
to let her know if the Tylenol did not help. LPN #1
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documented the resident did not complain of pain
the rest of the shift. There was no documented
evidence the resident was assessed by a
qualified professional when she complained of
pain.
The 24-hour nursing report written by LPN #1 on

1/28/2017 documented the resident did not voice
complaints during the evening shift. There was no
documented evidence LPN #1 passed on
information regarding the resident's complaints of
pain to the oncoming shift.
Registered nurse (RN) #3's progress note dated

1/29/2017 at 8:13 AM documented she was
asked to see the resident, as she complained of
leg pain. RN #3 documented the resident "cried
out when this writer attempted to move or touch
the area of the shin." RN #3 documented the
nurse practitioner (NP) was called, who ordered
an x-ray of the left leg.
The x-ray report dated 1/29/2017 at 10:25 AM

documented the resident had a spiral fracture of
the left tibia.
The 1/2017 MAR documented an order for Norco

(narcotic pain medication) 5-325 mg, 1 tablet
every 6 hours as needed on 1/29/2017, and it
was administered by LPN #2 at 12:00 PM for a
documented pain level of 8.
RN #3's progress note dated 1/29/2017 at 1:44

PM documented the resident did not have relief
from the Norco. The NP was called again, and
gave an order for a second dose of Norco.
The 1/2017 MAR documented LPN #2

administered the resident Norco on 1/29/2017 at
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1:57 PM for a pain level of 8.

PM documented the resident had increased pain
from the fracture. The Director of Nursing (DON)
called the Medical Director, who gave an order to
send the resident to the hospital.

documented:
- Early in the morning on 1/29/2017, RN #3 was
called to assess the resident for pain in the left
leg, which was reported by LPN #2.
- LPN #1's statement documented on the evening
shift of 1/28/2017, the CNA told her the resident's
leg hurt so she went and asked the resident
about her leg. The resident stated it hurt a little.
LPN #1 told her she received her routine Tylenol,
and to let her know if she had any more pain.
- CNA #4's statement documented the last time
she saw the resident on 1/28/2017 was at 10:30
PM. The resident was in bed trying to sleep, and
was having pain in her leg. CNA #4 documented
she told the nurse the resident was in pain.
- CNA #6's statement documented she helped
CNA #4 transfer the resident to bed on 1/28/2017
at 8:00 PM using the Hoyer (mechanical) lift. The
resident "screamed" in pain when CNA #4 tried to
straighten her legs, and CNA #6 told CNA #4 not
to bother the resident's legs. CNA #6 documented
she left the room first and when CNA #4 came
out of the room, she told CNA #4 to tell the nurse
the resident was in pain.
- CNA #5's statement documented on 1/28/2017,
she worked the night shift ending on 1/29/2017.
When she tried to dress the resident in the
morning, the resident yelled out that her leg hurt,
so she told the nurse.
- LPN #2's statement documented she did not
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have any information about the resident's pain, as
it occurred prior to her starting her shift.
- LPN #10's statement documented she was on
the resident's unit using the printer on 1/29/2017
at 7:00 AM, and she heard a CNA tell LPN #2 the
resident was in pain. LPN #2 asked her if it was
reported and the CNA said she told LPN #9. LPN
#10 documented she intervened and told LPN #2
to come with her and look at the resident. When
she got to the room the resident was fully
dressed, lying in bed, "clutching left leg," and
refusing to move the left leg. LPN #10
documented she told LPN #2 to call the
Supervisor.

#3 stated:
- On 1/29/2017, she arrived to work at around
6:55 AM. As she was walking in, the unit called
and asked for someone to assess the resident for
leg pain.
- She arrived to the unit at around 7:15 AM and
the resident was lying in bed and was dressed in
pants and a top.
- She stated the resident's right leg was flat on
the bed and her left leg was bent. She felt behind
her left knee, the resident said "no, don't," and
she tried to raise her pant leg to look at her leg.
- She stated she asked LPN #2 who had dressed
the resident, and she was told the resident was
dressed on the night shift.
- She stated LPN #2 told her as the night CNA
was leaving, the CNA told LPN #2 the resident
complained of pain. The CNA stated that prior to
calling the Supervisor, the LPNs finished report
and counted narcotics.
- CNA #4 told her she tried to put a Hoyer lift pad
under the resident on her own on 1/28/2017. CNA
#4 stated she was not able to, and after they put
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the resident to bed, the resident complained of
pain. CNA #4 stated she told the evening shift
LPN that the resident was in pain.
- While RN #3 was calling staff to obtain
statements for the incident report, she told CNAs
#4 and 6 they were suspended. She stated she
did this at the direction of the DON, who said they
were suspended because the resident
complained of pain and they continued to move
her and caused undue pain.
On 2/17/2017 at 2:23 PM, the resident was

observed sitting in a wheelchair in the hallway. In
an interview at that time, the resident stated she
broke her leg when a staff member transferred
her. She stated the staff member who helped her
that day was not a regular on the unit, she had
not seen her before, and she did not know her
name. She stated after the staff member put her
in bed she was "manipulating" her leg and it hurt
and made her leg pain worse. She stated she
was crying and screaming and there were a
couple of nurses outside the room who heard her.

LPN #2 stated she came to work at 5:45 AM on
1/29/2017, and as she was getting report from
LPN #9, the night CNA told them the resident was
in pain. She stated she and LPN #9 finished
report, counted narcotics, and she told LPN #9 to
make sure she saw the resident before she left.
She stated she later learned that LPN #9 left
without seeing the resident, so she went in the
room with LPN #10 and called the Supervisor at
around 7:00 AM. She stated when they got to the
room, the resident was lying in bed and was in
pain when they touched her leg. She stated the
resident was dressed and LPN #10 had
verbalized that she wondered how the resident
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could be dressed when she was in so much pain.

CNA #6 stated she came out of another resident's
room after dinner on 1/28/2017, and CNA #4 was
at the desk and asked her for help placing the
Hoyer lift pad underneath the resident. CNA #4
told her she had tried to place the pad under the
resident on her own and was not able to, so CNA
#6 helped her. She stated she and CNA #4
transferred the resident with the Hoyer lift and
when they got her into the bed, one of the
resident's legs was flat on the bed and the other
was bent. She stated CNA #4 tried to straighten
the resident's bent leg and the resident yelled out
in pain. CNA #6 stated when the resident yelled
out in pain, she told CNA #4 to stop touching her
legs and to let the resident straighten her own
legs. CNA #6 stated she left the room and CNA
#4 continued to provide care. She stated when
CNA #4 came out of the room, she told CNA #6
the resident was in a lot of pain, and CNA #6 told
CNA #4 to tell the nurse.

LPN #9 stated the night CNA told her and LPN #2
on 1/29/2017 at 6:00 AM that the resident was in
pain. She stated she and LPN #2 finished report
and counted narcotics and then she left. She
stated they had already changed shifts, and she
did not see the resident and expected LPN #2 to
call the Supervisor.
During an interview on 2/27/2017 at 9:35 AM, NP

#8 stated she and the other NPs were called a
few times on 1/29/2017 regarding the resident's
fracture and pain. She stated the first call she
received was at 11:00 AM when she was told the
x-ray was positive for a fracture, and she ordered
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bedrest, called the family, and ordered Norco.
She stated at that time, the plan was for the
resident to remain on bedrest and go to
orthopedics in the morning unless her pain was
not controlled. She stated they called her back a
little later, and she gave the resident another
dose of Norco as her pain was not controlled.
She stated her shift ended at 4:00 PM and she
did not hear back from the facility prior to then.
She stated she later learned the resident was
sent to the hospital that day.

Medical Director stated she was called by the
DON on 1/29/2017 after the resident's fracture
was identified. The Medical Director stated she
decided to send the resident to the emergency
room for treatment, instead of waiting until the
next day to send her to orthopedics as the NP
had recommended.
During an interview on 3/1/2017 at 7:10 AM, CNA

#5 stated she worked from 11:00 PM on
1/28/2017, to 7:00 AM on 1/29/2017. She stated
she saw the resident at 12:30 AM and 2:00 AM
on 1/29/2017 and during both rounds, the
resident was asleep, she checked her brief and it
did not need to be changed, and she did not
touch the resident. She stated between 5:00 AM
and 5:30 AM, she attempted to dress the resident
and when she touched her, the resident started
crying and kept saying "my leg, my leg" over and
over again. She stated she finished dressing the
resident and told the nurses the resident was in
pain. She stated the night and day nurses were
doing report and did not check the resident right
away. She stated after they did shift report, she
told LPN #2 about the resident's pain, and LPN
#2 and a nurse from the other unit checked the
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resident. She stated during their investigation,
she was asked how she could have dressed the
resident in pants when she was in pain.
During an interview on 3/1/2017 at 8:35 AM, LPN

#10 stated she was on the resident's unit using
the printer on 1/29/2017 at around 7 AM and
heard a CNA telling LPN #2 the resident was in
pain and needed someone to look at her leg. She
stated LPN #2 asked her if it was reported, the
CNA said yes, and the CNA wanted the resident
looked at. She stated she went to LPN #2 and
told her she would go see the resident with her.
She stated the resident was in bed and when they
lifted her pant leg, she started screaming and she
asked the CNA how she could have dressed her
when she was in pain.
During an interview on 3/1/2017 at 2:30 PM, CNA

#29 stated he worked the night shift from
1/28/2017 to the morning of 1/29/2017 with CNA
#5. He stated CNA #5 went into the resident's
room at around 2:30 AM to provide care and
when she came out, she told him the resident
was having leg pain and "she beat me up" when
she tried to provide her with care. He stated he
heard the resident moaning in her room and he
thought CNA #5 told the nurse the resident was in
pain. He stated the next time he heard the
resident was in pain was after CNA #5 dressed
her in the morning. He stated at that time, CNA
#5 and he left at 7 AM.

CNA #4 stated she was not a regular on the
resident's unit and was floated to the unit after the
evening shift started on 1/28/2017. CNA #4 stated
conflicting information as to whether the checked
the resident's care instructions prior to providing
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her with care. She initially stated she checked the
resident's care instructions at 8 PM after she
transferred the resident. Later in the interview she
stated she checked the care instructions later
than she normally did, but prior to doing any care.
After dinner she went into the resident's room to
get her ready to be transferred and noticed she
did not have a Hoyer lift pad underneath her. She
transferred the resident with the help of CNA #6
and used a Hoyer lift. When CNA #6 was
lowering the resident into bed with the Hoyer lift,
the resident's left leg was bent and CNA #6 tried
to straighten it with her hand. She stated when
she did this, the resident called out in pain. CNA
#6 left the room, and CNA #4 performed
incontinence care on the resident and possibly
changed her clothes. When she left the room,
she told the LPN the resident was in a lot of pain.
She stated the LPN told her she already gave her
medications and she did not see the nurse go in
the room. She stated she saw the resident again
at 10:30 PM and the resident did not need to be
changed, so she did not touch her. She stated
she asked the resident if she was in pain and the
resident did not answer her. She stated following
the incident, the facility had the physical therapist
(PT) educate her on how to provide range of
motion (ROM) to residents.

DON stated she was notified on 1/29/2017 that
the resident had pain and had a fracture. She
stated she was not aware the resident was not
assessed when she complained of pain on
1/28/2017, and also was not aware the resident
was dressed by the night shift CNA after she
complained of pain. The DON stated she also
was not aware the night shift CNAs told the LPNs
the resident was in pain at 5:45 AM and they did
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not call the Supervisor until 7:00 AM and stated
that was not timely. The DON stated after the
fracture was found, she had CNA #4 demonstrate
how she tried to straighten the resident's leg after
the transfer on 1/28/2017 and determined she
needed training on how to provide ROM care to
residents. She stated she did not consider this a
fracture of unknown origin as she determined the
fracture occurred during the transfer on
1/28/2017 completed by CNAs #4 and 6.
On 3/13/2017 at 10:42 AM, LPN #1 stated in an

interview, sometime on the evening shift on
1/28/2017, she was told the resident complained
of leg pain. She went into the room and asked the
resident, who said she was in pain but it was not
that bad. She stated she told the resident she had
already given her the routine Tylenol and if it did
not work, she should let her know. She stated she
did not hear from the resident again that shift.
She stated she would not have documented the
resident's complaint on 24-hour report, but might
have passed it on verbally to the next shift. She
stated she could not remember in this case, if she
passed the information on verbally.
10NYCRR 415.12
F 322 483.25(g)(4)(5) NG TREATMENT/SERVICES - F 322 4/5/17
SS=D RESTORE EATING SKILLS
(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy tubes,
both percutaneous endoscopic gastrostomy and
percutaneous endoscopic jejunostomy, and
enteral fluids). Based on a resident's
comprehensive assessment, the facility must
ensure that a resident-
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(4) A resident who has been able to eat enough
alone or with assistance is not fed by enteral
methods unless the residents clinical condition
demonstrates that enteral feeding was clinically
indicated and consented to by the resident; and
(5) A resident who is fed by enteral means

receives the appropriate treatment and services
to restore, if possible, oral eating skills and to
prevent complications of enteral feeding including
but not limited to aspiration pneumonia, diarrhea,
vomiting, dehydration, metabolic abnormalities,
and nasal-pharyngeal ulcers.
by:
Based on record review, interview, and
observation conducted during the abbreviated
survey (NY00195273), it was determined for 1 of
5 residents reviewed for quality of care (Resident
#1), the facility did not consistently provide
appropriate treatment and services for feeding
tubes. Specifically, for Resident #1, whose
feeding tube became clogged on multiple
occasions, the facility did not ensure:
- a thorough investigation was completed to
determine a root cause of the resident's ongoing
tube feeding issues;
- the medications ordered to address the clogged
tube were administered appropriately and when
needed;
- orders for the medication to unclog the tube
were written accurately and for the correct tube;
- feeding tube flushes were administered as
ordered; and
- nurses managed the tubes properly, as
observed.
Findings include:
Resident #1 was admitted to the facility on

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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
11/18/2016).
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. She
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 to have
his tube replaced at that time.
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(MAR) documented the resident had an order for
Creon (pancreatic enzyme) to be mixed with
sodium bicarbonate and flushed through the J
tube every 48 hours as needed for a clogged
tube. There was no documented evidence the
Creon was used in 7/2016 and the resident was
sent to IR to have his tube replaced on 7/10/2016
and 7/20/2016.
The 8/2016 MAR documented the resident was

administered Creon and sodium bicarbonate on
8/3/2016 and it was effective in unclogging the
tube. There was no documented evidence the
Creon or sodium bicarbonate were attempted
prior to him going out from the facility on 8/8/2016
to have the tube replaced.
The 8/2016 MAR documented an order dated

8/24/2016 for the resident's J tube to be flushed
automatically via a pump every hour (30 cc) and
manually (30 cc) every 2 hours. The MAR
documented flushes were done as ordered in
8/2016, 9/2016, and 10/2016.
The 11/2016 MAR documented:

- An order dated 11/11/2016 for Creon to be
given, mixed with warm water and the ordered
sodium bicarbonate, via the J tube every 24
hours for a clogged tube, and it was administered
on 11/11/2016.
- An order for sodium bicarbonate to be given,
mixed with warm water, via the J tube for an
upset stomach and for a clogged tube, and it was
given on 11/12/2016 and 11/13/2016.
There was no documented evidence the Creon
and sodium bicarbonate were administered
concurrently as ordered.
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The IR consultation note dated 11/18/2016
documented the J tube was "impacted with
feeding solution and like paste! Tube is not being
flushed per orders!" The consultant
recommended 30 cc flushes daily and after every
use. The note further documented that "clearly,
the feeding tube is not being flushed adequately."
The 11/2016 MAR documented flushes were

completed as ordered.
The 1/2017 MAR documented the resident's

sodium bicarbonate ordered was changed on
12/15/2016 and now documented it was to be
used via the G tube for an upset stomach. The
1/2017 MAR documented it was administered on
1/1/2017 and was "ineffective". The MAR did not
direct staff to mix the sodium bicarbonate with
Creon as previously and the 1/2017 TAR did not
document Creon was used as well on 1/1/2017.
Review of IR records revealed the resident's

feeding tube was changed due to it being
clogged/occluded on 1/6/2017, and the consultant
documented for the facility to ensure they were
flushing the tube routinely.
There was no documentation on the MAR or TAR

that Creon or sodium bicarbonate were attempted
when the tube was clogged prior to the 1/6/2017
tube change.
The 1/2017 MAR documented sodium

bicarbonate was administered via the G tube on
1/20/2017 for stomach upset and was "effective".
The MAR did not direct the use of the Creon as
well and the 1/2017 TAR did not document the
Creon was used on 1/20/2017.
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Licensed practical nurse (LPN) #37's progress
note dated 1/24/2017 at 2:47 PM documented the
resident's J tube was clogged and they were
unable to flush it. The Supervisor was called and
directed the nurse to let warm water sit in the
tube. The warm water was also ineffective, and
an appointment was made to have the tube
changed. There was no documented evidence
the nurses tried to administer the sodium
bicarbonate or Creon.
The IR consultation report dated 1/24/2017

documented that the facility should not be putting
pills in the J tube and should be flushing the tube
vigorously.

bicarbonate was administered via the G tube on
1/30/2017. There was no documented evidence
on the 1/2017 TAR that the Creon was also used.
LPN #38's progress note dated 1/30/2017 at 7:36

PM documented she had some difficulty flushing
the J tube and used the Creon and sodium
bicarbonate.

PM documented she called the doctor to get the
okay to use the Creon, as it was administered via
the G tube and not the J tube. The physician gave
the okay to use it.
The IR consultation report form dated 1/31/2017

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."

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documented none of the staff interviewed had
knowledge of who used a Q-tip to attempt to
unclog the resident's tube.

bicarbonate was used via the G tube on 2/4/2017.
Review of IR records revealed the resident's

feeding tube was replaced on 2/7/2017, as it was
clogged/occluded. The consultation note
documented "plugged by misuse again. Solid
food in tube."
On 2/9/2017 at 8:41 AM, the surveyor went to the

resident's unit and asked to watch administration
of his 9:00 AM tube flush and 10:00 AM
medication administration and flushes. LPN #40
stated she already administered the resident's 8
AM and 9 AM tube flushes and 10 AM
medications. She stated she did the medications
early so she did not get behind and also to keep
his tube patent.
On 2/9/2017 at 10:06 AM, the surveyor observed

LPN #40 administer the resident the 10 AM tube
flushes. When the surveyor entered the room, the
resident was hooked up to a kangaroo pump with
two bags (one with water and one with tube
feeding solution). Both were connected to the J
tube. LPN #40 performed the following actions:
- Unhooked the resident's J tube from the pump,
placed a syringe on the J tube, inserted 10 cc of
air into the J tube, said she "heard a little swoop"
and stated the J tube was in place, and flushed
the J tube with 30 cc water using a syringe and
plunger.
- Filled two new bags (one with water and one
with feeding solution).
- Placed a syringe on the G tube without a
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plunger in it, turned the syringe parallel with the
floor, and stated they checked residual of the G
tube via gravity and since nothing came out, the
G tube was in place.
- Filled the syringe with 30 cc water and allowed
the G tube to flush via gravity.
- Hooked the resident's J tube back up to the
pump.

#41 (from IR) stated she was very familiar with
the resident as he had numerous episodes of
clogged tubes. She stated it was "unbelievable"
how frequently the resident came to them and
they had no other patient who came in so often
with clogged tubes. She stated they did not know
what the J tube was clogged with when he came
in, it could be medications or feedings, and once
they found a foreign body of a Q-tip. She stated
IR had made specific recommendations for the
facility in regards to flushing; they did not make
recommendations regarding the medications for
unclogging tubes or for checking residuals, and
they would never recommend using a Q-tip to
unclog a tube.

Educator #32 stated that staff were not instructed
to check G tube placement via gravity, and were
not instructed to inject air into a J tube to check
placement.
On 2/10/2017 at 9:40 AM, LPN #42 was observed

administering the resident medications. LPN #42
checked placement of the G tube by placing a
syringe on the tube with no plunger. She stated
they checked it via gravity and since nothing
came out, it was in place. She also flushed the J
tube with 30 cc using the syringe and plunger.
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the Director of Nursing (DON) stated she had not
reviewed the resident's orders for
appropriateness, but yesterday the resident's
family member expressed a concern so she
asked another RN to look at the orders. She
stated she could not remember which RN she
asked to do this. She stated a few weeks ago,
someone gave the medication to unclog the
resident's feeding tube via the wrong tube, so the
physician was called and gave the okay to give it
in the proper tube. She stated she was not aware
the order was written for the G tube instead of the
J tube, and that the sodium bicarbonate and
Creon should be mixed together and given via the
J tube. She stated the nurses working the night
the medication was administered incorrectly
should have corrected the order. The DON stated
she was aware the resident had multiple
occurrences of the tube being clogged, but had
not completed a thorough investigation or
determined the root cause of these issues.

pharmacist #44 stated both the sodium
bicarbonate and Creon were to be mixed together
by nursing and administered via the J tube.

Supervisor #30 stated the resident had an order
for sodium bicarbonate via the G tube and Creon
via the J tube, and a nurse reversed it on
1/30/2017 and gave the medications via the
opposite tubes. She stated the physician was
called and gave the okay to give the medications
via proper tubes, as the tube was clogged.

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LPN #38 stated that on 1/30/2017, she used the
sodium bicarbonate and Creon on the resident's
G tube instead of the J tube. She stated the
resident's family member was present and told
her of the error, so they called the physician to
get the okay to administer it again via the proper
tube.

the attending physician stated she was new to the
facility in 11/2016, and so was learning the
resident's care. She stated she was told his care
was under investigation by the DON, so she was
waiting for the results of the investigation prior to
making recommendations. She stated if it was a
nursing practice issue, she would make different
recommendations than if they determined it was
an issue with the amount of flushes, for example.
She stated she heard about the Q-tip being used
in 1/2017 and did not know it was also used
previously in 6/2016. She stated she would never
instruct anyone to use a Q-tip in an attempt to
unclog a feeding tube. She stated the tube was to
be flushed every hour and the nurses should not
be combing the flushes, as the flushes were used
to keep the tube patent and clear.
10NYCRR 415.12(g)(2)
F 323 483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT F 323 4/5/17
SS=E HAZARDS/SUPERVISION/DEVICES
(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
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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

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 beds dimensions are

appropriate for the residents size and weight.
by:
Based on record review, observation, and
interview conducted during the abbreviated
survey (NY00195103 and NY00196850), it was
determined for 1 of 5 residents reviewed for
accidents (Resident #3), the facility did not
consistently provide a safe environment and
adequate supervision and the facility did not notify
the New York State Department of Health
(NYSDOH) and submit a safety plan for
construction activity involving the main entrance.
Specifically, for Resident #3:
- The resident's WanderGuard (alarming device)
was discontinued without an order and without an
assessment.
- The wandering risk assessment completed prior
to the resident's elopement event was inaccurate
and not consistent with prior assessments.
- After the resident's elopement, the facility did
not complete a thorough and complete
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investigation to ensure the plan of care was
followed and to prevent recurrence.
- Following the elopement incident,
recommendations from medical staff were not
implemented without documented rationale.
In addition, the facility did not notify the NYSDOH
of construction and submit a facility safety plan to
protect residents, staff, and visitors prior to
commencement of construction where the main
entrance was unavailable and secured.
Findings include:


WanderGuard device, and the goal was for him
not to leave the facility unattended.

thinking.

initiated by MDS licensed practical nurse (LPN)
#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.
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(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.
- From 1/1/2017 through 1/9/2017, nurses
documented they checked the placement of the
resident's WanderGuard on 22 out of 27
scheduled occasions.
Nursing progress notes documented:

- On 1/11/2017, the resident did not have the
WanderGuard on at 12:07 AM and 2:58 AM, and
the Supervisor was notified.
- On 1/11/2017 at 1:17 PM and 4:06 PM, the
resident no longer had a WanderGuard.
- On 1/13/2017 at 12:23 AM, the WanderGuard
was removed by the Supervisor.
- On 1/13/2017 at 8:01 PM, and 1/14/2017 at 9:10
AM, the resident had an order to remove the
WanderGuard.
There was no documented evidence an order

was written to remove the WanderGuard and no
documented evidence the resident was
reassessed for wandering risk when the
WanderGuard was removed on 1/11/2017.
The 1/2017 TAR documented the WanderGuard

was discontinued on 1/15/2017.

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
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known history of wandering.
The 24-hour nursing report for 1/28/2017

documented for the day and evening shifts, a
WanderGuard was placed on the resident. On the
night shift, the resident bought cigarettes when he
was out and reported he was going to cut off his
WanderGuard.
On 1/28/2017, the CCP was revised and

documented a plan for the resident to notify social
services if he was out of cigarettes as opposed to
going out unattended, and documented the
resident had a WanderGuard.
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 had
removed it.

was missing and the police were called. The
resident came back at around 4:30 PM or 5:00
PM. She stated it was very cold that day and he
had a heavy jacket on, but was wearing slippers
on his feet and did not have his walker. CNA #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. She
stated she did not write a statement for an
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incident report, as the LPN told her the
Supervisor said not to document anything.

LPN #24 stated that just prior to walking into the
room to be interviewed by the surveyor, she went
to the unit and put in a late entry progress note in
the resident's medical record regarding the
resident's incident on 1/28/2017. She stated she
did not document on the day the resident went
out, as she was told by the Supervisor that she
would handle everything related to the incident.
She stated at around 11:00 AM that day, the CNA
told her 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.

AM documented the team met to discuss the
resident's diagnosis of dementia and confusion.
Nursing determined he was alert and oriented,
and the WanderGuard was removed.

Supervisor #21 stated the unit called her at
around 1:30 PM on 1/28/2017 and told her the
code yellow, and she learned from the staff that
he told a few people that day that he was being
discharged. She stated she completed a
wandering risk assessment on 1/15/2017 and
discontinued his WanderGuard. She stated she
did this because the resident felt other residents
were making fun of him for wearing a
WanderGuard. She stated when she assessed
him on 1/15/2017, she based her assessment on
the conversation she had with him that day, she
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did not review the chart, and did not review the
prior assessment. She stated after the resident
was missing for a while, the CNAs told her he
was confused so she called the police and the
Director of Nursing (DON). She stated he came
back on his own, she assessed him, and she was
told he drank a few beers while out. She stated
she did not complete an investigation, as the
DON told her it was not an elopement and they
would not do one. The DON told her to document
her assessment and a statement in a Word
document and she provided that to the DON. She
had retained a copy of what she gave to the DON
on the Supervisor's computer, and provided a
copy to the surveyor. The statement dated
1/28/2017 documented:
- RN #21 was notified at 1:30 PM the resident
was not seen for a "couple of hours", and the
facility was searched. A code yellow was called,
and the police were notified.
- At 2:55 PM, the resident returned and said he
went and got lunch, bought cigarettes, had his
- RN #21 assessed the resident with no injuries,
and she told him he needed to tell staff if he was
leaving the facility.
- The DON was called and said she spoke with
the Medical Director. Although the resident was at
low risk to wander, he was to have a
WanderGuard, as he had dementia ands a past
stroke.
The 2/3/2017 progress note by nurse practitioner

(NP) #23 documented the resident had dementia,
his Mini Mental Status Exam (MMSE) score was
22 (mild to moderate cognitive impairment), and
the NP recommended the resident's
WanderGuard be re-applied "due to recent
events."
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The LPN progress note dated 2/19/2017 at 5:25

AM documented the resident commented that he
could leave the facility and no one would know.
The CCP, printed on 2/27/2017, documented the

resident had impaired cognition and impaired
decision-making related to a past stroke and
dementia. The CCP did not document the
resident was at risk for elopement.

NP #23 stated she was not officially notified the
resident had an elopement incident. She stated
she heard about it in passing, and checked the
medical record and found no specifics
documented. When she heard about the incident
on 2/3/2017, she recommended the resident's
WanderGuard be re-applied and she expected
her recommendation to be implemented. She
stated the resident's MMSE score was 22 out of
30, which meant mild to moderate cognitive
impairment. She stated if a person had a brief
conversation with the resident, they might think
he was cognitively intact, but he was not. She
stated he could fool people that did not know him.

DON stated she was called about the resident on
1/28/2017 by RN #21. The DON stated she called
the Administrator and they deemed the incident
not an elopement, as RN #21 recently determined
the resident was alert and oriented. She stated
the Medical Director initially recommended the
WanderGuard be re-applied, and the Medical
Director did a cognitive exam on the resident. The
team since met and discontinued the
WanderGuard. She stated a code yellow was
called on 1/28/2017, and she did not know if code
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yellow paperwork or an incident report were done.
She stated she did not know if she asked any
staff to write statements about the incident, was
not aware the incident was not documented in the
medical record, and stated she would verify
whether there was an incident report. At 5:20 PM,
Administrative Assistant #27 told the surveyor the
DON said there was no incident report or
investigation documentation for the resident.

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. She 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. She
stated she was not aware he did not have a
WanderGuard at the present time, and stated the
interdisciplinary team should meet to discuss a
plan for him. She stated she thought there would
be an incident report completed about the event,
and if there was, she had not reviewed it.

Administrator stated he was called by the DON
about the resident on 1/28/2017. They deemed
the event not to be an elopement because an RN
said the resident was alert and oriented. He
stated he was not aware whether the resident had
his assistive devices with him or was dressed
appropriately when he went out, and said if he
was not, that would speak to his cognition. He
stated after the incident a WanderGuard was
applied, but after a full review, it was
discontinued. He stated if he was able to locate
an incident report, he would provide it.
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On 3/9/2017 at 12:35 PM, the surveyor received

an email from Administrative Assistant #27 with
an incident report for the resident attached. The
incident report did not contain an investigation.
The report documented an incorrect date
(1/29/2017) as to when the incident occurred, did
not document how the facility determined the plan
of care was followed, and included 1 statement
from a staff member taken on the day of the
incident (RN #21).
The facility's code yellow policy, revised

12/3/2012, documented when a code yellow was
called, specific code yellow paperwork and an
incident report were to be completed.
2) A police report dated 9/26/2016 at 2:35 AM

documented a police officer responded to the
facility to investigate a trespass complaint. The
report documented a caller stated a male who
appeared to be under the influence of drugs had
entered the facility. The Nursing Supervisor
stated in the report the male individual had pulled
multiple times on the front door (north side) entry
door until it broke and opened it to enter the
building. In the police report, the Nursing
Supervisor reported and showed the officer the
front door was secured by a "small chain and the
metal bar which the chain was attached to was
now broken." The police report documented the
front entry door handle was damaged by the male
subject.
On 3/8/2017 at 11:00 AM, in a telephone

interview with the Director of Maintenance, he
stated the following:
- the facility replaced the concrete entryway and
threshold for the automatic sliding front door;
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- the project was completed in less than 1 week;
- the facility utilized the side entrance to the
facility when the whole front entry area was
closed off while the concrete was replaced;
- the inner front doors were secured with what
looked like a plastic chain, and a door magnet
that was switched so the door locked at all times;
- the front entrance was not staffed 24 hours a
day, and was only staffed from 8:00 AM - 8:30
PM;
- the only incident involving the front entrance
during the project that he could recall was when a
person walked over the wet concrete; and
- he recalled an incident where a drugged
individual gained entry, but it was not during the
construction period. He stated he believed it was
in the evening when the operator (receptionist)
was still present.
During the telephone interview on 3/8/2017 at

11:00 AM with the Director of Maintenance, he
was reviewing the facility maintenance log. He
stated on 9/26/2016, facility maintenance staff
documented a drugged man broke a lobby door
and tried to jump out a window, and the door was
fixed and the window was closed with plywood.
The Director of Maintenance stated the sliding
door on the outside may still have been out of the
opening and not installed. He stated the inner set
of swinging doors was in place. He stated at no
time was the front door locked to prevent
emergency exit. He stated a sign was in place at
night that the exit was an emergency exit to
discourage use.
Review of the door contractor invoice dated

9/28/2017 showed documentation that included a
contractor visit date on 9/26/2016 to install 14 feet
of door track and a threshold for the sliding outer
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door. The contractor worksheet dated 9/26/2016
recorded staff were onsite on 9/26/2016 and the
door was repaired and in working order at 4:45
PM that day.
Review of a printed email received on 3/8/2017

documented the contractor responsible for
replacing the concrete billed the facility on
9/19/2016 and documented the concrete was
poured on 9/15/2016.
As of 3/13/2017, a safety plan addressing

resident, staff, and visitor safety in the event of
fire during the construction period between
9/15/2016 and 9/26/2016 was not submitted to
the NYSDOH prior the commencement of the
project or as requested by the NYSDOH in an
email to the Director of Maintenance on 3/8/2017.
10NYCRR 415.12(h)(1)(2)
F 514 483.70(i)(1)(5) RES F 514 4/5/17
SS=D RECORDS-COMPLETE/ACCURATE/ACCESSIB
LE
(i) Medical records.

(1) In accordance with accepted professional
standards and practices, the facility must
maintain medical records on each resident that
are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
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(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the residents assessments;
(iii) The comprehensive plan of care and services

provided;
(iv) The results of any preadmission screening

and resident review evaluations and
determinations conducted by the State;
(v) Physicians, nurses, and other licensed

professionals progress notes; and
(vi) Laboratory, radiology and other diagnostic

services reports as required under 483.50.
by:
during the abbreviated surveys (NY00185273 and
NY00195103), it was determined the facility did
not maintain clinical records on each resident in
accordance with accepted professional standards
and practices, that were complete and accurately
documented for 2 of 5 sampled residents
(Residents #1 and 3). Specifically the facility did
not provide all staff statements obtained during
an investigation into the mistreatment of Resident
#1, and the facility did not ensure full
documentation of Resident #3's elopement
incident in the medical record.
Findings include:


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WanderGuard device, and the goal was for him
not to leave the facility unattended.

thinking.
The medical record contained no nursing

progress notes written for the resident on
1/28/2017.
The 24-hour nursing report for 1/28/2017

documented for the day and evening shifts, the
resident was issued a WanderGuard (alarming
device). For the night shift, the report
documented the resident told staff he bought
cigarettes when he was out and reported he was
going to cut off his WanderGuard.

the resident stated he went out a few days ago
because the doctor discharged him. The resident
stated that when he came back, they put a
WanderGuard on him.

was missing, the police were called, and the
resident came back at around 4:30 PM or 5:00
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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.
CNA #25 stated the resident stated he walked to
a restaurant, had lunch and a few beers, got a
haircut, and got a ride back to the facility. She
stated she did not write a statement for an
incident report, as the licensed practical nurse
(LPN) told her the Supervisor said not to
document anything.

LPN #24 stated that on 1/28/2017 at around
11:00 AM, the CNA told her 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. She stated
she did not document on the day the resident
went out, as she was told by the Supervisor that
she would handle everything related to the
incident.

Supervisor #21 stated the unit called her on
1/28/2017 at around 1:30 PM and told her the
code yellow, and notified the police and the
Director of Nursing (DON). She stated she did not
complete an investigation, as the DON told her it
was not an elopement and they would not do one.
The DON told her to document her assessment
and a statement in a Word document. She
retained a copy of what she gave to the DON on
the Supervisor's computer and provided a copy to
the surveyor. The statement dated 1/28/2017
documented:
- RN #21 was notified at 1:30 PM that the
resident was not seen for a "couple of hours;" the
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facility was searched; a code yellow was called,
and the police were called.
- At 2:55 PM, the resident returned and said he
went and got lunch, bought cigarettes, had his
- RN #21 assessed the resident with no injuries,
and told him he needed to tell staff if he was
leaving the facility.
- The DON was called and said she spoke with
the Medical Director and although the resident
was at low risk to wander, he was to have a
WanderGuard as he had dementia and a past
stroke.

nurse practitioner (NP) #23 stated she was not
officially notified the resident had an elopement
incident. She stated she heard about it in
passing, and checked the medical record and
found no specifics documented.

DON stated she was called on 1/28/2017 by RN
#21, and she called the Administrator. They
deemed the incident not an elopement, as RN
#21 recently determined the resident was alert
and oriented. She stated a code yellow was
called and she did not know if code yellow
paperwork or an incident report were done. She
stated she did not know if she asked any staff to
write statements about the incident, was not
aware the incident was not documented in the
medical record, and stated she would verify
whether there was an incident report. At 5:20 PM,
Administrative Assistant #27 told the surveyor the
DON said there was no incident report or
investigation documentation for the resident.
On 3/9/2017 at 12:35 PM, the surveyor received

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an email from Administrative Assistant #27 with
an incident report for the resident attached. The
incident report did not contain an investigation.
The report documented an incorrect date
(1/29/2017) as to when the incident occurred, did
not document how the facility determined the plan
of care was followed, and included 1 statement
from a staff member taken on the day of the
incident (RN #21).


needed.
The consultation report form IR (interventional

radiology) dated 1/31/2017 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."
Per request on 2/6/2017, the facility faxed the

surveyor the 1/31/2017 incident report which
documented none of the staff interviewed had
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knowledge of who used a Q-tip to attempt to
unclog the resident's tube. An attached statement
from registered nurse (RN) Supervisor #34
documented she was in the nursing office talking
about the resident's IR report and RN Supervisor
#35 stated "she knew that could be correct
because she had overheard another nurse telling
staff to use this and to try to open up the tube."
RN Supervisor #34 documented she told RN
Supervisor #35 to tell the Assistant Director of
Nursing (ADON) what she heard. The faxed
incident report did not contain a statement from
RN Supervisor #35 and did not contain
documented evidence the facility spoke with her
to verify whether she heard a nurse instructing
staff to use a Q-tip in the resident's tube.

Supervisor #35 stated she heard conversations
among nurses about the resident's feeding tube
and how it was often clogged. On one occasion,
she heard staff taking about using a Q-tip to
unlclog it. She stated she could not say exactly
when she heard this conversation, but it was in
the nursing office. She stated on her last night at
the facility, the Consultant RN #36 asked her to
write a statement and she did.
On 2/8/2017 at 4:00 PM, RN Supervisor #35

provided the surveyor with a copy of the
statement she wrote in regard to the resident's
1/31/2017 incident. The statement documented a
unit medication nurse called the Supervisor about
a week ago to report the resident's tube was
clogged and a Supervisor advised the nurse to
use a Q-tip to unclog the tube. The statement
documented RN Supervisors #30 and 31 were
present in the office when this conversation
occurred.
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the DON stated that the Consultant RN #36
completed the investigation into the 1/31/2017
incident and she reviewed it. The surveyor asked
if there were any other statements taken as part
of the investigation. The DON left the room for
several minutes and returned with the statement
taken from RN Supervisor #35. She stated she
got it from the Administrator and he did not
provide it initially as
it was a hearsay statement because RN #35
could not remember what day she overheard the
conversation between the nurses.
In an interview with the Administrator on 3/6/2017

at 10:06 AM, he stated the surveyor was not
provided with the statement written by RN
Supervisor #35 as it was a hearsay statement
and they could not verify it.
10NYCRR 415.22(a)(1-4)

James Square Violations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

918 JAMES STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 483.12(a)(3)(4)(c)(1)-(4) INVESTIGATE/REPORT F 225 4/5/17

483.12(a) The facility must-

(3) Not employ or otherwise engage individuals

(i) Have been found guilty of abuse, neglect,

(ii) Have had a finding entered into the State

(iii) Have a disciplinary action in effect against his

(4) Report to the State nurse aide registry or

(c) In response to allegations of abuse, neglect,

(1) Ensure that all alleged violations involving

918 JAMES STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 1 F 225

(2) Have evidence that all alleged violations are

(3) Prevent further potential abuse, neglect,

(4) Report the results of all investigations to the

918 JAMES STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 2 F 225

1) Resident #5 was admitted to the facility on

The Minimum Data Set (MDS) assessment dated

The comprehensive care plan (CCP), printed

On 2/16/2017 at 4:47 PM, the facility reported to

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 3 F 225

The incident report initiated by the Assistant

On 2/21/2017, the DON reported to the NYS

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 4 F 225

During an interview on 2/23/2017 at 1:30 PM, a

During an interview on 2/23/2017 at 2:05 PM, the

During an interview on 2/23/2017 at 4:05 PM, the

918 JAMES STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 5 F 225

During an interview on 2/27/2017 at 11:40 AM,

During an interview on 3/1/2017 at 11:00 AM,

During an interview on 3/1/2017 at 12:30 PM,

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 6 F 225

During an interview on 3/6/2017 at 9:50 AM, the

During an interview on 3/6/2017 at 10:06 AM, the

2) Resident #3 was admitted to the facility on

The initial comprehensive care plan (CCP) dated

The Minimum Data Set (MDS) assessment dated

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 7 F 225

The 12/23/2016 wandering risk assessment

The 1/2017 Treatment Administration Record

A nursing progress note dated 1/11/2017

The 1/15/2017 wandering risk assessment

The resident was observed on 1/30/2017 at 12:00

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

F 225 Continued From page 8 F 225