VI at Grayhawk, a VI and Plaza Companies Community

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure resident safety was provided in accordance with professional standards of practice regarding the use of a gait belt during transfer of one resident #23. Findings Include: Resident #23 was admitted on April 1, 2024 with diagnosis including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, adult failure to thrive, anxiety disorder, unspecified, muscle weakness (generalized), difficulty in walking, not elsewhere classified. The MDS (minimum data set) assessment dated April 28, 2024 revealed a BIMS (brief interview for mental status) score of 15, suggesting intact cognitive abilities, no indicators for mood or behaviors were identified. Further review of the MDS identified substantial to maximal assistance for toileting, partial to moderate assistance rolling left to right, sit to lying, bed to chair to bed transfers and lying to sitting on side of the bed. A review of the physician's orders dated April 2, 2024 included an order for use of siderails as enablers for assistance with transfers, bed mobility and aid in positioning related to diagnosis of weakness related to femur fracture. Review of the care plan-initiated on August 5, 2024 included that resident #23 had a right femur fracture this year that still caused her some discomfort and she has chronic pain and was at risk for fall due to debility from recent illness, new surroundings, advancing age with comorbidities, polypharmacy, poor balance, impaired gait, and weakness. Interventions included to handle gently and try to eliminate any environmental stimuli, position for comfort with physical support as necessary and staff to cares in pairs whenever possible. A review of the physician progress notes dated August 12, 2024 revealed that the resident #23 felt tired that day and was visited by her son. The note further stated that per the staff and son, there had been issues with the resident's care by CNA (Certified Nursing Assistant). The note stated that was being further evaluated by the team, supportive measures were being provided, escalation of opiate dosing was offered and the resident stated she will discuss further with her son. The social services progress note revealed resident #23's son informed social services of a claim presented to him by his mother's caregiver that the facility's nurse's aide was rough when helping his mother back to bed on 8/11/24 and his mother referred to the aide as aggressive. An interview was conducted on July 21, 2023 at 1:33 p.m. with resident # 23 who stated CNA (Staff #198) had assisted her to the bathroom and to bed. Resident stated while transferring her to bed Staff#198 caused her pain in both her upper legs and to her right hip. The resident stated staff #198 had placed her wheelchair by the side of her bed and had the resident place her arms around her waist lifti

Based on observation, staff interviews, and review of facility documentation, the facility failed to ensure one resident's (#27) oxygen tubing was safely secured. The deficient practice could result in a preventable accident. Findings included: Resident #27 was admitted to the facility on 09/28/2023 with diagnoses of acute and chronic respiratory failure with hypoxia, gastro-esophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. Review of the MDS (minimum data set) assessment dated 02/17/2024 revealed a BIMS (brief interview of mental status) score of 11 indicating moderate cognitive impairment. A care plan dated 09/28/2023 revealed resident was at risk for incontinence due to advanced aging process, new surroundings, debility related to activity intolerance and weakness complicated by acute on chronic respiratory failure. Interventions included to assist and offer to toilet frequently and as needed and encourage independence. The care plan also revealed resident was in need of assistance with self-mobility and functional tasks due to debility from recent illness, advancing age with comorbidities and interventions included 1/4 side rails to bedside as appropriate to encourage/foster mobility independence. The physician order report revealed an order dated 11/15/2023 for oxygen at 2 liters (L) to 4 L via nasal cannula for diagnosis of chronic obstructive pulmonary disease. An observation was conducted on 02/21/2024 at 10:13 A.M. The oxygen concentrator inside the resident's room was located between the door to the hallway and the door to the bathroom. The bathroom was located between the concentrator and the resident's bed. The resident was observed wearing the nasal cannula and the oxygen tubing connected to the oxygen concentrator was placed above the bathroom door frame with the bathroom door open. A follow up observation on 02/22/2024 at 11:37 A.M. revealed the oxygen tubing connected to an oxygen concentrator remained above the door frame of the bathroom door. Review of the progress note dated 01/20/2024 revealed resident was on continuous oxygen via nasal cannula at 3 L and displayed shortness of breath with minimal exertion. The note on 2/14/2024 revealed resident reported feeling "like he can't get air." On 2/20/2024 in was noted that resident reported increased dyspnea. An interview was conducted with Licensed Practical Nurse (LPN\ #280) on 02/23/2024 at 9:47 A.M. at which time she observed the oxygen tubing over the resident's bathroom door, staff #280 stated that maintenance/engineering fixed it that way to prevent resident from tripping and keeping it out of the way. Staff #280 stated it needed a top right corner bracket to keep the door from closing and clamping the tubing. During the interview, staff #280 opened and closed the door several times and the tubing fell in between the door and the door frame. The LPN started to close the door but stopped just before the door clamped the tubing which she

Based on observation, staff interviews, and review of facility documentation, the facility failed to ensure one resident's (#27) oxygen tubing was safely secured. The deficient practice could result in a preventable accident. Findings included: Resident #27 was admitted to the facility on 09/28/2023 with diagnoses of acute and chronic respiratory failure with hypoxia, gastro-esophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. Review of the MDS (minimum data set) assessment dated 02/17/2024 revealed a BIMS (brief interview of mental status) score of 11 indicating moderate cognitive impairment. A care plan dated 09/28/2023 revealed resident was at risk for incontinence due to advanced aging process, new surroundings, debility related to activity intolerance and weakness complicated by acute on chronic respiratory failure. Interventions included to assist and offer to toilet frequently and as needed and encourage independence. The care plan also revealed resident was in need of assistance with self-mobility and functional tasks due to debility from recent illness, advancing age with comorbidities and interventions included 1/4 side rails to bedside as appropriate to encourage/foster mobility independence. The physician order report revealed an order dated 11/15/2023 for oxygen at 2 liters (L) to 4 L via nasal cannula for diagnosis of chronic obstructive pulmonary disease. An observation was conducted on 02/21/2024 at 10:13 A.M. The oxygen concentrator inside the resident's room was located between the door to the hallway and the door to the bathroom. The bathroom was located between the concentrator and the resident's bed. The resident was observed wearing the nasal cannula and the oxygen tubing connected to the oxygen concentrator was placed above the bathroom door frame with the bathroom door open. A follow up observation on 02/22/2024 at 11:37 A.M. revealed the oxygen tubing connected to an oxygen concentrator remained above the door frame of the bathroom door. Review of the progress note dated 01/20/2024 revealed resident was on continuous oxygen via nasal cannula at 3 L and displayed shortness of breath with minimal exertion. The note on 2/14/2024 revealed resident reported feeling "like he can't get air." On 2/20/2024 in was noted that resident reported increased dyspnea. An interview was conducted with Licensed Practical Nurse (LPN\ #280) on 02/23/2024 at 9:47 A.M. at which time she observed the oxygen tubing over the resident's bathroom door, staff #280 stated that maintenance/engineering fixed it that way to prevent resident from tripping and keeping it out of the way. Staff #280 stated it needed a top right corner bracket to keep the door from closing and clamping the tubing. During the interview, staff #280 opened and closed the door several times and the tubing fell in between the door and the door frame. The LPN started to close the door but stopped just before the door clamped the tubing which she