cms_WV: 13
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 13 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 309 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure eight (8) of thirty-two (32) Stage 2 residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility did not assess and monitor a resident's pain, did not ensure implementation of physician's orders [REDACTED].#163). Staff failed to properly position residents during meals and/or in bed (#76 and #101), did not ensure monitoring of residents receiving [MEDICAL TREATMENT] (#159 and #45), did not obtain neuro checks after a fall (#59), and did not follow physician's orders [REDACTED].#59). For Resident #100, the facility failed to monitor the resident's [MEDICATION NAME] as ordered and failed to provide physician ordered foods to Resident #124. Additionally, the facility failed to follow orders for restorative ambulation for and assessment of a pulse rate prior to administration of a medication. Additionally, the facility failed to follow physician's orders [REDACTED].#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141). Facility census: 116. Findings include: a) Resident #163 1. Medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) #72, revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. When asked whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed as ordered for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml, administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17 and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). The facility's pain management policy, reviewed on 05/23/17 at 9:00 a.m., required a pain evaluation be completed in the resident had a change in pain status. Residents receiving interventions for pain would be monitored for the effectiveness and side effects. On 05/22/17 at 2:57 p.m., the electronic medical record and paper medical record, reviewed with the CNE, confirmed no information was present to indicate the change in condition, or need for increased use of pain medication. The CNE agreed the change in the order was not a clarification and should have been discontinued, or noted as an error. The initial order indicated [MEDICATION NAME] sulfate 20 milligrams per milliliter (mg/ml) administer 0.75 ml sl every hour as needed and clarified to be administer 0.5 ml sl every hour as needed. 3. The bowel movement monitoring assessment indicated Resident #163 had no bowel movement on 05/01/17, 05/02/17 and received milk of magnesia (MOM) with no results noted until 05/04/17. No follow-up was noted on 05/03/17. No bowel movement was noted for 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, and 05/17/17. The action taken indicated MOM was administered on 05/14/17 with no results and no follow-up to ensure the resident had a bowel movement. Additionally, no information was present to indicate the facility had assessed and monitored the resident for complications. On 05/22/2017 at 4:15 p.m., Resident #163's medical record was reviewed with the interim CNE related to omission of data for bowel movements, not following physician's orders [REDACTED]. The CNE acknowledged the facility failed to assess/reassess Resident #163's pain and/or constipation per physician's orders [REDACTED]. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. b) Resident #159 A medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident was in the hospital on [DATE] and the resident was readmitted to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. [MEDICAL TREATMENT] communication records, reviewed from 12/15/16 to present revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for a facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records included 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., an inquiry as to the facilit's responsibility related to the permacath and graft site, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, (MONTH) and (MONTH) (YEAR). c) Resident #101 A Stage 1 observation on 05/15/17 at 1:27 p.m., revealed Resident #101 in bed, leaning to the right side against the siderail. No support devices were in place to assist with maintaining an upright position. The bedsheets were tucked tightly over her toes holding the feet in plantar flexion position. On 06/01/17 at 11:19 a.m., a Stage 2 observation revealed the resident leaning against the side rail. The head of the bed was elevated between 45 and 90 degrees. Resident #101 verbalized she slid to the side, did not like lying that way, and would like to sit up. She had no positioning devices in place to maintain upright positioning. When asked if she could reposition herself, the resident reached back in an attempt to grab the siderail, but could not reach it. A Nurse Aide (NA) entered the room at that time and said she would assist the resident into a comfortable position. Physical Therapy Assistant (PTA) #52 and Physical Therapist #104, interviewed on 06/01/17 at 3:56 p.m., said Resident #101 was currently on the occupational therapy (OT) case load for wheelchair (w/c) positioning. Upon inquiry as to how the facility identified the need for therapy, the OT verbalized the resident was picked up on 05/23/17, during a routine screen by therapy. The OT said the resident had a spinal cord injury and was hoping for neuro-recovery and strength. The care plan indicated Resident #101 required assistive devices for bed mobility and limited to extensive assistance of one (1) person. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 04/18/17 indicated Resident #101 required extensive assistance for bed mobility. d) Resident #76 The medical record review yielded a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17. It noted Resident #76 required extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides, upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m., revealed Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m. the resident was in bed, lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 had slid down in his bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Upon inquiry, LPN #62 confirmed he was not positioned correctly and needed pulled up in bed. She asked the NA to assist her to position him correctly to eat his meal. e) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. f) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. g) Residents #101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days | 2020-09-01 |