Sixteen Acres Health and Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at Sixteen Acres Health and Rehabilitation Center LLC, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 7, 2022

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her plan of care related to his/her individual care needs with transfers. On 07/28/22 during the evening shift, Resident #1 was transferred into bed by two staff members without the use of a mechanical lift, he/she sustained a laceration to his/her left leg, was later transferred to the Hospital Emergency Department where he/she received twelve sutures to close his/her left leg wound, he/she was also diagnosed with a left ankle fracture and admitted to the Hospital for further treatment. […]

• Actual harm, isolatedF689Sep 7, 2022

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the appropriate level of assistance, which included the use of an assistive device, required to maintain his/her safety, in an effort to prevent incident/accidents resulting in injury. On 07/28/22, Resident #1 was transferred into bed by two staff members without the use of a mechanical lift, he/she sustained a laceration to his/her left leg, was transferred to the Hospital Emergency Department where he/she received twelve sutures to close the wound, was also diagnosed with a left ankle fracture, and was admitted to the Hospital for further… […]

• Actual harm, isolatedF760Jul 20, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physicians' orders included nursing to administer 2.5 milligrams (mg) of [MEDICATION(S)] (narcotic) oral liquid solution for pain management, the Facility failed to ensure Resident #1 was free from a significant medication error. On 6/20/22, Resident #1 was administered 50 milligrams (mg) of [MEDICATION(S)], 20 times the prescribed dosage. As a result Resident #1 became extremely lethargic, was found slumped over in bed and could not be aroused by nursing, and required treatment with [MEDICATION(S)] (medication to treat a narcotic overdose in an emergency situation). […]

• Actual harm, isolatedF600Feb 7, 2022

  Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2), the Facility failed to ensure Resident #2 was free from abuse when, on 1/27/22 around 10:30 A.M., Certified Nurse Aide (CNA) #1 found Resident #1, a confused resident with a known history of sexually inappropriate behaviors, completely naked laying on top of Resident #2, a confused, non-verbal resident who was unable to move away from Resident #1 or call for help. CNA #1, Nurse #1, Nurse #2 and Unit Manager #1 did not immediately intervene or separate the residents, instead they left Resident #1 laying (naked) on top of Resident # 2, stood outside of Resident #2's room and observed the residents for around five minutes, waiting for the Director of Nursing (who staff called twice) to come to… […]

• Actual harm, isolatedF689Feb 7, 2022

  Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to provide adequate supervision for Resident #1 and Resident #2 to prevent an avoidable incident/accident, when, on 1/27/22 around 10:30 A.M., Resident #1, a confused resident with a known history of sexually inappropriate behaviors, who was completely naked, got into Resident #2's bed, and was found laying on top of Resident #2, a confused, non-verbal resident who was unable to move away or call for help. Although staff were aware that Resident #1's behaviors were escalating, that he/she was able to remove and disengage personal alarms, no additional interventions were put into place in an attempt to prevent further incidents from occurring. […]