THROGS NECK EXTENDED CARE FACILITY I MEDICAL suwrmmay SHEET AND FINAL - 5' . la}? . ATTENDING PHYSICIAN rs. DISCI-IARGED: I WHERE . IMPROVED . IVIEDICAL I I I 6 0 DISCHARGE I TRANSFER (TRANSFEERED -- DIS HOME -- . - nu. I'lUIl.l Admission Date: Discharge DaIe:__l_ Ju- Rlesidcm Name: 2. "flu . 1 Home Phonezfi -ggc-'2. . 0 . Mcdicarefl: ET Mcdicaidil: I-IMO ff; 1. nmcNos1s:_HTrd fic_L_, Hcazrf mmaz 2. ADVANCE DIRECTIVES: I Care Proxy v__'__Li'ving Will 3. IJOWEIJBLADDER FUNCTION: i?oxve--l: . mincm __Colo?Iomy Comments: - - - 4. TREATMENTS ANDIOR SPECIAL CARE PROCEDURES: (skin care. diabc_l_i.c I - teaching) . 5. MEDICATION: pasagc" Route Time Precautions Qemkfie ELD +'fnm;'15 Fm 7 I E79 oi'. I0 Hm . I T4415 pa Qamiffin 6. PHYSICAL THE - . . Transfc-rst' - A I /00 Stairs: 723 :22Signature: 7. 0 c: I Feeding: Groomingmemaking: Vt}? ., Comments: Fa-milyzraining 'flux, VC 3 - 8. SPEECH . - Cognil-ion.' Means ofCo:mnumca1ion: Expressive Com fl_ Receptive Comn1enis.'{ farnily Iraining, HEP, . . A SigtIai\:rc_ 3102 Continued nfi side $4 Diet ,c?0 I, J3 Comments: My T: 4?j?Eg%% o?ovb ?s?a Cl 10. THERAPEUTIC . - . . I . 11. Signature - \zmz9;aef 1 Nu' .i Unis; uf 1 I2. FOLLOW UP Within -I-2 weeks following discharge C?im'ca'Doctor Telephone - . 13. DISCHAR 'zE RECOMMENDATIONS: - Agency Used: A0 Contact..Persou - I Phone: Services Requested: - - 3 i" a_H_Nursi_ng OT Work "_4_Home Health Care (ff of daysihours) Ordered: DMT7 Vendor: WCC Phone: '7 6' I have '2-cad and u1_1derstam_;i the above instrucntions :_1nd all my questions have been answered. I have been adviscd that m?ditatiolis provided are NOT in childproof contaim-.13. A copy ofthis discharge plan has been provided . ReviewingNursc: . .. .1.- Dale: while the.-medication is in my possression. The medical: - Signattjre offaci__lity rcpreseuta-t'ive releasing Signal-tire ofpanen 0 Medication THROGS NECK EXTENDED CARE FACILITY I DEPARTMENT OF NURSING MEDICATIONS RELEASED ON DISCHARGE Gzewrac M3 Last -Name of Residczil 3% First-Name "Physician ed tion Rx Number Amoudtou Dischs1_ The ab0ve--namc<2' have been released to oh physician orders. I understand -thug' rlzisfacilizjy wili not be held any' improper use' and/or admfniqtrarion om' are accepted in mm-childproofcontainers. t'-km andfor sponsor receiving medication . - . /Eff ii gnoz/J/\ Ite -- ate The amount afmedicatiar: dircltarged has been counter! am! recorded. LA flufl . -. -. .. - . 3 . Ht: 5033 1 TO BE. us' FLESIBEMT 71': filmfiinfifill 5 1 1 11- '"151JEILOQUEL 501% #0 Qfh" I ?lomc ?inptuemaa 'at I dose L) i nmrh. uncn. I n\o.J..F 5:13:32 mo RESTRICTION -E-absgu. 53', .. . . RESTFLICTI . 4. - - 12:5 E.-E1aw' ?.er,RATIOIJALE RATI ONA.L.E fi_in!) CONS I . THE ABOVE omens mm EFFECT res: THE mix? pt: zisvxawzo av: ""33 SIGNATU . - . 3 5.: - Swnuwu c, I pqcac ICD9: . [jfijmg mg "jg,-g 5-3533 sci:-2- 94:35..-. (A41) /mg I I . .. s'4mI passe. 544 AM ,2 amamwugmjg USE BALLPOINT PEN mum . FIRMLY . . - An Omnfcare Company Please piece' :2 che?kmarkl in the box I marked Eggid to indicate that the' orderwas faxed to, the Pharmacy. For - tracking purposes please_ indicate the ti_rn.e . - INTERIM ORDERS FORM. I I ALLERGIES: ms: M: I . -"mm nocrows NAME Wvmirmlc 3a>%z> Pam Dd if FHEGLJENCY AND noursrrom?r WHEN BRAND NAME REQUIRED-INDICATE Ml TING VBRAND MEDICALLY SIGNATURE DTE TIME 546 ..he>! fli/#2 (1 /4 cmm/Zr . I fir" I. Checkharasl mu wru. BE FILLED GENERICALLY I UNLESS PRESGRIBER wanes a IN THE BOX - 1. DATE DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING I'=LaAse: use BALLPOINT PEN mess FIRMLY Wt?' An Omnicclre Company Please place a checkmark in the box marked Eaited to indicate that the ordgr was faxed to the Pharmacy. For tracking, 'purposes please indicate the time the order was faxed. . INTERIM ORDERS FORM Form No. 1620-2?: PATIENTS NAME: ALLERGIES: . . - FACILITY: ROOM 3: DO NOT USE THIS FORMUNLESS A NUMBER IS SHOWING PHYSICIAN to INDICATEIDFIUG NAME, DOSAGE, - WHEN BRAND NAME REQUIRED-INDICATE IW WRITING MEDICALLY SIGNATURE . DATE 1 TIME .. one-csrbeca Iw -R fax-est.' EM!-if lime. THIS PRESCRIPTION WILL BE FILLIED GENEBICALLY it /02! I unuzss PRESCHIEER - DATE I TIME - IL.--I 0'1 - . '$133-563 VI - -. - - . muecknergar THIS-PRESCRIPTDN WILL BE FILLED GENERICALLY - -- -. PRESCFIIBER wmres NAME-PRINT I UAH: WM k?mj-M Check hers El AM PM I taxed. ., THIS PRESCRIPTION WILL BE FILLED GENERICALLV UNLESS PRESCFIIBFR WHIIES a - IN me Box MAMEPRINT SIGNATURE . DATE . - USEBAIIPOINT Even ONLYE PRESS FIRMLY An Omnicure Company I Please place a cherikmark in tire box marked Eaired to indicate that the order was faxed' to the Pharmacy. For tracking purposes please indicate . the time!-he order was faxed. PHYSICIANS ORDERS FORM NAME: ALLERGIE5: 012>> cm J3 r'Acu_nrr 4 Room': uoc'Ton*sNAME TW :23 sewa-= PHYSICIAN ro onus NAME, DOSAGE, FREQUENCY AND BRAND .w RAND NEG PERSONNEL 5 TIME dz/X /Oat I Checkhemll PFIESCFIIBEFI WRITES a THE BO mus WILL GENERICALLY THES PRESCRIPTION BE FILLED GENEFHCALLY NAWEPH UNLESS PRESCFIIBEFI WFUTES a IN THE BOX . CISFEIJSE as WWTTIN j;m I ._DATl5fi'_. - .. "Mk3 WWNN 15124:) /raw yr Checkherai! . A we riliauf . Do NOT use THIS FORMUNLESS A NUMBER rs SHOWING Please place a checkmark in the box marked Faxed to Indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the prder was faxed. use BALLPOINT PEN oum PRESS FIFIMLY AR Omnicare Company INTERIM PHYSICIANS ORDERS FORM V1 Form No. 15203271! ALLERGIE3: 'Ms mace ,5j"5i5 PHYSICIAN TO INDICATE DRUG NAME, DOSAGE, IFFIEOHUENCY AND ROUTE FORM WHEN BRAND NAME REQUIRED-INDICATE IN Wm I NURSING PERSONNEL SIGNATURE paw. TIME I 1 (R) WIN I/Rag 02 1, (May I fflr?ilfl?ttg/64?: "check her?if faxed. Enter tIn1e. . THIS PRESGFIIFTIUN WILL BE FILLED GENERICALLY . a IN THE BOX ASw'am'm DATEImgum - -- - mr/WM: 7V0 02,0 UNLESS PRESCRIBER WFIITES _d a IN THE BOX THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY RS fla.SdMM/e 2; 12 020:'? h?re if 7 faxeld. Enter lime; . I I <> FACILITY: . 2 ROOM 33.' 77 3 P2243 ALLERGIES: DOCTORS fimw wmcars DRUG NAME, DOSAG E, FR-EIUDUENCY AND Hoursx fionm WHEN ammo NAME IN WRITING MEDSCALLY PERSONNEL . DATET TIM-E I Mr /84f/4,6,4 WW I Check . . - . . - . . . - - - - - - - - - -- - - '7 talked: Enteriine. runs" um. 92 FILLED esweaucam UNLESS WFHTES "rd a IN THE BOX um-Luszaswmneu we - Chelckhereii -H PMEJ faxed. |?nle'r fifria. - . THIS PRESCFKIFTION WILL BE FILLED GENEFIICALLY I - UNLESS PHESCRIBER WHITES IN THE BOX . NAME.-PRFW . -. - aw - Checkl1ereif PM faxed. Enter tirne_ . THIS WILL BE FILLED GENEFHCALLY . UNLESS PHESCRIUER WRWES (J IN THE BOX NAME-PRINT - - 3 DO NOT USE FORM. UNLESS A NUMBER IS SHOWING Ii Numeric identifier MINIMUM DATA SET (Mos) -- VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING an SIC A SSESSMENT FORM oemiricnrtort INFORMATION . as - . NAME - (9 ,1 b_.rr.Eriddietnitiai 2 E9 I.-Male 2. Female 3; BIRTHDATE (Con-rpipr 1'-par gt; -4. 1. tnd'rani'Alarsl-can Native Hisparuc Emurcrw istonder 5.White.oot.ol - J. Blactr, not or Hispanic origin Hispanic' origin 5. SOCIAL AND MEDICARE NUMBERS a. Social Security itiurntrer I - -rt "l Medieap; nun_tber_[oI' oornperalaie reiiroadihsurance number) 9. Signature: at Persons who Completed 3 the Assess rent or Tracking Form - funds and continued participation in the government-lunded health care programs on the accuracy and oi title and that] may I certify that the accompanying iniormetion accurately reflects resident assess- ment or tracking -u for this res'rder-it and that coflecred or conrdirtoted ool?ection of this int; rrnatiorl on the. dates specified. To the best of my tmrm-ledge. this was ooltectert in aocorderice with applicable Medicare and Mecficaid requirements. i understand met this inlormatiorr Is used as a basis lor that residents receive appropriate and quality care. and as a basis tor payment from federal funds; 3 iurther rmderstard that payment at such letters! he personally subject to or may EIJIJJBCI my organhation to rzrirninal. civil. oncifor adi'ttiristratiVe penalties let subrttillinq iaise lriiormation. I also certily that I am authorized to this iniormotlion this taciity on its behali. Signaturearid Title arm .5 I Sections tr :0 re>> 6 tr 131510 4. Medicare 5 tliiedlcaro a 31:5: I r'care I dayassessrnerrtl Other .. may item: ror camgauruueo resaoent-uacsilrrg .. I when burr bianii, must enter ,1 when letter in boar. check it nurnbor or letter CutJr-r it itrturmofiorfl or rroknown J-.P conrfition applies e. mciurv - I Pangaea. A 6? rxzdaane?ggns pi_ Assess. mtigsi-on rrssessrruent (required byday rt.-rem Li assessmen M- 3. S'rgni'i'tcani changain stotus.a3sesarriei1t' - Significant of prior full assessment . L- - 5. Otretterty assessment "am" 13. ii cl prior quarterty assessrnert . 7 . GENERAL WSTRUCTTONS - llseaarl er . - - complete this r'nror-maifarr !or submission with art run and qr.rarterly iilferiicartl assessment-5. (Admission, Arr.-war, Change. 'State or- covered. at "Medicare required assessments, or Ouorieriy Reviews, ere}. 3 QUALITY INDICATORS I QUALITY MEASURES LEGEND: Chronic Care 8: Post-Acute (3) 1.1 Incidence at new fractures Qt 1.2 Prevalence of tail: <> 9.2 Residents who of their limo in bed_o'r in a diet: Gm 9.3 Residents whose obnily to move in and around their more got worse 9.4 Incidence of deciine in ROM Residents whose need for help with daily activities has Increased Prevalence of use, in the absence oi or (air 4.1 incidence oi 'c'0-grtilive impairlmiaht 133395 CUUCWOUS 5.1 Low-risk tost control oi lireir bowels or bladder 0 10-2 Prevalence of use 433:>> '5 2 Residents who truvefhad a catheter inserted and leil lr'rlhe'ir' bladder 10.3 Prevalence of hypnotic use more than two trrnes in _I.'esi week 5.3 Prevalence oi occasional or lrequarrt bladder or bowel incontinence -65* 11 1 Resitierits who were ohtrsicaflv restrained wfo a toiietlng plan -tar 112 Prevalence of little or no activity 5.4 oi 'local irrtpaction 12.1 High-risk residents with pressure ulcers 6.1 Residents with a urinary tract infection (C) 122 Low-risk residents with pressure ulcers G9 7.1 Residents who lose too much weight 4m) 13 't Shor1--sIay residents with delirium Post-Acute < . - -- - - an-mutt. GENERAL INSTRUGNONS tmnalo 5_ complete this Jnformalfon Ior submission <> Last nu ah on-m |rItast1a_a day: do}; rim?>> . La. ?13962 3. -U b. 9/ 5:939'? I 5. STABIEJTY Conditionaidisaases make tesid'entReside", mahmd an acute episade or 3 "awup 3. IHSTUFW OF zhatgaas zexztued cs cam an 0! a I: 355013.513 . .- . {Erma umber Fdayzj . - -- ii. smrus cm.-1a um ra . swafiawfiw pmmem .57.. . b_ Pnasnrasiuiiw?siustfiv Momg, pain 15 In gxusszur to 9' NQN5 CL . _Si-in Haas: C2313 {what {fun an-gory) HEIGHT oands; Base wouzxaa weight rnost rgcfinr measure an last 30 -siys: measure WEFGHT WE OODSISIEM I slandgm tacifily practice "fig" in am-"Haw" Nah" I meg': mm 513305 on and In fifini "5 net 159- 1:1: ac-mistsonsarma - wmm-rr' ormma - - CHANGE gt Nmgre 1251130 . 0 _i -1 .01' 190 4815 Acmca?mm - 4' huh: many Goods 3 amnion at mossl 9' than law 9' as .. or! ugga - - mwsosawvs pom {Check . . - PROBLEMS 2 I cammaams-o' mm' -- - . noun; . ., yr nun ctgne ms. rmmoaing rug. pm . APPROADEP gzrabhama Ma:hz1k:alIyflere_ddI21 12 . On; plar-pad wagal I 12 g, I. char-nu program" n. 9:37' I 2 521'.' .3 - . fit we flguflifldfidfl Nxfiuafim of an v.-320131 mlk?at I HOME - . SESTIOH N. Ham": rwrnenrss TIME AWAKE 10B cinly OTH Ina - and 0 app date time ads 5 7 days . . Morning . ion - . . Aflembcn ?hm> -R253 {him 13.: 3:3 chime was i 3.u:me ma 3. ah' ?c2rf3t?:gsr ggi-wt: are preferred}- . Iadmy - GENERAL - a. - - - - cranszans 5V outdoors ENCES Exercisoispurts - "falcfring {Ac led to C. re:ig:nI's =MusI7c _-Gardenmg or plants _i . :53: -Heauingiwriting Talking orcmversing k. Spmiualfrefiguous Helping others I-. NONE OF ABOVE in Form K3 WW4 Dc: lofoiflos. IA 50306 I300) 24? 2343 nuns: .5, Emile: in additipn or nigger. wdmg. DI and OM syslerns I 6 of 11 M03 213 September 20(1) .4- 1; Enter cwrem unit number. Follow instructions in NUMBER 2. PRESSURE Record the appropriate response; Stage 3 or ULCERS sites present upon admission or rrsadmiasuz-n admission or readmission. on admission or readmission. on admission or readmission. 4. No Stage 3 or 4 sites currertliyreported.-I SUBSTANCE Substance Abuse the resident wl - ABUSE in abuse behaviors more than one :11 Record the appropriate response. No Yes 2. Resident does not have HIV -3 pressure ulcer 1. mt currently reported sites were present on 2. some of the currently reported sites were present 3. None of the currentiy reported sites were present continue to influence care currentty-given" to the resident?- Numeric Identifier "manual. In HIV engaged . oath ago which . during #:9135330 days. {Do "not list tnaotrve . HN Dementia HIV Wasting . 'Spinal cord Injury Hemiplegia . Hemipareses . Huntington's Disease Dementia Registry Reporting . 2. Physician ficensan or 4I2 Noneoftne above -Record gay those disease diagnoses lhat barre}: relatioriship DIAGNCISES to current status. ant} behavior status; medical treatments. nursing m'onitorin ,-or risk 01 death - disorder iottowing brain damage . disorder loltowing organic brain damage .1. County (FIPSJ code 01- prior --no cf>> [[41 1 Form 17233RHH I993, 200-! Briggs Corporation. Des IA 50306 tirntted to artrtilion of trigger, carting, GI and 0 (H00) 24'-'-2343 IWNTED in us A recognition systems B0111 MOS 2.0 sepmmnarzcm SPECIL a. RECREATION number or ys and total mirttrias Numeric Identifier "The totiowing criteria am used In classilyrresidenu in Ila: FttJO.li! 'czassrrir::rttan groups. In Sections' of the M05, record the ttuntber- minutes at PT. OT. ST received by the resident during the observation period that end: on the Assessment Da_letA3a). or recreation therapy _admr'nr'sio-red {for at least 15 minutes a MENTS day) in the last 7 days (Enter 0 ii none) 1 Em" DAYS MIN - it 0 da atimini-st or IA) 15 or more m_ . . total it o_t minutes pron"-idodin 0 I 0 I last 7 days . . Skip unless tfrists a Medicare 5 day or ltltedloaref readm ission/return ass ess b. ORDERED rritiowirty therapies to tiogindn stay-._ physical rheraptz, oacltpafionat Na I. Yes If not ordered, skip to item 2 Through day 15, provide an the number at . -- Wonatre been delivered. d. 'Through day 15.-provide an .. number of theiapyf minutes" be". SELF SUFFICIENT WALKING ftromprera from 2 rr ADI. self-performance scare ror WHEN TRANSFER least' one MOST . of the are present:_ Resident received physicat therapy involving gait training" - Physicai therapy was ordered for the resident involving gait training . Resident received nursing tahabifitaiion tor walking (53.3.1) . Physical therapy imrotving watt-ting has been discontinued witltin past lat] days to item 3 If resident did not walk In last 7 days FOB FOLLOWING Frt/E (FEMS. ON JHE EPISODE WHEN THE RESIDENT WALKED THE FARTHEST WITHOUT SITHNG DOWN. INCLUOE WALKING DURING RE- HABIL I a. distance walked without sitting down during this as-pimet - 0. 150+ tee: 1. 51-149 feel 2. 26-50 feet b. Time walked wrilhout sitting down during this episode. 0. ,1-2 minutes 3. I145 minutes f. 3-4 minutes 4. 16-3!} minutes 5-10 minmes 5. 31+_minute3 . Selt-Performance in walking during this episode- 0.. INDEPENDENT -No help or oversight 1. encouragement or cuetng pmvided . 2. highly involved in walking; received physical help in guided maneuvering of limbs orother beattngastalslance - 3. EXTENSIVE A5513 TANCE-Resident received weight bearing assistance while walking 3. 30-25 feet -1. Less than 10 feel d. watitlng support provided associated with this episode {code regalt.1l- of resident': sell-pertormance 0. No setup or physical help trorn staff t. Setup help only 2. One 3. persons physical assist 9. Parallel bars used by reside-ntin association with this episode. 0. No 1. Yes "sums MUST as ms .6. on 14 on rtssassttenn tm;mear'3og'm'tim CASE MIX 6 ROUP r_ Medicare I state I I web Link For More tntorrnation: Nursing Home Quality Initiative 'Wm tn 199:1 200-t Briggs Cornnrattnc, Fina. Maine-5, IA 50305 (sea) 247-2343 rrarr.-ran Nutut . Copyright to addition Oftrigger, 01- and OM rfigogniihjn systems Eiofii How time the therapist spends, e-raluatirtg the 1: on it is an evatuation UI an evaluation pr'ertarmed atterthu course at therapy has begun. The titrto it takes to perform unlrtitial and ttnetoptnq that treatment goals and plan at cart: for the resident CANNOT BE COUNTED A5 MINUTES OF raceiyr.-rt by the (Pia. D. at. Howeirer. movaluntions that are per- formed once 'a therapy regimen under wy may be counted as ot therapy received. Documentation time may not but in P13. It. 1'20 minute': a liar:-ek minimum. at least 2 t:Iist:ipilnp:t_ 1 5 days a week, 2:333 days' tr weak film - 506 minutes at weelr mini:-num. at least I discipline 5 days a week at 325 minutes :1 ttrtaelt toast 1 disciptina 5-days a week or it is a Madith?re 5 day at Medicare Fleadmissianrnatum Assusmont, than the tolltw-it-tg apply: I Ordered Tharstpit-:3, is fitifl . .- Heo'o_ivetr55 or r-nose Pm 889 - -. In itrst 15 clays" tram nd_t11is.tton- 520 o: more expected; T16 mp er.-wines expected on nritwru days, T1: Ijfll - -I50 mlttutas a meet: 5 days 3 or it 'this as rt - M95133: 5 day on: Medicare .hsse:sm-ant. than the following apply: - therapies rs clurclrort AND - in the 15 day-.--from admission: 240 ct! more mirtut_eitt. are expects ti. Tid rrhtilaifltation expected on 8 fit' more dayi. Tn: 3 mitt It minimum, Neg. mttob I week?! rutswratlva or It this is at 5 day or A tlh-'dr'cwn Ranomtaxiatv Return the following mpfy. - 'Nb ll days Item or more rnbiulatl ore AND rtmataltltauon sat-trlr.-es expected an more < LEVEL or cane; BEHAVIUR (NOT AUTOMATIC LEVELDF CARE) EEIU . AUTOMATIC MEDICARE SKILLED LEVEL OF MDS 2'.o Seplembt-1 znoo - Resident Numeric Identifier - MINIMUM DATA SET (MDS) 2.0 FOFI NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING yam I Enter for all ass?ssmenla and tracking forms. if available. 1 pgownsa .- - {his aam?rnant or {fate discharge .ua5I?:a1gform as ix.-Mecn July 1 and 30, siup Eu W3. a 2, INFLUEINIZA Did ihf-'J receive the II'1flU6l1Zfl -I'vaI:cir1o in this ws.GclNE- Iacifiy for tins year's Influenza season (October 1 through March 31Item mu; MP . in vaccine not receive szate naasen: -1. Not In lacifit durin this year's flu season if 9 . 'are . 2. Reoeiguq arutsida aI Ihia -Imp I 3. Not eilg?bie .. 4. Olfaredand deciined . 5. Not raflerad Inab?azy main vaccine pIBfl_ 3. I n. slams up to dam? . . . COCGQL (cf In Item W323) 5 I. Yes (II skip item w:soI_ b. P1-"Vac! received, szata reason: 1. Not eligible 2. declhed 3. Not ofienad I i 200:: '99- 200*! Bfigss Gorsaorauqn. Des 50305 mom Mos 2,3 May, 2005 Imuecu In adrtizion ol trigger. cod'-ng. 0| and GM rccognillan sysiems . . 11 of 11 'Fails I -E59 .. . Pm'oot4I I 3R3SkICoinpIic.alions'; Cf! olPr. cud . U- '3 <5 Docifiiun: Sig: . - I -- I2. Nisuitionaistalus - ]Pmct.od "RiskfCompii'caliohs; {Nut Proctcd Referrals: - Date: II'aIi'onalc for CCP.Dc-zisionz Sig'. fccding Tubcs Prob!cn1lCausc:- I .]Nol . Rationale for CCP-Doqision: i 'sf: . . 1 Date: 1lJ1_/fiat . _RaIi'o'na?c' CCP Bccision: I ifiefenals-:. - . . . - Dalc: . - 3R3tion_alr.: for COP Decision: I -Sig: I 2 1 [Cafe-. - I - . .I }HolPr Date; I Rationa'1c'f0rCCP Decision; Pr cf; Ulcers aux; Izud Ri$k!Camp1fcaiiqns: . I :iW, sag; - 17- PSJIC W-cf J9-o _R3sk}CompIicat'ious: I 153Date-:3 MW m-uimaxc for cc? 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T. nmfi amfi <> mt. mm". aauk .Ca1d-a.r- In L. ax!' I AL /34icPu.'1n- lad' . Mrba?y I am!' i' .-ire; I carat Zia; A - S: (L. > Primary Care Provider Sigmturj' (II, >>;2rr2, Rcsiuenfs Last Name . Firs: 30/9? 5' 3 33 03' 2qea--o2on SYMBOLS Mlaging - - Pontic .- Crowned HT - Root hr' Bsank I - Tooth Present 0 - other [Specify] Medical History: fl Allergies: - Resident Has: Dcntums or removable bridge Type FU PU PL Functional 3. Broken Ioomor carious teeth 4. gingiva. om] abscesses. sw-olle_n fir gmfis or tashcs N. NM Pcriodoruat Condition Good Fair Poor Hyperplasia .. 5. Oral Hygiene Good Fair Poor [Mouth Odor LD. 2. Sou-nclafi natural teeth lost. Does not have or did not use or partial plates 1' . Patient functional with pncsenl oral condition NIA COMMENT SIGNATURE Ajax ORDERS E: NOTES 'a;99 mov--21--_2005 Tue 16:18:05 mum nmc: 634fB'39 NOSTIC LABORATORY INC. 1412 BAYRIOOE AIIENUE NEW YORK 11210 - TEL. (713) 037-was (5222) 2500000 - LAROOEA. GEORGE IECHNOLOGY HHPHEIDHIIJIIE: :r1a-4300003 PATIENT: REVAN SHARON. MD. SEX: REQUISI-TION 611212258 IPATIENI 1013726 707 THROGSNEC-K COLLECTED: 1112112006 07:25 AM 10:0 . THROGSNECK, NY 10465 A RECEIVED. 111202000 01:13 PM 3330 . . -- I I . PM STATUS: COMPLETE REPORT - - HEMATOLOGY I I comP.I._ErE- aL0O_0'couuT- - 0 TEST A RESULT OUT OF RANGE UNITS REF RANGE WBC . 5.5 Kim. 4.0 - 10.3 REEDBLDOD COUNT - 3.68 MAIL 4.70 -0.10 HEMOGLOE3-IN 12.4 gidl 13.0 -10.0 HE-MATOCRIT 37 00 42 -52 102.9' fl 30.0 -94.0 MCH 33.0 pg 26.0 - 32.0 MCHC 32.9 33.0-37.0 RDW as 11.5-14.5 PL-ATELET 115. 130-450 NEUTROPHILS MONOCYIES 5- as 0 -- 15 EGSINOPHILS 3 0 --0 0.2 0.0 -3.0 ABSOLUTE NEUTROPHIL8 3.4 fut 1.3 - 7.0 ABSOLUTE 1.7 ml 1.0 -- 4.8 . ABSOLUTE MONOCYTES 0.3 In! 0.0 - 0.0 ABSOLUTE EOSINOPHILS 0.17 0.00 - 2.00 A9-SOLUTE BASOPHILS 0.010 ml 0.0% - 2.000 CHEMISTRY COMPREHENSIVE METABOLIC PANEL . - - TEST RESULT OUT OF RANGE UNITS REF RANGE GLUCOSE 03 70 - 115 - BLOOD UREA NITROGEN 2.4 0 - 24 CREATININE 1.20 0.70 -1.50 - SODIUM I42 mmol/L 135 - 143 4.6- 3.5 - 5.5 110 . mmot/L 05 ~112 CARBON DIOXIDE 21 mm0llL 23-33 TOTAL PROTEIN 5.0 9101 6.0 -0.0 Generated on 1101,2055 at 03.45 PM Ciinical Laboratory Information Systems Ver. 2.42.00 by B58m_ AutOLI'ms 450456" I 1121:2006 Hov--21_-2905 Tue 16:13:52 635/339 DIAGNOSTIC. LABORATORY INC. 1412 amrmocse BROOKLYN, NEW 11219;- TEL. 4713) 83.7-LAB2 (5222) "romoaaows room- REVAN SHARON.M.D. - or;-amcsej sex: Mg maoesmecpc EXTENDED cm; REQUISITION 611212253 1%0m26% . I 707 THROGS-NECK 11121/20050225 AM- ru: . THROGSNECK, NY 10465 . - 1112112005 01:13 PM 3330 I . aepoarso; A 11212005 03:46 STATUS: - CHEMISTRY COMPREHENSIVE PANEL - . - - TEST RESULT our or RANGE A uurrs REF RANGE ALBUNHN 3.4 gldi 3.2 - 4.7 CALCIUM 9.30 8.20 - 1-0.10 TOTAL BILIRUBIN 044 9.1.0 1.23 ALKALINE PHOSPHATASE '59 U11. 4'1 -142 27 I WL 12 _'45 gt?ulws TRANSAMINASE. I In 16 I 7 '40 GLOBULIN, CALCULATED 2.4 gm: 1.3 -4.0 RATIO 20 ENDOCRINOLOGY THERAPEUTIC DRUGS TEST . nasurr our cs Rance new RANGE 2.20 mm 9.40 - 4.70 eucam . THE RESULTS ARE ACCEPTABLE, NO FOLLOWUP. MD. 1 1 THE RESULTS WILL BE FURTHER MONITOREED. Clinic?l Laboratory Imormafidn Sy?t?aiis var. Generated on By_ we? 'fig . UIK . 450455 AutoL_ims RM Hov--22--2996 Hed 15:55:09 51.9/2.1? MODERN INC. 1412 BAYRIDGE AVENUE - a?oomrm. NEW YORK 11219 - (5222) . TECHNOLOGY 3330 . - I CHEMISTRY. LIPID PROFILE TEST [5 5 RESULT OUT OF RANGE UNITS REFFEANGE CHOLESTEROL . 135 mg/dl 1'17 200 TRIGLYCEFHDES - 68 mg/dl 23 200 HIGH Dewsirv - -- CHOLESTEROL . 39 rngidl 29 -33 DIR. LOWDETNSITY - UPOPROT . . 5 80 70 VERY LOW DENSITY .- UPOPROT - 14 LDL 30-130 timecroajcooann EUGEN am. 5 . THE RESULTS ARE NO FOLLOWUP. MD. - THE RESULTS WILL BE FURTHER 5 Generated on ",22,2m5 3' 03:45 PM By Systems Var. 2,942.00 by 86197_ - 2 Au_toLIrhs ?9 - 451652 file odcm-0 I \/kulnl ims .html 1 11232006 PATIENT: LAROCCEA, GEORGE REVAN DOBIAGE SEX: THROGSNECK EXTENDED CARE 611222220 - - 5 7'07 THROGSNECK -PATIENT 1013726 -- 3 THROGSNECK, NY 10465 RECEIVED: AM .- - - REPORTED: 111232006 . "Feeding THROGS NECK EXTENDED CARE LITV PTIOTSCREENING mum NAM E: I I ROOMF4: "fig Primary Diagnosis: 3 - itiai screen I ].QuartorIy fl Isignificani change 'i ]Rc'-ndmission 1. in COGNITIVE STATUS: Follows instructions: YES -- I NO 2. FUNCTIONAL LIMITATION-S IN RANGE OF 7 Indicate :ff(0M doexjnor impede ADI. pezf. provi'.in'ori_ or put: res. at riskforfalls, Range of Motion Voluntary Movement Comments 7 Neck :3 Arm 3 .. 1 . Hand 0 *7 M, Lei; . Foo: owe: Code'. no linmaiions 0- no loss I- Limitations on one s-id: Partial loss" 2- Total loss 2- Limilations on boll: sides OM Trunk . ~50 I -180 . add 0 abd, I603 - -90 I -i was! c-xi 7 -- Run. 3 and grasp 3. PHYSICAL Bed ("out 5. Transfer I Ambuiation Locomotion mom zoour EKTHEMIT A J. 3- . {'20 A to Personal hygiene: 3 A. no In.-ip 2- Lid assist 3- :xt_a_ssist 4- totai assist 8 Support Code: ADI, suppon 0- no set up up 2- one person assist 3-mo par nassist 4. BALANCE: Balance while . Balance' while si-uing Cod::0- mainiaincd position as rcquired in ms: I-. unszcadyi but am: to balance without physical suppon 2- panial physicaisuppon during tester stands (sits) but does not followdircctions for res: 3- notable to lost without physical help - - 5. MODES OF LOCOMOTION: Straight cane Quad cane []cruu:ht:s If I Toilcting 8- did not occuf 'bu E-did not occur 1 Rolling walker []None: To be osscsoedl Wheelchair: No Type: ]S1andard' Rec,linirI'g 1 I Gerircciiner Wheeiczliair mobility: -HTo1a| Partial Iridopcndenl . . . - WIC positioning deviccs%/fi 6.. wisx 0~No I-Ear" 7. DEVICE: []Ycs Type; Wearing schedule: . or in inn Recommendations to gt g} 13.. 5 . is a candidate for I Residcni a-Nag. Rehab. program 1 Resident is on an active therapy for UT Rcs. does require rehab. interventio at this ti no Signaiure: Revived 03/05 013' Initial /Issessrnent .. . Reason for-Referral I . =3 Edema veg . . - Bed Mobillityfroilingl -Supine to Sit I I"/fClo b?dlmat I - up 3 35 Qtand jag" 1 Dthersf - - I 1) THROGS NECK EXTENDED CARE FACILITY Histonyfmedical Com licalionsPrior Level of Funption: 7 61., 3 3 .2: Sign; Prior Therapy-History; i 53 1 bearing status: Shack and an the area: that impaclfuncriorr be a I . . EUR essed in rrearmenff Jognitionz +0 Uconfuscd simple commands. 'ain: Scat Location: . Tone: Sensation: Skin Condition TREMKTY Hip flcx.( (man Hip ext. Hip abd.{30 Hip -20 Hip ER (3914 Hip ext. 0' Ankle d. flfix. 40' Ankle p, flex. 0330' I PROM Lari" . C, .N0 _"Commenls__ . - -- l=S_upcrvision _3='Extensive SUP CGA MIN MOD . MAX "Reason for 'ts/05 Part A Part Other . I I 3 Therapy Plan of Treatment (imlrial or I I 1: Last Name Patient First Namt: Malclj I -. 0 9/33 Onsct Date I I SOC Dat? I 0 Med Rafi bate Adm Dale . I It A In 99'/0 xx /992/as i Primary Diagnosis DX) Treatment DX code DOB I I Provilrixvarjfi I I . . 33 7/ zaxf?rnigagp CA FA cum' Phyfibn! Tkarbpy Tre?trizcni . Part Room .'.icntLastNamc: fiatienl First Name: HICN: ?30 Onset Dale: . -- I SOC flale: I M-and Rev Date: Adm. Date; Primary Diagnusis BX): TrealmentDX1'lCD9 code: 79/3 9) DOB: Provider #2 }+~Jrd .. T. 717.1314 . 1 . . restorative X/wk for/2"' mm. Data16:. {6 2' aw Daily Leg in mihutes ofhitect rcsidenfcare {day S-Sick I C<5 AT A /2//we . . I [7 id". - /fiat -L . . I . flfl/xi/' f.fl7iTJ I . T. .2, . -Revised 9.0004 . 7' Other" .v . - in -., Room ti. 33:7? ,4 Rcsidentggatment consists of: H0 Therapeutic Exercise 392910 Hot/Cold Packs 97! I2 Balance Train'ing- /Neuro Re-ed! Coordination . Other (ncpc Code) (specify) -: .'s-ick Cr?l 16 Gait! Stair Training ?3 97504 Ortholic Training Paiienl'L'ast_ Name: (3/fl; Patient First_Nnn1c; 3,0 925:; Onset Date: I I SOC Date} I Med'Rc Adm. Date; - Primary Diagnosis {Pertinent Mcdicai DX): code: - fif7'_ 99 DOB: Provider Resident restorative PT X/wk min. Unto'ModaIitics Minutes: -- 'Da-i'I'y Log in minuics ofdircci-rcsidcnl care" trt?zzo WI. shifl-! Transfer Training [1 927520 Prostlletic?haining I i: Range ofrvlotionn (M -_Muscle Strength' 6/gf '1/5 H. 5, /4 I Baiance . 571,, 'fly/*/3 fawd (3 - . ??t?afflz?uw 2? $391' 2695,; Revised 6/05 NECK CARE Parl _Other _Ruom# 7 Occupational of'Treatment Ev-alunnluion Rn-evaluation) Rcsidcnl LasI_ Name 1 I 7 In Rcfiitlcril I-"irsll Name HICN . {Cq 'If: Onset Dal: I SOC Dale I Med llcv. Data: - 'Ada: lime I I N5 I Primary Diagnosis Mcdical Trcauhcni IICD9 code . . DOB I mwnfia (tn -am lru't1'a! . . Reason for Referral: ck, .- 9 LL 90.. History/Medical [-11 . _cLno -3;-fie ftp' cu 4" '5 'rm run Kg!' LA :9 . Luz: L, . - . Check and comment on Ike' areas that impact- fmc-Han and MN be treatment: ?3Cognit_ion_: A DCon-fused 131'-'o'lInws simple conlmands. Comments . 1. .E'_IPairz: 3 4 5 6? 3 910 Location': . mg. . CJTOIICI - H1. - Shbuulder Subluxationr UOrtl_mtic/Prosthetic Device I STRENGTH MM -50 4 -do-.3 130-90') Elli 0" Wrislexl ea Wrist flux, (of-30') Handgrasp I Comments-_ . . .. Hand V'olun1'c1-Volumcter Wzilcr EvaIuatiotI_. . . -- . Lcfi . H20 displacement WA: Right ml 3 Edema Yefs . 4 ='Tota! Mobility Slalus 1 ml)" sur MOD MAX 113350.. 0 -.3 2 3 3 Bud Mubility(ro1liug} "EaScoolup/'Down {Q/xv E1 SiBridging I . . - Sin to Sl;u1dcviscd (#05 Parux Olhcr PaticntLastNatn<:: I -. 3 I . - Mcd_R?v' ate; Adm Date: I Prirnary Diagnosis (PcrtinentModicaIIDX}: Code; Pmvidcr#i'_ I I . 1 3 trizzg . OT .537 tops:/L mi_r_a__fwk.. fiat: Si. 21/4 2;-fr "Mada.-InDaily Log Eh minutes ofdirect . I I R: Re I-"us-Cd fbluilfling ecific Skilled . 3.322; it)" luau"-ham: A iyrimunh imam vb 014.7', 'imafl-_WEUR--~ ?2.Achievcd<< . pa5?.2; Progress yes - no" flew sl1ort_term - V041 4-. - n39"b0 i I I Yw?fi I I rwufia; . I "Walk?! '31" I am, I . . rH.ac_ . 1 _t - . 249 /933@-am ;efij%~b C7 .535 Em flue: <1 - 19.0.9-u-J -5 I-IL-vised 93004 ca>>4-M- . [Du rm . LL33}-eug NECK i occum T10N.>>fl.' . _e Part A Part Olher Room ratient Last Name: Patient Finrsilflamez I :_'OIIsct Date: SOC Dale: I Adm. Date: . .1, . . . Prirnary (Pcrlinent Medical nx) Treatment DX IICD9 code: . - DOB: -Provider #1 'iAl'L15 rW'3'Us ("Tin fi'iu5LEURz iaasvvr Resident receives resloralive _'Xfwk'for3I3' daleDireclminutce: 7 'Modaiit}/minutes: ;3 - Daily Login ini'n_iites S-Sick R-Refused 0?Ou'tr1f'building consists of: . - 9 m67ll0Ther:Ipculic Exci-ciee ADLZB/{aiiagement Paraffin Cognilivc'Fraining' 7530 Bed Training Packs 97112 Baiancc Training !Neur'o Coordination: 97542 WIC Training 0 Code) (specify) Orientation: Alert and oriented 3 Fo|Iows commands (circle) I %%muIti- stew IMF FUNCTIONAL Range of Motion . Muscle 3 Strength fie>> Tone_if- "1 Indicated I . I 4 g?im, I mrno I L7. I Lu," Balance I i _i i 7 vii B'ed'Mobility ififis I Revised U05 REGEIS CARE CENTER DESCHARGE SUMMARY RESIDENTS NAME: ROOM 5/ CHART 57350' DATE OF ADMITTING DIAGNOSIS I aw fl I /3 SU BSEQUENT DIAGNOSIS VEFIFQAL DIAGNOSIS BRIEF HISTORY AND ESSENTIAL FINDINGS DURING cou RSE OF IN NURSING HOMEAg" FINAL or= DISCHARGE: (DISCHARGE DATE) 356 If SIGNED I M. PHYSICIAN) DATE 2 5' I ERJML 5-92 Fiueboro Printing (719)431-9500 . REGEIS CARE DISCHARGE SUMMARY G6 EUR52 (Ft? cH2e.m:.- 5793?) 2 DATE or-' ADMISSIONIRE-ADMISSION 5 /1 5 I. ADMITTING DIAGNOSIS -- 1' . I SUBSEOUENT DIAGNOSIS JNAL DUXGNOSIS BRIEF HISTORY AND ESSENTIAL FINDINGS DURING CDUFISE OF STAY IN NURSING HOME: gr. - (L. Cf /fig: OJ :7 I Zn>>-ta' .. . FINAL DISPOSITION OF DISCHAFIGE: (DISCHARGE DATE) ii i .- SIGNED (ATTENDING PHYSICIAN) DATE 5'92 . . . Fwebom 431-9505 Form No. HNH-3-F 0 REGEIS CARE CENTEP SUMMARY FJIWIE: 66 L01 '9 (F4 ROOM 5 57333 DATE OF ADMISSIONIRE-ADMISSION 5 '0 I . ADMITTING DIAGNOSIS I, Cfifd .4 suaseausm DIAGNOSIS - 517/0 517 DIAGNOSIS BFIIEF HISTORY AND ESSENTIAL FINDINGS DURING counse OF IN NURSING HOMEH_fi J1 I If FINAL DISPOSFHONOFDISCHARGE: (DISCHARGE DATE) Q-I I 7 SIGNED M. (ATTENDING DATE EFUML Fw-eI:mru Prfniing (718) 431-9530 Form No. FINH-3-1 Retzeis liare Center 0 Med Rec 5039 Re'! I "t Date' 3200 Bavehester Avenue Room: 528B Unit: NW ltomitted From: ALBERT EINSTEIN HOSP . Bronx.NY10475 DNR Order Adinission Date: Gan:/2007 7183203700 - Resident Name GEORGE DOB: Age: 80 Medicare 091220925.-A Primary Residence_ Sex: MALE Part A: 0110111 982 Marital Status: Married Part B: 2713 YATES AVENUE PHRace: White, not ofilispanac origin Part D. NY Relitrion' PROTESTANT lnS- Flam - - . . Residence Tel No. Occupatiow pong}; Spouse: Maiden: Education. P?ledicard QV63543R Mail" Citizen' lies Vet' Spouse' 1 MNY 5:3: 25 as Prior Hosp Stay: ALBERT EINSTEIN HOSP Attending ne #516-859-.l 120 Address: Physician 234 CENTER STREET Date: TO: UEIISIZUG7 BARE my ]]59fi Social Worker: MCNAB, KARALYN Mortuary Dentist: phnne #7 . . pharmacy: Podiatris' DESIGNATED REPRESENTATIVE CONTACT #1 Email Add= Horne: Name: LAROCCA ANNA Relation: WIFE POA HCP Address: 2713 YATES AVENUE PH City: BRO Cell: CONTACT #2 Email Add: Horne: Name: LAROCCA GEORGE Relation: SON POA HCP Work: (713)944-5330 Address: 2713 YATES AVENUE PH. City: BRONX, NY 10469 Cell: CONTACT #3 Email Add: Home; Nome: Relation: POA HCP Wm-k; Address: City: A Cell: BILLING INFORMATION Relation; Church: Name: Home; Clergy: Phone Address: Work: Funeral Home: Phone City: Can; Address: ADMITTING DIAGNOSIS Description: PNEUMONIA ORGANISM NOS Code: 486 CHRONIC PROBLEMS Description: Description: AORTOCORONARY BY. Code: V4581 Description: DEMITNITIA W10 BEHAV .Code:29410 Description: ABN INVOLUN MOVEM Code: 7810 Description: COR ATH UNSP VSL Description: ABNORMALITY OF CAI Code: 7812 Description: ATRIAL FIBRILLATION Codenl-2731 A Description: HYPERTENSION NOS Code: 4019 Description: Code: DISCHARGE DIAGNOSES Discharge to: Autopsy Date: Time: Description: Code: Date of Death: Time: Description: Code: Description: Code: Location of Cards: Tissue Bank: Ph: Body Released on: Time: Body Donate: Ph: By Nurse: RELEVANT ALLERGIES: Diabetic: Na Mortuary. 1) Address: Phone' 2) . 3) Special Instructions: PT WAS ADMITTED FROM THE COMMUNITY Physician Signature Date . Medflec #2 5030 Reizeis Care Center 3200 Bavchester Avenue Room: 5288 Unit: NW Lolnl -rem: I - nit'al Admission Date' 0515/2007 Bronx" NY 10475 DNR Order' I 7183203700 LAROCCA. GEORGE DOB: Age: 80 Medicare D9122O925A ,d Sex: MALE Part A: 35' . Marital Status: Married Part B: {ll/0111982 2713 YATES AVENUE Race: White, not offlispanie origin PHIT 132 BRONX. NY1fl469 . . Pl . Religion. PROTESTANT 51"- Residence Tel No: Eluficy Spouse: Maiden: ecupzt n. Medicaid ii: I-'other: Mother. - County Birfl]PlacE_ Citizen: Yes Vet: Spouse: ins MEY us .-.: {2'_'e2fi355lB Prior Hosp Stay: ALBERT EINSTEIN HOSP Attending ne #516-859-1120 Address: Physician 254 STREET Date: 02/03/2008 To: 02/143003 PARK Social Worker: MCNAB. KARALYN Momlaw Dentist Alternate Rhone Physician pharmacy: DESIGNATED REPRESENTATIVE CONTACT #1 Email Acid: Home: (718)832-0605 Name: LAROCCA ANNA Relation: WIFE POA HCP WOW Address: 2713 YATES AVENUE PH ciori BRONX. NY 10469 CONTACT #2 Email Add: Home: Name: LAROCCA GEORGE Relation: SON POA HCP Work: (7131944-533u Address: 2713 YATES PH. City: BRONX, NY 10469 Cell: (347l134_344(} CONTACT #3 Email Add: Horne: Name: Relation: POA HCP Work: Address: City: Cell: BILLING INFORMATION Relation: Church: Name: Home: Clergy: Phone Address; work; Funeral Home: Phone City: Cell: Address: ADMITTING DIAGNOSIS Description: DISTAL LOWER EXT Code: 45342 CHRONIC DIAGNOSESI PROBLEMS Description: DVTIEMB DISTAL Description: HYPERTENSION NOS Code: 4019 Description: ACUTE Description: COR ATH ARTRY BYPA Code: 41404 Description: COR ATH UNSP VSL NTVCode:414t}0 Description: NOS Code: 4280 Description: ATRIAL. FIBRILLATION CDde:42731 Description: AORTOCORONARY BY: Code: V4581 - Description: PARALYSIS AGITANS Code: 3320 DISCHARGE DIAGNOSES Discharge to: A Autopsy Date: 51;; Time: Description; Code: Date of Death: Time: Description: Code: Code: Location of Cards: Tissue Bank: Phi Body Released on: Time: Body Donate: Ph: By Nurse: RELEVANT ALLERGIES: Diabetic: No 1) HALDOL 2) we DYE 3] RADIOPAQUE AGENTS "special Instructions: PT WAS ADMITTED mom THE COMM UNITY Physician Signature 02fl5/200 Date . "Med Rec#: 5030 A Re-eeis Care Center aIost.Rec.rntAdm1ss1on Date; 06115/2007 3200 Bavchester Avenue Room: 585A Unit NW Front: ALBERT EINSTEIN HOSP .. B1onx.NY 10-175 mm Order, nmal Admission Date: 0511522007 7183203700 - Resident Name 091--22--0925 GEORGE DOB: Lm Age: 79 Medicare 09l22fl9?.SA tprimary Residencfi Sex: MALE Part A: 01 I982 . . Marital Status: Married part 2713 YATES AVENUE PHRace. White. not ofHIspaxuc origin Part D. BRONX. NY 10469 Rafi . PROTESTANT ms' plan: . 1 - gion. . Residence Tel No. (713)333-0503 Occu m_i0n_ poi"). Spouse: Maiden: Educgtimr I13:/Iedlcatd g: QV6354SR Fame" Mother: Citizen' \"cs Vet: Spouse' rnzurn-W . MCR Qg] 72gg75A Bu-thmace: Ins MN Prior Hosp Stay: ALBERT EINSTEIN HOSP Attending INVKITEL Phone ft: (713)424-2304 Address: Pliysician Date: 061120.007 To: 06/15I2l}l}7 NV Social Worker: Mortuary -Dentist Alternete Phone (718)461-0373 Ph)'SlC1Etn phanuacy; Podiatrls NY REPRESENTATIVE CONTACT #1 Email Add: Horne: (7 181382-0605 Name: LARUCCA ANNA Relation: WIFE POA Hop Work: Address: 2713 YATES AVENUE PH City: nRo Cell: CONTACT #2 Enu'1ilAC1d: Home; Name: LAROCCA GEORGE Relation: SON POA HCP Work: Address: 2713 YATES AVENUE PH. City: BRONX, NY 10469 Cell: CONTACT #3 Email Add: Home; Name: Relation: PDA HCP Work: Address: City: Cell: BILLING INFORMATION Relation; Church: Name: Hgme; Clergy: Phone Address: Funeral Home: Phone City: Cell: Address: ADMITTING DIAGNOSIS Description: PNEUMONIA ORGANISM NOS Code: 486 CHRONIC DIEAGNDSESI PROBLEMS Description: PNEUMONIA Description: AORTOCORONARY BY: Code: V4531 Description: DEMENTIA WICI BEHAV fCodc:294l?} Description: ABN INVOLUN MOVEM Code: 7810 Description: COR ATH UNSP VSL. Description: ABNORMALITY OF Code: 7812 Description: ATRIAL FIBRILLATION Description: HYPERTENSION NOS Code: 4019 Description: Code: DISCHARGE DIAGNOSES Discharge to: Autopsy Date: Time: Description: Code: Date of Death: Time; Description: Code: Description: Code: Location of Cards: Tissue Bank: Ph: Body Released on: Time: Body Donate: Ph: By Nurse: RELEVANT ALLERGIES: Diabetic: No Mortuary: 1) Address: 2) Phone: 3) Special Instructions: COMMUNITY PT WAS ADMITTED FROM THE 06/181200 Physician Signature Date Regeis Care Center 3200 Baychester Avenue Bronx, New York 10475 Tel. (718) 320-3700 - Fax: 0'18) 671-2554 FACE SHEET . NAME DRART 2 PREVIOUS ADDRESS A0125 PH IU '7 EWSL . TATUS OFIEGIN MEDICARE I - TELEPHONE it SAM I NAME .9 _i ALTERNATE PHYSICIANS TELEPHONE DATE OF BIRTH AGE MARITALAS OCCUPATION RELATIONSHIP ADDRESS TELEPHONE OK) (3) fig fir fimw ADMISSION AFIRANG 3 ADMISSION FROM LU L459 QQ/mi FUNEHALARFIANGEMENTS - CI 0 II Ca||tl'Iis gm er:1(8D 443-345". I MNISP (/1635) 5% ADMISSION DATE D1SCHARGE DATE DISCHARGE TO DISCHARGE DIAGNOSIS SI NA UFIE 51507 A PRIMARY DIAGNOSIS 0 LLJLEQ Wimp? Qg Ixirv?x DIAGNOSIS ARISING REGEIS CARE CENTER. Sm TUS FORM NAME 12. fizeir own he-ahh care, even when incapacitated. In with above and for family Designated Representative, nazfxc of fesideni Ls: r::c.CCz.~ and relationship' . z_m'd? or Sponsor 74:? rift provided-; and the following Advanced Directives have been discussed: .5533' Regeis Care Center,_in conforfnanc-E: with 111 patient Self-Dcrtermination act of 1990, nfi-zczogjnfizcs that adult individuals have :1 fight lo execmc the following Advanced Directives: Do Not Qrders (DNR), Hcaith Care Proxies, and Living Wills. enables; them to take part in decision-makingwith respect 19 has been hnformed offifis right. Cmmselizng has been AD VANCED RESIDENT AD VANCEI) REFUSED HAS 1mu:7C2"1vEs 13053 NOT AD VANCED IN CHART mu: -- HEALTH CARE FROXY 11/' LIVING WILL 31mirage-5 .7. -24:9 :14. CL 3., if - . /Wm: sociALwom<1a11 I1-ATE COMPLETED U.P.DA TESY SIGNATURE Date: new Advancaci Directive{s) I - Advanced Directive{s)- 6 - 9 Specifirf Comments: a . ?951. uate new Advanced Dnectnm-(5) R?vised Acfvanced Specify! Comments: Date: new Advancexl Advanced - Specifirl Cummentsf Date: No new Advanced Directive{s)- :NewiRevi5ul Advanced Direcfive{s) Specify! Comments: REGEIS CARE -- ADVANCED DIEECTIPEY STA TUS FORM LCLVO - Regcis Care Center,_in confonzizancre wiih the patient act of1990, that adult individuals have :2 right to etxecute the foliowing Advanced Directives: Do Not Resuscitate Orders 1-ficahh Care Proxies, and Living wins. nu'; enablc? them :0 take part in decisiommakingwith 'respect to their own health care, even when In aocdrdance with above and for famiiy Designated Representative, nninc of resident . or Sponsor A-flame; In') has been informed ofthis right. has been . name and relationship prm'ide_cI, and the following Advanced Directives have been discussed: ADVANCED RESIDENT ADVANCED - REYIDENT REFUSED HAS DOES NOT IIDVANCED . IN CIMJIT H.-IVE .vm{ [/51 HEALTTI CARE PROXY WILL COIVHVIENTS: SOCIAL WORKER COMPLETED UPDA - QUARIFRLY VIEWS: SIGNATURE Date: 0 new Advanced Directive(s) Advanced - Specify! Comments: jq 4 3Q new Advanced Advanced Dimctive::(s) Speczifyf Date: new Advaucfxi Directive{s) -fl Advanced Dimctiv c{s) - Specifirf Cornmentsf Dale: No new Advanced :NewIRcvis:e=d Advanced Dirt:ctivc{s) Specify! Comments: . .1. AVENUE . NEW WebsiteLox R062: 98$" (ii: . pidv?mreu r-new arzuizzsr. IT. is ocaczssa?t ?iasstfir?-E-ATIEHT as: IDENTIFIED: THE . - . Is HOT CAPABLE ARE TO - (AS INCLUDES 1-Hz: or me MEDICAID I T-educmc DECISIONS conzcemlcguc ELECTIONS .3 3% I 1 - REGEES CARE CENTER m:MuE\n zprra om RECORD NAME (3 9 PHYSICIAN xv TB SKIN TESTING: a: TWO INITIALS: SKI TEST 1 us: GIVEZNIRESULTS IN INITIAL. DATE GIVEN - I 4 BATH GIva:n.:. 3 I . l_ Lo'r#: - - PMELIVIDVAJC IMMur~uzA1'1oN: far TETANLS BOOSTER noszs [zv?nv TEN mans) DATES GIVEN AND mrpuauzn VACCINE (YEARLY) DATES GIVEN mm on-rr; auvsu. . . ALLERGIC. IF r-I110: ERIML. fl Fiveboro Printing, Ltd. (718) 431-9500 Form No. RNH-57 I A Regeis Care Center PRINT NAME Last, First. Middle) ROCCR CHART OR ADMISSION NUMBER ID DATA (WELFARE HISTORY {Circle} ON AGE 96" SMWSEP. COMPLAINT AND DURATION mt>> P51 ="fl se?ausmcs EVENTS a '3 dag 7 5,43 3C2, ?16' ball-fig" mam Wm 377 D9 C749, 1 i a?17B7IIua% Me Wm <> moa [1 Chappaci 11 Puma UflC DET5 AS 11 NCE 111m: Chalesteml QTY fl Law Patasaimn Laetuse Ftee [1 Low High Fiber C31. (117 . 1, .25 - 112gmrqe, :1gm3,sog,mm 110mg-_ 3 3 Tm mums; I]Nectar 11 Honey 11 Pudding I I nozm 11 s; I SEHD See Tube Feeding U1't!erFmr Eco-H, 3:15 mg, H9 119.1: 110.1'. 3521-mra 11 DONGT SEND 0-73- QTY SPEECEISWMLUW: E-ONOT E3 SEND Typigmm 11m mo Raloass above I0 nflotiug DO NOT SEND QTY ACTIVITIES: 111mm [1 Ya: mire DONQT [1 Yes [1 Na CGNSULTS: warm 11 012130 11 REAR 11 0 0LOGY [1 NEUROLOGY arm SEND QTY SEND Ailergiest Diagnosis 5: 0 5,1111), 19,10, 3/,0 ?245 6 2.. WKJ4, {77Lt2,w1.,945 Faa}'Ir'L 7/ THIS PRESCRIPTION BE FILLE 4' ZW 55:/is SIGNATUEE: .13: zuucawr UHLES5 THEBDXBELUW 'rm, LEE BY: (NKJESE): BY: VIEWED BY: 1 4' ,1 . /76) mg: DATE: JR DATE: ORDERS I0 EGLE FCPR (39) EAYE -- PREVIOUE USE PEN PRESS FIFIMLY An Gmnicare Company Please place a checkmark fin the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM E. _i Fonn Na. $0 NOT USE THIS FORM UNLESS A NUMBER 8 SHOWING PATIENTS NAME: ALLEFIGIESZ LAST FIRST ME FACILITY: Room :2 NAME I - -. '7 Care 59.5 I9. PHYSICIAN TO INDICATE DRUG NAME. DOSAGE, FREQUENCY AND Rourex FORM WHEN BFIAND NAME FIEQUIFIED-INDICATE IN WRITING MEDICALLY SIQNATUFIE DATE TIME I3 I -- I - .3 5/35} U: 07 719 C1-Irrf-E In 5 +0 fir; GAIQII fly W7 - Check here if AM CI PM I faxed. Enteriime. I-=5-s . THIS PRESCRIPTION WILL era FILLED GENERICALLY D17 UNLESS PRESCRIESER WRITES RINT UISPEIJEEASVIHITTEII for zT:'Im'In$ I19,-Ifie-mpesrfic I34: I here if AM PM hqacfaflrfiag ILEIQI iaxed.Ente1-time. - Max,' use THIS PRESCRIPTION BE FILLED GENEFIICALLY A UNLESS PRESDRIDER WFIITES cI a -- IN THE 302-: I 0 '7 NAME-PRINT DISFETJEEAEVJHITTEN SIG ATLRE DATE TIME 533'42 . ex, RTDHI bc:IIcmc:c__ I I Check hareii Lam: AM PM 6'5: I1 Dam- m;::zI THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS PRESCFIIBER -- a IN THE BOX I 5' NAME-PRINT DATE . An Omnicure Conipany . . Piease checiflnarlc in the box rnarlced to indicat? thai the . . order wasiaxed to the-Phannacy. For . purpbses please indicate the time tt_1e~ordar was faxed. MAME: - r72, . .-.- - we FACILITY: - MI DOCTDFUS - . .. . fiwx A . - - . NURSING TO INDICATE DRUG AND HOUR: - PERSONNEL 7 NAME TE IN WFHTING MEDICALLY SIGNATURE . 5 TIME I5 no afi poult?ue. PPD, min 0. an: Eepm ag.teJL .425 4125 6" - - . Check here If AM PM X-my, <> 6/of/91 2w Jim;/, I at/[2/I 1 o'L ?1.27-rag, /55' Sv?i//I (PI I 7 I Checlcharell AMEI I 7 KWL: UNLESS PRESCHIBER WFIITES cl 3 IN THE Box v/I7 NAME-PFII NT Inusrar-Isa A5 wfinr-"EH SIGNATURE DATE TIME gr?fou /30 \Im fl Chackher-3'Il Lax AMI: PM CI faxed. Enter time. THIS PRESCRIPTION WILL BE FILLED GENERICALLY I II '37 UNLESS PHESCFIIEJER WRITES cl 3 I IN THE . NAM E--PRINT nuepanse as IIRIITEII SIGNATURE DATE TIME $2 THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PFIESCFIIBEFI WFIITES a IN THE BOX NAM E-PRINT .. 1 "gr :1 I - I Check here if Lana AM [5 PM CI faxed. Enter lime. #3 MI 5 YIRITIEIJ SIG ATU FIE DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING FA TY PHARMACY JRDERFORW1 #35511 Ina-T. rs. IESIDENT NAME 8. MEDICAL RECORD 3% UNIT FIOOM BED DATE OF BIRTH SEX DATE OF ADMISSIO -memcmrom onnens omen omens Ea 325mg TQBLET <3xF: DIET CDHSISTENCY: EceTR?m> fiE@uLaa 1 Tag 3? %%#ufl NUT THERAPEUTIC: 1 g;flJr@ 1 5 /Sfl Q. 1 THERAPY: FT axrwm, WINIHUH 0? 05x:5x07 fi1E15Q4?? 8--1E wEEu$ THEE. Ex. Dumas e.2:mG Iaalgz REE QAITISTAIPS: BALANCE: Ta: THECE FDR HUME EuaL UCCUPATEQNRL THERAPY: GT axwm, HENINUM UF . BETH 5hnuuUtL dfifib/yfiWLEi HUBILITY. REL RETRRINING: - EV THECE CGGNETIUE TH EPWN): MUDQLITIES ?PfiH}; HDHE EVQL HAY USE MC ii: Tau .efl.3" . TE: PREVIDUS BR FEE -3 aavs_ FE 1 gang . 63: KSI HfiLGfiL> HDUTH - 4 HDUHE Fflfi if /fgz, /lf~I C. I3 Imfififififlfifi :e-T . - .93'/9 6 7577719 15/; X. 5, gag" xg (3 I xfifljl Q96/ht I ggvzawfia /2 I 1 gm "3 Waamfi Slgnamre 1 $17 Q?d 3 it) THIS PRESCRIPTION WILL FILLED GENERICALLY A . - . UNLESS PRESCRIBER WRITES "daw" IN THE BOX BELOW +1 f'}n 51. '-43 5 1 DIAGNOSESI ICDQ CODE ALLEFIGY REVIEW DATE I 23'; .4"u C16: /1 CH7 Dispense As Writicsi .--. PHYSICIANS NAME. TELEPHONE NUMBER a DEA NUMBER F: I Ia'. . 1 P. 13$: 5:359?' I -J .55 i-'1 1' 1 $2333 '11 .Ei?7= PAGE 1 1 .13? ESEDENT NAME 5.: 5: .. Fl'; ?2 5 An Gmnfiwre Company Piease place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM wm I-IKJ. PATI NAM E: LAST Ag (15% - FIRST Ml ALLEFIGIES: DOCTORS NAME NAME-PRINT f' ,1 4-, . 7/5 THIS PRESCRIPTION WILL BE FILLED GENERICALLY ff '7 UNLESS PRESCRIBER WRITES a IN THE BOX A5 II'fFfl'i_rEN IGNATU TO INDICATE Imus NAME. DOSAGE, FFIEQUENCY AND FORM WHEN BRAND NAME REQUIRED-INDICATE IN WRITING MEDICALLY SIGNATURE DATE TIME 1 Ga yavww/a 6 Q, E//#3/lfiql I I . up' 5 aim /5.11) 'ah PMI3 Checlchereif 5 faxed. Entertime. .7 /7 W53. I tka>> . /2712? 54//4472. NAME-PHI NT DISFEIISE A5 SIGNATURE DATE /fl I7: {fawn cg/I: 0; 1' npgafiyz r; .-.. . 3 Chechh re_'r PM II EnlerlI:11e61//40?' HS DATE TIME 3 I I . 04;, er/II/0,7 fig Ce/'Chec:khere'II PMS iaxed. Enier li DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING TM A n__f4;I Clcfiu; - 3.515 W0 aw/7 I I . mean 5 ,4 Afzpoma//$5 DO T-EST STETND I 5 /:90 (:45:/afd QTY 11105: Hf,' ,j l]?mS: OT (as:/wiz, mia$murn 3-12 weclrfii fifi"-417i rEUR?7fl5r?7ry. 7 DO HGT SEND J. .-.. i 1 SET a PH-I E3 9 5 HTEE 5;-ea: . 2'3 Him 34' A..- I 7 :'nLrz1u.. n-r 8-12 use we 4' 4. .I LE- EGNSELTS"ft? 07 QVGUGHW L1 I '5 .. 712.. axflfi' A "I.-zghez wwa/'5 M19 ,:i:cLe.r:r5 SIGNATURE: in.4. DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING - . }7D,.mNo_ "-330. An Qmnicere Company We "j Please place a checkmark in the box I marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM PATIENTS NAME: ALLEFIGIES: LAST FIRST M: FACILITY: FICIOM ooc:Ton's. NAME REC PHYSICIAN TO INDICATE DRUG NAME, DOSAGE, ROUTE WHEN BRAND NAME IN WRITING MEDICALLY SIGNATURE DATE TIME 1 f' (vw 9&Era'? Le, 1' ea THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PFIESCFIIBER WFIITES a IN THE BOX 1 I NAME-PRINT Dn5r'EusEAsrmn7sn SI NATUFI UTCEE DATE TFIVIE r"//I39 II 1'25' cglk. IQ (7/1"/fig If Checkhereif L..E-ta AMCI PMEI faxed. Enter time. 62% 12 THIS GRIPTIDN WILL BE FILLED GENEHICALLY UNLESS PRESCFIIBEFI WRITES cl 3 IN THE BOX NAME-PRINT . TIME I I @041-..- Ur 7 I I CICE-ezllraf'-'A If . . '1 I gt.-rzruq ., . Ch Ih '5 AMCI Ir --T. "Wu; 6 {ire 5-an I THIS PRESCRIPTION WI FILLED GENERICALLY Z77 UNLESS ITES a IN THE BOX 5, Ii' NAME-PRINT - SIGNATURE . DRDERFORM ACIEKJTI RESIDENTNAME Es MEDICAL RECORD ROOM BED DATE OF BIRTH SEX DATE OF ARDCCA, 930995 ?5930: 57 535 10x39/39 Mx15ro7 MEDICATION ORDERS THEFI OFIDEFIS TABLET . . DIET CDNEISTENCV: - MEQHMMICML SOFT SGFT - g.g: MM LDH LQH CHDLESTERDL oakisxo? R12294744 CBREG e.25M9 TABLET - TMICMEMED LEQUIDS: 1 TAB BY MGUTH DAILY HGLD MECTMM TMICM LIQUIDS an BELDN . - LIHETEE 3 fl, oax15xo7 912294751 --.M . MM: 5 My jg PHYSICAL THERAPY: RESTGRATIVE PT axxwm. MINIMUM APPLY TUMGENITAL RASH THECE DAILY SGMIMXSEBSIGM, 8-12 MEEM5 MIT HER. Ex. 2M -rs:-Vj-I BED BALANCE. MUDALITIES HBME EUAL 3 1 05x15/0? R12294753 SERQQUEL 25mg TABLET 1 DCCUPATIGNAL THERAP 1x2 TAB t12.5Me> BY MOUTH IN THE RESTURATIVE OT axwm, MINIMUM MGRNING AND 1 TAB SQMINXSESSIDN: WITH 7% .Ex, BEDTIME FDR Ejbg FUNCTIDNAL MOBILITY, MDL RETR Ime, CDGNITIVE TX ALITIE8 f_ oar19;o7 (PEN): HUME EVAL (PEN) . MAY we I I Pf) BRDERS TD HDLD FDR 1 DAYS. ANGEL FE ?h?v3' ?+aM PREVIOUS ORDERS (NURSE) 1 AVMJ 1fiDTEfi'J 7hfTfiY" REVIEHED (NURSE) 2" /0 Dale: Dispense As Written" ICDQ cone ALLEFIGY REVIEW DATE LIQUIDS RAD EIUPJQGUE PVC FWERHERS MEMENTIA, can. case 1 113 7x05/07 NAME. TELEPHONE NUMBER :1 DEA NUMBER BORIS N. . (l3F?30t552E17) 1 HE I GHT53 75 a 1 1 SIDENT NAME RESIDENT I PAGE GEBRGE 1 EF- "fig USE BALLPOINT PEN PRESS RRNILY An Qmnicare Company Piease place a checkrnark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM Form No. 1520-335 DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING PATIENTS NAME: LAST or: cIf+ FIRST . FACILITY: ROOM LI -I K_flQ E5953 I 1/ TO INDICATE DRUG DOSAGE, FREQUENCY AND ROUTE I FORM WHEN BRAND NAME REQUIRED-INDICATE IN WRITING MEDIGALLY SIGNATURE DATE TIME /biz; - I I I lbs! (3 C) II Check herei! AMER PMEI faxed. Enter time. - THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PFIESCFIIEEFI WFIITES a -- IN THE BOX NAM E-PRINT a Isr-sues I-.5 SI G'f\lfiIUfiE IME (R) c-=K7: Check here if L:-as AME faxed. Enleriime. - THIS PRESCRIPTION WILL BE FILLED GENERICALLY (3 I UNLESS PFIESCFIIBEFI WFIITES a IN THE BOX NAME-PRINT 915951455 as SIGNATURE Um axrre Tm Check hereif faxed. Enter time. rim THIS PRESCRIPTION Mg BE FILLED GENEFIICALLY I UNLESS PF-IESCFIIBER WFIITES a IN THE Box NAMEPFIINT ursrsusz SIGNATURE DATI: PHAFWACY - QRDER. Egmw CENTL FHA. 3 Fi RESIDENT Mrme ea RECORD um? ROOM BED DATE OF BIRTH SEX om; aaocca, 45030) STH 523 9 loxaogga D5/15x07 fl MEDICATION (moans OTHER ORDERS SERBQUEL 50mg TABLET DIET CBNSISTENCY: 1 TAB BY MGUTH aT EEDTIHE SDFT SOFT THERAPEUTIC: LEN Na+ LDH CHDLESTERUL . O7f1lfG7 H124a5o5? 325fiG TABLET THICKENED LIQUIDS: 1 TAB BY HDUTH DAILY NECTAR THICK LIQUIDS LAB ACTIVITEES: 3 3 FULL 05x15/07 R12294744 CUREQ ?.25flG TABLET . PHYSICAL THERAPVBELDM B-12 WEEKS HITH THER. Ex. BED GAITISTAIRE: BALANCE: MUDALITIEE (PRN): HUME EUAL (PEN) 05/15:07 25mg TABLET OCCUPATIONAL THERAPY: 1 TAB BY MOUTH EVERY MORNING RESTDRATIVE OT axwm, MINIMUM OF 3 WITH FUHCTIDNAL ADL RETRAINING. BALANCE: (PEN): MDDALITIES o7x11xo7 R124253a1 (PEN). HUME EVAL (PEN) MAY USE we MYSTATIN (NYSTUF3 10o009u119 FUHBER NYSTATIM ORDERS TU HOLD FOR :33: DAYS. CANCEL FE APPLY TD TWICE DAILY D?afi I -- 2. FR DRDERS king 3 *il EQITED (NURSE) Egg NGTED . . REVEEWED (NURSE) aarzi 5- 1' 'lg Date: 1' Signature WTLI. BIZ FILLED UNLESS WRITES THE BOX BELCIW [Dispense A5 written ICDQ CODE ALLERGY HEVIEW DATE axon LIQUIDS (NECTARJ ALZHEIEMR3 HALDPERIDBL5 HADIDPAQUE PVC MARKERS DENENTIA. CAD, can; DBJG 1 NAME, TELEPI-IONE NUMBER 8: DEA NUMBER PREMANATH N.. BANAD PARK BLVD, BRONX: NY. 10453 PAGE -EDCCA. GEORGE 05x15/0? 1 OF 1 . --I - .. USE BALEPDINT PE-EN ONLYITPRESS FEIMLV Fm, An Gmnimra Company Please place a checkmark in the box marked Faxed to indicate that the order was faxed tn the Pharmacy. For tracking purposes piease indicate the time the order was faxed. INTERIM PHYSICIAIWS ORDEFIS FOFIIVI THIS PRESCRIPTION WILL BE FILLED GENERICALLY - -- NAME PRINT UNLESS PRESCRIBEFI WFIITES cl a IN THE aux SIGNMURE DATE IL: DATE (R) fmfimm (GD 15% MAME-PFIINT SIGNATURE Dm I5 '1 am TIIWE 3 L. 59PATIENTS NAME: LAST A E0 C-CA FIRST Im MI FACILITY: ROOM II: DOCTOITS NAME IZCC 523 PHYSICIAN r0 INDICATE DRUG NAME, 003,495. FREQUENCY AND ROUTE FORM WHEN BFIAND NAME FIEQUIFIED-INDICATE IN WRITING NIEDICALLY SIGNATURE DATE TIME AMM .x M19. +9 Of IEVLCIEI I . Check here if Lana. P-MCI PM faxed. Enter time. I CISSISYL a? 2 perrovrs. Checklhereif PMCI faxed. Enter THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS PFIESCFIIBEFI WRITES a IN THE BOX Check here if faxed. Enlar lim. THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS WFIITES a IN THE BOX NAME-PRINT DSPEIISE IIS SIGNATURE DAT I: NOT USE THIS FORM UNLESS A NUMBER IS SHOWING PHARMACY . JRDER 1 CARE SHORE I zE3|nEr-1T NAME 5, UNIT ROOM BED DATE OF BIRTH SEX DATE OF ADMISSIO (5030: . 529 A nan Sm? EEQCCE. 3 MEDICATION ORDERS OTHER ORDERS SERUGUEL EOMG TABLET 1 TAB BY MOUTH AT BEDTIME FDR OYFIIKO7 ASPIRIN EESNG TABLET 1 TAB BY MBUTH DAILY FOR CAD O6/l5fO7 CDREG TABLET DR BELUN FOR CAD 1 TAB BY HDUTH DAILY HULD SEPCIGD SERDGUEL E5NG TABLET 1 THE BY MDUTH EVERY NBRNING FDR O7f11fO7 H124E53B1 TABLET 1 TAB BY MOUTH TWICE DAILY FUR DEMENTIA OSXIDIO7 NYSTATIN IOOUDGUIIG PUHBER (SIF: TD GENITAL HASH TWICE G6f15fO7 $31. 3 ITRI-5 - 4. DIET CDNSIBTENCY: NECHANICRL SUFT SUFT THERAPEUTIC: LEN LDH CHDLESTERDL THICKENED LLQUIDSI NECTAR THICK LIQUIDS ACTIVITIES: GMLINITED 3 MODERATE 3 FULL MI 8- EEKS WITH THER. EX. BED BALANCE. HOME 2 PHYSICAL THE RESTDRATIVE PT exxwm. IMUM BF 5. 1.1 DHDERQ TD HELD ma ?3.33 DAYS CANCEL Fi PREVIOUS URDEHS 03-1' 31'; EDITED (NURSE) . NOTED (NURSE) REVIEHED (NURSE) I:rflTE cg Sigrlutmt: THIS PRESCRIPTION WELL BE FILLED GENERICALLY UNLESS PE-IESCRIBER WRITES "Ll:1w" IN THE BOX BELOW 2 As Written AUERGY fiEwEwEmTE LIGLJIDE ALZHEIEMRS RADIDPAGUE PVC CAD. Sf? CABG 1 1 PHYSICIANS NAME, TELEPHONE MUMBEFI 2. DEA NUMBER PREMANATH BQNAD 392% BLUE. NY. 10458 QDMITTED Imamawa PME (EEURGE O5f15fO? 1 OF aesloem NAME MEDICAL RECORD REE GEORGE {$039) umr 523 A ii": PHARMACY . EHORE FHA DATE OF j?f1EfD? D'r'flf-E OF BIFITH IUIBOESB ROOM MEDICAHON ORDERS OTHER ORDERS SEREGUEL BONE Huu.h H9 run -. 3 TAB Ofifiififfl? DIET EOHSISTENOV: 5OFT.SUFT LON LEW CHOLESTEROL THICHEHED LIQUIBBI THICK LIQUIBS 3 LEHITEO 3 3 FULL CERES ?.25fiG TABLET THERAPY: 3 Ev MQUTM 391;? HELD 109' HITH ma BELGH Hfiififl FQR egg HELE ASSIST OF DREERS TO HOLD FER 3 Ufifc CANFEL Ff A 9fif15/O? FREUIGUE QRBEHS EEHQQUEL 2SflG 1 T?fi BY HOUTH Hfififilflfi FDR . o?x1:xo7 e12425Ra; tkfi*a marr?zawazz-r-. zcme TEHBLET 3 33*' A av MDUTH Twice Fafi 'l 5 CZ 1 -- ?:11?fl? TO GENITAL Hfififi Twiifi DQILY EDITEB iaffii/k-- Gfifliffl? 31:2 4753 DATE "jm. :3 a 5% 5 3_ Signature - w11..1.. BF. FIIOLED GENERICALLY A5 omemomszmoacons HEWEWDNE fifl HALOPERIDDL5 PVC I [353 I-. 'er: hm IESIIJERIT NM-JIE ?2 F-. .- HEDRQE PHYSICIANS NAME. TELEPHONE NUMBER a DEA NUMBER PHEMANATH BEDFafifi FARM BLVD, 5ifi~B5?~1l2O NY: 10453 ABHITTEU Hamawx PAGE 1 BF Rfig USE SALLPDINT PEN PRESS An flmruicinre Com an 3' Please place a checkmark in the box marked Faxed to indicate that the order was faxed tn} the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM 7" 7. Form No. 1620-2 735 "Jr ALLERGIES: LAST FIRST Ml ROOM DOCTOFPS NAIVIE Rec 528 PHYSICIAN TO INDICATE DRUG NAME, DOSAGE, FREQUENCY AND noun: FORM gffi WHEN BRAND NAME FIEQUIHEDJNDICATE MEDICALLY [32 DATE TIME - In 3; fi ., . ~*RLwz:u 'Dr; re-rkrm-hwa OT 2 c2cJwe~re,naerzCheck here if PM faxed.Entartime_ r"=lsv= - THIS WILL BE FILLED GENEFHCALLY (9 - UNLESS WRITES a IN THE BOX NAME-PRINT SIGNATURE UPITE DATE I i"iME DO NOT USE THE FORM UNLESS A NUMBER ES SHQWENG Check hereil AME faxed. Enter time. THIS PFIESCRIPTDN WILL BE FILLED GENERICALLY UNLESS WRITES a IN THE BOX. 0 - DISFENSEAS wmzraa SIGNATURE (3/7 5: -- To fi@@ /o Am fimflz 1% 27 a hi Check here if AM PM faxed. Enlertime. - THIS PHESCHIPWON BE FILLED GENEFHC-ALLY \~3k?vL UNLESS WFUTES 3 IN THE BOX NAME-PRINT SIGNATURE DATE C: use BALLPOIHT PEN PRESS FIREUILY mm ,m,m5 An Gmnicm-e Company Please place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FOFIIVI PATIENTS ALLEHGIESI LAST LA IZO FIFIST MI FACILITY: ROOM DDCTOWS NAME IZCC 5:28 Pr - I7- - PHYSICIAN TO INDICATE DRUG DOSAGE, FREQUENCY AND ROUTE FORM WHEN BRAND NA ME REQUIRED-INDICATE IN WFHTING MEDICALLY smgruns DATE TIME 319$ 'o I QCIF I-efecrge c:IIc2'Ir" 45,. .?q-F-efy - I {:34 1:90:63 I Clweckhereif PM CI - faxed. THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY "2 1 .3 UNLESS PFIESCHIBEFI WHITES a IN THE BOX SIGNATURE DATE NAME-PRINT TIME A Io/am <33 flew 5% (M I cm' (ea/sew gem-IL? (em "3 7' .52 I THIS PRESCRIPTION WILL BE FILLED GENEFIIGALLY "1 UNLESS PFIESCFIIBER WRITE-S cl 3 IN THE BOX NAME-PFIINT SIGNATURE DATE DATE - I I420VY-L0 Check here II AM - I THIS PRESCRIPTION WILL BE FILLED GENERICALLY 5 I UNLESS WHITES a IN THE Box _r NAI-.I1E- PRINT I:IIsr-Ease as SIGNATURE DO NOT USE THIS FORM UNLESS A NUMBER 3 SHOWNG ORDERFORM L2 PHARMACY . H91 -. EU -.-: SEX DATE OF ADMISSK RESIDENT NAME 5. MEDICAL RECORD if UNET ROOM BED DATE OF BIFETH GEURGE ?5939: STH 52% A }fi?]SfQ7 omens men omens SERDGUEL TABLET DIET CBNBISTENCY: 1 TEE av MOUTH FER SOFT SOFT LDH Nfi+ LDH CHDLEETERDL 913405055 ASPIRIN 325mg TABLET . THICKENEE LZQUIDE: 1 Tfifi av HDUTH DAILY NECTAR THICK LIQUIDS FOR can - vT 3 FULL ca/15x07 TT . CARUEDILQL &.25me TABLET 'f fTi_I . 1 i'1 -ff" HITH HAP 1 TAB EV MOUTH DQILY HELD ASSIST DF 2 DAILY DR HELEN Hfii?fi Ffifi .T . 2 . - - DRDERS TB HOLD FDR I Davs; CANCEL FE - PREVIOUS DRDERS. . SERDGUEL Qafig 1 TAB BY HDUTH MQRNING FDR o?x11xo? R12425381 qa?gjfig? zems A 47 1 TAB BY MQUTH THICE DQILY FUR s9:uTT:1 . -.- . /flg?) TT: TT- '09x11ro? n12a732e5 . (mv5TQ?) PDHDEE (SIP: NYSYATIN APPLY TD HASH TWICE DAILY (NURSE) oax15xo7 R122947S3 REVIEHED (NURSEDane: .T .-I. . Signature' I WILL BE FILLED GENERICALLY - . . - - - - . BELOW L~=c j\cK-W1 7 I DIAGNOSIS I ICDQ CODE ALLERGY REVIEW DATE -gag ALZHEIEHRS HALDPERIDDL 11xo2xo7 L, DEHENTIQ. CAD, case - NAME, TELEPHONE NUMEIER a DEA PREMANATH mamas 51a~a5@~112o 3929 PARK HLum, BRONX: 10453 ESIUENT NAME I RESIDENT PAGE Lamucce, QEUHGE agmag; 05x15/Q? 1 BF 0 USE BALLFOINT PEN PRESS FIRMLY -I. gri I eve An Gmnicare Company Please place a checkmark in the box marked Faxed to Indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM ORDERS FORM Fonn N0, I D0 NOT USE THS FORM UNLESS A NUMBER IS SHOWING I I I PATIENTS NAME: ALLEFIGIES: ms? FIFIST Ml FACILITY: ROOM #1 NAME 6 5' 2, 3' PHYSICIAN TO IIVDICATE mus NAME, DOSAGE, AND ROUTE WHEN BRAND NAME REQUIRED-INDICATE IN WRITING NIEDICALLY SIGNATURE DATE TIME 9 EU 3 \0 TN Check here-If AME PM-fin faxed. Entertime. - THIS PRESCRIPTION WILL BE FILLED I UNLESS PRESCRIBER WFIITES CI 3-: IN THE BOX SIGNATURE URIE DATE TIME E2) Check here if M1 CI PM faxed. Enter lime. - THIS PRESCRIPTIEIQI FILLED UNLESS PFIESCRIBEB WF-IITES a IN THE BOX SIGNATURE [3 DATE If 1/ I Check he;e/iI/ AM PM faxed. Epte Ime. fie-a - I 1/ THI PRESCRIPTION WILL BE FILLED GENEHICALLY UN 53 PRESCFIIBEFI WFIITES :3 IN THE BOX DISPEIISEASWFIITTEII SIGNATURE . =vI-wssmaw 3 JRDEKEQBM 5: CARE - - NAME 3 UNIT ROOM BED DATE OF EHRTH SEX DATE OF ADMISSIO 1. .9. MEDICATION ORDERS OTHER ORDERS SERUGUEL EOMG TABLET 1 THE BY NUUTH QT BEETIHE FER ASPIRIN 325MB TABLET 1 TAB BY MBUTH DAILY fl%D Q&i15fO7 P1229474 CARVEDILBL TABLET ESIF1 1 TAB BY MOUTH DAILY HULD UR BELOW Hfii?fl FUR CED BIQVAN EOMG ABLET DIET CDNBISTEHCYI MECHANICAL SUFT SDFT 7 . THERAPEUTIC: Law . LUH CHULESTERDL THICMENED LIQUIDS: THICK LIQUIDS - AGTIVITIES: 3 LIMITED 3 NUDERATE 3 FULL REHAB FLOUR QMBULATIDN 100' HITH Ha>> HELD ASSIST er 2 PERSONS DAILY RESTRAINTS: SELF RELEQBE WC SEATBELT FDR SRFEY PURPDEEB DRDER3 TD HOLD FOR 3 CANCEL FE PREVIOUS ORDERS 11202107 FURDSEMIDE 4dhs TABLET {5fF: LASIX) 1 TAB BY HDUTH DAILY FDR LEG EDEHA 1Qf24fG7 PBTASSIUW CHLURIBE 192 taamsaa BY MOUTH FDR EUPPLEMENT . -- EDITED MUTED zoxaaxo? 919375594 EEVIENED DATE ruby SERBEUEL asme TABLET 1 THE BY MOUTH EVERY HURNING FDR mw\\(3nw -- BE FILLED GENERICALLY . . (37 1 3 1 34.35331 UNLESS PRESCRIBER THE BOX BELOW mmHmA1mm'mmMOUTH TWICE DRILY FDR 1 A5 Written: DIAGNOSIS I ICD9 CODE REVIEW DATE 41cm LIQUIDS (NECTARJ ALEHEIEMRS RADIDPAQUE Pu: MARKERS 11x30/07 QEMEMTIA, can, cans I 1 DEA NUMBER BANAD 4932355279) 51a--a59~112o PH FIFE RN31 104-5233. ESIDENT NAME EDM 1 T-FEE) RESHJENT 13 PAGE Lmaacca, GEDRQE ?50361 05/1510? 1 BF 5 IESIDENT NAME MEDICAL RECORD ROOM BED OF BIRTH SEX DATE OFADMISSIC -0. 1 -- 5 ORDERS OTHER 5 52 LDTIDN TWICE TD BETH LEGE FBR DRY SKIN 3,1 - I /fl "rig 929. EDITED- . fig NDTED cmueszng??fifikaawaflfi'??wA?7 -- REVIENED nATE'w4wLm - Signature THIS PRESCRIPTION WILL BE FELLED LESS "daw" IN THE BDX BELOW . Dispense A9 written." DEAGNOSIS I ICUB CODE ALLEFIGY REVIEW DATE 41cm LIQUIUS ALZHEIEHHS HALDPERIDULI RADIDPAQUE PVC MARKERS 11/30/07 gafimamrxa. cam, SIP case . 11r21zo? NMAE. TELEPHONE NUMBEFI DEA NUMBER PREHANATH anman PARK ESIDENT I T-I-ED FIESEDENT if PAGE Laewcca. GEGRGE ?50303 05x15/G7 2 BF - PHA RMACY PEb:i$ CARE cEmTm? SHORE RESIDENT NAME 8; MEENCAL HECDFID UNIT ROOM BED DATE OF BIRTH SEX DATE OF ADMISSH GEUHGE (5030) BTH 523 A zaxaoraa .5x1%/0? f' MEDICATION ORDERS OTHER ORDERS SERDGUEL sane TABLET DIET CHNSISTENCV: 1 TAB my MOUTH HT BEDTIME FDR MECHANICAL BDFT SOFT 3 . 9 THERAPEUTIC: LEM . Law CHDLESTERDL - . . . 07/11x07 aigaososa ASPIRIN 325mg TABLET THICHENED LIQUIDS: 1 Tan av MOUTH naxpv HECTEE Tmzca LIEUIDE FUR can 1 LIMITED 5 3 FULL oexis/0? .. ?.25fiG . ELET (SIP: I REHAB THERAPY: A CQREG1 r_.g -- --1 AHBULATIUN PROGRAM :'1oo* HITH 1 THE BY DAILY HBLD HELU 0? 2 PERSUN5 DAILY DR Ribfi FDR can ?fi?g_ iyfd//? RESTRAINT3: ea/15x9? SELF RELEASE we SEATBELT FUR SAFEV FURDSEHIDE 4on9 TABLET <3xF; PURPQSEE I 1 TAB av MOUTH DAILY FDR LEG ORDERS TD HQLD FDR Egg} DAYS. CANCEE FE EDEMA PREVEUUS URDEES bi; owe Enjas mg>> mafl 10/24/0? R12a7o42a - - - LISINDPRIL 1on9 TQBLET 1 THE BY MOUTH DAILY FER HYPERTEMSIDN I E- (3(uxgX) . I 11x20/0? R129a20e1 PQTASSIUH 192 LIQUID a;fi14? (EGMEGJ BY MUUTH FDR - SUPPLEMENT EDITPQ NUTEEQ . Zf ioraaxov fi1aB7a5?4 fieuizwea 3 . zsme TABLET 1 1 TAB BY HCEUTH HOE HIRE FDR . I -- Date: Signature: I 9 I -. THIS PRESCRIPTION WILL BE FILLED GENERJCALLY - - . O7 I 1 /07 1 242538 1 UNLESS PRESCRIBER WRITES "duw" BOX BELOW NAHENDA 1on9 TABLET 1 TAB BY MOUTH THICE DAILY FDR DENENTIQ Dispense As A 09/11:07 212573235 DIAGNOSIS I I009 CODE ALLEHGY REVIEW DATE ICE LIQUIDS ALZHEIEHRS REDIDPAGUE PVC MARKERS iEf2Bf07 DEMENTIA, can, case Earxa I 12x19xo7 NAME, TELEPHONE NUMBER DEA NUMBER PREMANATH BANAD 392a Pafim BLVB, Bfiuwx, 19453 EEDENTNAME PAGE Lafiacca, 950995 HR/1min? 1 my PHARMACY . ORDER FQRM A UMT ROOM BED DATE OF BIFITH sex DATE oFAoM|ss:c L?fi5CCfi: GEURGE ?55303 ETH 328 MEDICATION ORDERS OTHER ORDERS 5 5% LUTIGN TWICE DHILY BUTH LEGS DHY 11x?2xo7 (Li? iflb 0 .. ff I <1 191/ gel' {+marsh 3 214$, REVIEWED 1" Date: /22 Si gnufurr: WILL FILLED GENERICALLY UNLESS PRES CRIB ER WRITES "aw" IN THE Box BELOW Dispense As \Vlt'iIte11 com: ALLERGY REVIEW awe LIQUIDS ALZHEIEHRS HALUPERIUUL5 HQDIDFQGUE PVC 5 DEMENTIFH: I 1 2/ 1 NAME, TELEPHONE NUMBER 3: DEA NUMBER N. . 120 BEDFURD NY: 19458 ESEDENT NAME ADM 1 T7313 RESIDENT PAGE IE3 PHARMACY ORDER mam IS CARE SHEBRE FIESTDENT NAME 8. MEDICAL RECORD UNIT ROOM BED DATE OF BIRTH SEX DATE OF AOMIESI: GEBRGE ?5030: 5TH 523 A 10/30/33 Ir: - MEDICATION omens OTHER or-mans SERBGUEL same DIET CDNBISTENCY: 1 TQB BY MGUTH QT LEDTIHE FUR ASPIRIN 325mg TABLET fl 1 TAB BY HDUTH DAILY FUR can O&f15fO7 R122?4?44fl CQRVEBILDL 3.125HG TABLET CUREG) 1 TAB BY MOUTH DAILY EXP ?109 BR HULD IF PULSE FURDSENEDE 4QMG TEBLET (SIP: LASIK) 1 TAB BY MOUTH DAILY FDR LEG EDEHQ 10/24507 LISINBPRIL IGWG TABLET 1 TQE BY MDUTH ERILY FDR HYPERTENEIDN 11f2DfO7 PUTASSIUH 10x LIQUID ISNL (QOMEQ) BY MOUTH DAILY FER SUPPLEMENT IDXEEXO7 fiiEB7?S?% SERQGUEL ZSMG TABLET 1 BY HDUTH EVERY MORNING I FDR O7f11fQ7 R124253BN NAMENDA 10mg TABLET 1 TAB av MOUTH Tw:cE DAILV FDR DEMENTIA MECHANICAL SOFT SOFT THERAPEUTIC: LGH LOW CHULESTERUL I THICKENED LIQUIDS: NECTAR THICK LIQUIDS ACTIVITIES: .5 LIMITED 3 MDDERATE 1 FULL MODERATE RCTIUITIES REHAB THERAPY: FLUDR AMEULATIDN 103' WITH HM ASSIST UV 2 PERSONS DAILY RESTRAINT3: SELF RELEASE NC SEATBELT FUR SAFEY PURPDSES ORDERS TU HOLD FUR PREVIOUS uenzag fl 3179 fil, 3 EAYS. CANCEL Fl 4. -- at _f EDITED NGTED >; PT ?y/wk.m1n[]Ye5 mas cm' 1.23313! W5 QC fig' WW . QTY nozwr 27 A '3 SEND Allefgiasz b\ C, C. Relnm above I it} aiieting DO NOT -ye. viscgza ACTIVITES: umonmm [1 FIJLL cg carmrm Fife: mm NOT SEND WGUIHIWLCEE: Yes Nu -ma DOW, La.3am'romz: 71* 335*' fl' flc, "-Nuns. SEND 1 QTY mN51:aLTs= warm :3 came gmmtal xowix fin [1 NEJEOLOGY fl mummy Diagnosis .--.. at Vt SIGNATURE: %Nt'2'm 31'; (NURSE): - THE WILL BE FILLED UNLESS FRESERIBERWRIYES IN THEBOK 1 Tflaifi tcumr: DEE: 33*; axw-~w mm; Ii: BY: (PHIESE): amams HGLE FEE BASES CANCEL PBEVEGEJS Avg Wu-.I..Ju-All! . use BALLPOINT PEN ONLYIIPRESS FIRMLY An Omnicare Company Please place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM ORDERS FORM Tl Form No. 1620-2735 PATIENTS NAME: ALLEFIGIES: LAST S7-aft FIRST (LE MI FA ROOM DOCTOFPS NAME om 5; D0 NOT USE THIS FORM UNLESS A NUMBER IS SHOWING PH TO INDICATE DRUG NAME, DOSAGE, FREQUENCY AND ROUTE FOFIM WHEN BRAND NAME IN WRITING MEDICALLY SIGNATURE DATE . 3- I we, 'w I CQI: Crvx-I' 7-3-3-,5 2 In 'tram 1} ed Imfit Qfixjwiilj - THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS PFIESCFIIBEFI WFIITES a IN THE BOX NAME-PRINT DISFEHSE As SIGNATURE DATE DATE Tl 1.1-0 I - 3 549Gheckhere it Lass AM PMCI taxed. Enlerlime. THIS PRESCRIPTION WILL BE FILLED GENERIGALLY 5 UNLESS PRESCRIBEFI WRITES 3 IN THE BOX NAM E- PFIINT 5:599:55 as IGNATLI RE DATE DATE Nuns xv 5: NW. at 13Us" Check here ii AM PM CI faxed. Enter time. raw: THIS PRESCRIPTION WILL BE FILLED GENERICALLY (3 I 3 UNLESS PF-IESCRIBEFI WFIITES a IN THE BOX nI=_=rIEus5 .15 SIGNATURE DATE 9 use PRESS We An Gmniccare Company #23 Please place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM ORDERS FORM L. Furrn Np. DO NOT USE THIS FORM UNLESS A NUMBER IS SHOWING PATIENTS NAME: ALLERCWSI fig, FIRST M: I 57/, i mam Room Doom-H's NAME ?2251 Ocsab flyc/b?av 5 9? fl TO INDICATE onus NAME, DOSAGE, FREQUENCYAND FORM WHEN BRAND NAME REQUIRED-INDICATE IN WRITING MEDICALLY SIGNATURE DATE TIME 4 - I bfi/ d'a&duC&/ 357:9 we /20 cuTHIS PRESCRIPTION WILL BE EILLED 32$ :2 iggfk NAME-PFIINT UNLESS FRESCRIBER WRITES a IN THE BOX SIGNATURE DATE DATE 0 aw 2 baflx if DZ (5, If Checkllereif 1% AMCI PMEI faxed. Enlertirne. ERIE EILLED 9 ~13 3 Ess PHESCR 3 IN THE BOX SIGNATURE 5 av" gt 0 flug I 'r a/vi' fie/J Pl Check here if l:1xed_EntertIme. ii f' THIS PRESCRIPTION WILL BE FILLED GENERICALLY -. UNLESS PRESCHIBER WHITES a IN THE BOX A5 WFIITTEI: SIGNATURE me An Omnicure Company use BALLPOINT FIFIMLY -L. Please place a checkmark in the box marked Faxed to indicate that the order was faxed to me Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM ..-I.. . Form No. 1620-2? 35 NAME: ALLERGIES: LAST I5 FIRST 9'3' It Ml ''15 FACILITY: ROOM accrues NAME ti'. DO NQT USE THIS FORM UNLESS A NUMBER IS SHOWING PHYSICIAN TO INDICATE DFIUG NAME, oosaee, FREQUENCY AND aoursx FORM WHEN BRAND NAME IN WRITING MEDICALLY SIGNATURE DATE TIME 3! TI FEIL HI - 93.5 6" Jd 3" c5'\g'It' Check here If AM PM (L \a faxed. Enlertirne. I-bu - THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY KP . (N-3 UNLESS PFIESCRIBEFI WRITE5 a IN THE BOX NAME-PRINT SIG DATE DATE If AM PM faxed. Enter time. E-1.: - THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS WFIITES a IN THE BOX NAME-PFIINT DISFEIISE-15 wane: SIGNATURE DAT DATE 'rm saw>> 5 we 0 &/Ifikfi? /I4/fla?/gay flu' I ?55 520cc if /iau 7? 55;; I Checlchereif AM PM I: I - THIS PFIESCFIIPTION WILL BE FILLED GENEFIIGALLY -. UNLESS PRESCRIBER WRITES a IN THE BOX SIGNATURE ON I: 937-299-3405 0 USE BALLPOINT PEN FINMLY An Omnicare Company Please place a checkmark in the hex marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTERIM PHYSICIANS ORDERS FORM Na. DO NOT USE THIS FGRM UNLESS A NUMBER IS SHOWNG PATIENTS NAME: ALLEFIGIES: LAST LIA gluc FIRST Cx ?1542 Ml 'vs II M) FACILIW: ROOM 3: DOCTOFFS NAME 'a . . I R. 3 PHYSICIAN ro rwoscms mus NA ME, 003,4 GE, FFIECI uavcv AND ROUTE FOFIM WHEN BFIAND NAME REQUIRED-INDICATE IN WFIITING MEDICALLY SIGNATURE DATE TIME . I I xs>> . "1 *2 spa 3- ca-J vent Check here iI L.faxed, Enter Iirne. . -J -U THIS PRESCRIPTION WILL BE FILLED GENEFIICFILLY UNLESS PRESCRIBER WFIITES a IN THE BOX NAME-PRINT DIEPBISEASWEIITTEII SIGNATURE WITE . A - I I swam. (=-um-air - -- LI 33' figflc-?31. Tb 1 Check here_ir AM CI PM faxed. Enterhme. r-La THIS PRESCRIPTION WILL BE FILLED GENERICALLY SO . UNLESS PFIESGFIIBER WRITES CI a IN THE EICIX 1 A SIGNATURE DATE DATE -rm12/'CIIJPIL 6- I7/tixlfii I I. at 1 4 I 'ItCheclc here_il Eu AM PM CI X. faxed. Enter time. THIS PRESCRIPTION WILL BE FILLED GENERICALLY - I32 UNLESS PRESCRIBER a IN THE 80>: NAME-PRINT SIGNATU FIE DATE . USE BALLPOINT PEN PRESS FIRMLY Form ND. 1620-2715 An Dmnicare Company Please place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. INTEFIIM PHYSICIANS ORDERS FORM NAME: ALLERGIES: LAST Q-QR FIFIST MI FACILITY: ROOM II-. I Decrees NAME CMI Q) PHYSICIAN TO INDICATE DFIUG NAME, DOSAGE, FREQUENCY AND ROUTE FORM WHEN BRAND NAME IN WRITING MEDICALLY SIGNATURE DATE TIME 31 912*" . I I we>> em a 3 II-I C: I THIS PRESCRIPTION WILL BE FILLED GENERICALLY I 9 UNLESS PHESCFIIBEFI WHITES a IN THE BOX NAM E-PRINT SIGNATURE DATE DATE g,1IIab>< ax DWI: WM m/65% . INK Check here il LI. AM CI PMCI la=eI:l. Enter lime. THIS PRESCRIPTION WILL BE FILLED GENEFIICALLY UNLESS FRESCFIIBEFI WHITES Ila:/703$ I I k? I wen, - NAME-PRINT DATE TIME uusrsr.-5: as I-Imnsra EMU RE 1 eckherei! Lam AME 9 fnxed.EnlerIfn1e. THIS PRESCRIPTION WILL BE FILLED GENERICALLY umuzss PFIESCFIIBER wanes I1 a I IN THE Box NAME-PFIIHT DESPEIISEAS DATE NOT USE THIS FORM UNLESS A NUMER IS f: if EDD-133-2012 0 USE BALLPOINT PEN PRESS FIRMLY -- 'lira An Gmnicare Company Please place a checkmark in the box marked Faxed to indicate that the order was faxed to the Pharmacy. For tracking purposes please indicate the time the order was faxed. ORDERS FORM Faun No. 1520-335 NAME: I-- EM 0 (.0: ROOM IIU FIFIST MI ALLEFIGIES: DOCTORS NAME I9 PHYSICIAN TO INDICATE DRUG NAME, DOSAGE, ROUTE NURSING PERSONNEL WHEN BRA ND NA ME REQUIRED-INDICATE IN WRITING MEDICALLY SIGNATURE DATE TIME I 3 (R) 7/5) 3% /33 Enwjv 53,69 IM IL Checichere if faxed. Enler time. THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PRESCRIBER WFIITES a IN THE BOX NAM E-PRI NT DISFEIISEASWI-ITTEII SIGNATURE CF IE 0 I (L tflfi' Ir Check here if IE AM CI PM faxed. Enter lime. - ax THIS PRESCRIPTION WILL BE FILLED GENERICALLY ID 2 UNLESS PRESCRIEIEFI WRITES a IN THE BOX NAIVIE-PRINT nasaaI5Es-srmmetl SIGNATURE W1 DATE TIME - Rx'. 5 Check Imre if I AM PM CI faxed. EnIer1in1e_ THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PRESCRIBER WFIITES a IN THE BOX NAME-PRINT DISPEIISEAS WFIITTEII SIGNATURE D0 NOT USE THIS FORM UNLESS A NUMBER IS SHOWING I . . I 1* ?35 iexame' 7* 'Be i it Ere>>. 2 at ff' rpastmom A 7' - -t%I'Abn'ern1eis 1 Abnermale _FieTcornrnendaticms and Plans: CHESTILUNGS i/ HEART C?iifitl ABDOMEN BACK EXTREMITIES PULSES NEURO . LEGEDEMA 45/ ES 'x i fl BREASTS -. 12. Assessment and Plan of Care A I BX Problems _%Meds/Treatment rFi'esults '1 "P_|a1Ls V. ewe-u~-- A flea; . i i at' turd . *7 ca 4 _e . I: Adverse D_rug'H_eaction_: free . - . . ..1_.4..7Hestraintst E: Yes I if yes, type Discontinuation Attempted - Yes 15. one :1 Yes Health Care Proxy 0 Yes . . 16. I certify that this atient continues to require Skilied Nursing Care to ause: - - <1 17. The resident ad been informed of his {her medical conditionisi3C]_Yes tad)?' iino, indicate reason I i Physician's Signature: 1 Date: H. I i IHTERIM NOTES 1 A iiv?fivro fififitifig i=5rrH 37 I -I Asse 1; Ph_ysica_iex__a_m; BF eneasrs 7srne_nt -3: of Care . I?ae ff" (eastmonrnj UWNL '.Abnorm'eIs List Ail Abnormeis, Heeommendations and Plans: HEART ABDOMEN BACK EXTFIEMTTIES PULSES er Rue saves . Ijwo 12. Assessment and Ptan of Care A DX Problems Res Plans E?uoa. - flfmAuafi~y' .55? - .. . Adverse Drug Reaction: in If - ._if yes, - I Fiestreints: Physics! I T. D_Yes The resident had been informed of his Iher medical condition(s]: . - lfyes. type - Discontinuation Attempted No Yes 15. DNR No Cl Yes Health Care Proxy No Yes 16. I certify that this patient continu? to require Skilied Nursing Care becausca? F0 0. hfeea ffibfhf if no, indicate reason - .- I _TDate: INTERIM NOTES i='hysician's Signature: L18 fgappi i Van and A A - CHESTILUNGS HEART - - I .3 a I ahd P1_ar 1 bf_Caf? .. . . - Problefns f_ i'fi' . I -. -7Fles.,uIts '2 -"Plans . - .'Disco'fitinuafion Attempted No "El Yes . 1- -fives Health Care Proxy . - 18. {certify that this patient continu?s to require S!-tilted Nursing Care because: . - I. The .reSident hadT%b%ee0Lir1f0rmed NOTES Fi?aficiri 7 7% 4 it :ossri's115 -- in i I I I 9'5. .1'oa - -- -. 'n - A i Pian _ofCa_re_ . - arr '70 if is E. E. _7AbnormEi|s and Plans: I ii NECK BREASTS cnesraunes HEART ABDOMEN BACK EXTREMITIES PULSES NEUFID -- r_C|_vEs ACINO i I 12. Assessment and Plan of Care . ox Problems 7' Medsrneaiment 'Results arm can I - 6.: . 'Sam1:3.Adverse Drug Reaction: Yes . Restraints: Physical . I. NO CI Yes if yes. type - Disconiinuation Attempted No Yes 15. DNFI -9 No Yes Health Care Proxy No Yes 16. lcertify that this patient continues to require Skilled Nursing Car because: The resident had been informed of his {her medical condition 5): - Yes I3 No lfno, indicate reason . i Jam" l: J2 -rrknin Physicians Signature: 1 1? fg Date: INTERIM NOTES --1 A zt; . Fmrii -. Assessment F_Ia_n__o_fCa_re_ 1 "ii; i i; Abniornwelsi Fiecornrnendatinons end Plans: BREASTS CHESTJLUNGS HEART ABDOMEN BACK 435"'? PULSES NEURO LEG EDEMA i i l:1_vEs_ Eltmo 12. Assessment and Plan of Care . . DX Problems I I A Results Plans if 53313. 5 f, L: Adverse Drug Reaction: i EFNO - Yes -fd i 14. Restraints: Physical 2 - Yes _lfyes,type I i ifliscontinuation Attempted . No Yes DNR Yes 7 "Health Care Proxy 'Dive - Yes - 7 I 16. I certify that this patient continues to require Skilled Nursing Care beceuse: I Yes l3'NoAIf_no. indicate reason 9 -t si9n?t.ure{ A 1 i The resident had been informed of his {her _meclica_i condltion(s): I '4 -i INTERIM NOTES 0 73Ca'u'se( i 5 I =sr F'T_h_ysTieiTaTn_ TAssTessmen_tTT_& Pian__oTf Care T: H. I .M 2 exam: 5 '3 TR (Past month) - -. if -VR_ecom_me_ndet_ioris anti Plans: BHEASTS CHESTAUNGS - HEART ~e ABDOMEN BACK Exreewwnes PULSES LEG Elves -T 12. Assessment and Plan of Care 1 .t . - - 1 aegis A Eteus New . - 'sin. - 5 .5 'T5}.qva~ j: \otVyAa~ Jesse Hwfi - - 5 AdTTve_rse Drug Fteacti0n:T T- EN. 0 TT expbiln .. .. . TT14. Restraints: Physical T. If yes. type - . Discontinuation Attempted No Cl Yes 15. E-i--No CI Yes Health Care Proxy N0 Yes 16. I certify that this patient continues to require Skilled Nursing Care because: (at. '17. The resident had been informed of his Iher medical condttion(s): Yes BN0 If no, indicate reason an I -3 Physician's Signature: Q) \2 Date: INTERIM NOTES uw%wwmm mw@wmm Ci r9wwvywamm>> 2i% huh i"BREAsrs Fiestralints: .PhysioeI -T 1 i 9- Psge Two - Physieian Assessment 8: Plan _o_f'Care I Physioal examj in I i* -A HEART -e ABDOMEN BACK - PULSES 5 NEUHO LEG EDEMA P.V.D. EIYES I .VI - . - I-- A_ssessmen_t and Plan of Care _i 2 I and Plans: i" If yes. type Discontinuation Attempted CI No 15. DNR EFNU Health Care Proxy No 16. I certify that this patient continues to require Skiiled Nursing Care because: The resident had been informed of his {her medical Yes If no. indicate reason Physicians Signature: El Yes Yes Yes INTERIM NOTES \x\yss~ Date: A I ficounuuesy. 5:28?" ;i ax} 2&3? Cara -. CHESTAUNGS HEART ABDOMEN BACK EXTREMH7E8 PULSES . NEUHO . ;?j,CfYEs $12. Assessmg-nt'and'Plan'of Care "The resident had been informed of rnedicai [3 Yes If no, indicate Physician's Signature: I T. I rh If yes, type [inf L. "Ci" 575/ Attempted 15.DNR A CENG .'i:3Yes Health Care Proxy No Yes. 16..l certify that this patient continues to require Skilied Nursing Care because: )2 r! Dat..: Problems In "Mada/Tf?ainfiefii I I h" I igt;esults% I {Signs 1 .-A I T7 A *1 A1 rlili -7 I Fivefififfi firafi 7' I Response: %LP??i%?fitN?j?%t?p?-if. I 1 F-I 5 E. 1 BF .Plar5?:A I I BREASTS CHESTILUNGS HEART P"r- E-U be ABDOMEN lswar BACK ee"'e "Te EXTHEMITIES PULSES Pian?fcarPreblenme A . Mnecnfguzu "Re H. 'sir:- . . (2330 -3:-Hgfifthucare Proxy 16. l_certify that this patient continues to require Skilled Nursing Care because: - tax. .17, The resident had _be_en__inforrn_e_d or his _/her medical condition(5): Yese UN9 lint>>. indi?ataereas?ri. A INTERIM NOTES 7 2X5 ff} 5" 44 0 .3.-. 644 rm" ..: It 53.595560*?' 1 A Mr>> xv kw /av /awe>> i . 7 rhea' to" 105" be r/T ram; 1 ~m4{;L (5 - {reifgr?figfng mg p'a as rd st?ms' 'TTnaa:ms+nr "ran rd '-In hriheifig (713) ma} 3; _fl_i_j nab; - g9 3 51. - F-zflv-u. Tfih - 1.. - I 4 ML Cxur.2r4.J-- 91" an 7' flaw. "mg. y_ xa-\x 1 cm LcawAW- rra'.arm'a'nrr an; be fprfauwf be fiv?bofd r=c'mfi .91 A 5 M. . - 12.. 7 NJ) A 51' asa.ch33? - if I5 :'r?ferah'cin?'rhs' to sta rug rrbarnfanr blah" ra' be' Sign and'dare' in (:fiaj' Regeis Care Center Weight Record Log '7 - . . - Resident's Name: - Year: 910' Udfl Room 52%' Ht: 5' CNA Nurse"'s Dietician' Date rite D3 16) Weigh Type of Signature Signature Signature Janna Wk- Wk-1 Wk-2 Wk-3 Wk-4 Wk-5 Wk-2 Wk-3 Wk-4 Wk-5 Wk-1 Wk--2 Wk-3 Wk--4 Wk-5 Revised 1/16x'O6 CNA Nurse's Dieu'cian's Date rm-3 Dam Weight Re-Weigh Type of Scale Signature Signature Signature Wk-1 Wk-2 Wk--3 Wk-4 Wk--5 Wk-1 Wk-2 Wk-3 Wk-4 Wk~5 tember Wk-1 Wk-2 Wk-3 Wk-4 Wk-5 October Wk-1 November December Revised 1.'16.'06 HPATEN F@fi%. (INTER-AGENCY 1.. PATIENTS L1-Aobniz?? (sir?sot. City, 51319. Zip coco)" A 5 DATE on oinn-i .. ., I 3 ,'"fii .- . if :7 Ii A QL if" TnAn?'En HAMEANH TRANSFEFIRING lg. iwsicmli IN AT we or 'i'nAnsFEn' 2 2 5 i Ag" fly Will! is pl1y5iI:i:!n care for -_itien now i L3 Kr" 7* 1 mm-,r7 LII 'res LI no DATES OF STAY AT 1. SOURCE Eon CHARGES To PATIENT SELF on C. EILUE cnoss E. AGENCY FAMILY BLUE SHIELD [Give name; Aomisslom 5 DISCHAHGE PRNATE D. EMPLOYER F. OTHER 5 3 5 5 INSURANCE on UNION 12-A. NAME AND ADDRESS or FACIUTY THAI-ISFEHRWG 12-8. rmme AND ADDRESSES OF ALL HUTSFITALS AND GARE mom WHICH PATIENTWAS DISCHARGED EN i=AsT'na DAYS. 41ffi'-K cunio APPoirm.iEi~n DATE TIME CI our-no 14. DATE OF LAST .2 DAHD ATTACHED If'xx; GUARDIAN. 'a 15. DIAGNOSES AT HME OF TRANSFER l.'J 'res ?1 mo Pllniary lb] Secondary VITALS AT TIME on 3 W29 Fl ALL THAT APPLY Di Incontinence U/Bladder 5ParaIy$is Cl _Bowel Conlracture Dvsaiiva Pressure Ulcer Acliviiz Tolerance Uvyone Moderate Ci Severe . is Pati-En1 Family Cl air .re of diagnosis? Cl YES 5] NO 1' DIET. DRUGS, AND omen at Time oi' Discharge lmpairmenis 3 Mental Palieni knows diaonosis? . Xv! Ll Speech 0 Yes CI Hearing I3 Vgsjon Polenzial for Rehabilitation (Physician, please sign below} sensation in Good CI Fair Influenza vaccination: Dale I . "xi PFIEUNTUCUCCBI Dali? KN (stage allergies if any', TetanusfTetanu5-Diphtheria uaccinalion: Dale Last B.M.: Date I ax' DIRECTIVES TB Test: Dale I Type 4 Flasult 3 VES N0 COPY Chest K--Ray: Dale 2' 2" Result UUDE STATUS Date I I Result Serology: Date If ll-Esult Urinalysis: Date Hesull SUGGESTICINS FCJFI ACTIVE CAFIE WEIGHT BEAFIING LOCOMGTION BED CI Full Partial CI Nona Walk times/day_ Position in good body alignment and on Log Change every hrs. ,qe37'|VmE5 Avoid position EXEFICISES Encourage '3 Group Individual} activities Paone position limes./day as tolerated. Flange of molion Iimesfday. (U Dumdel to by panel," 3 tam'-W Transportation: Ambulance CJ Car hrs. limes/day. Stand Min. limes/day. Car [or liandicapped Bus Sign:-ilure of Physician or Nurgse Pu rm BB2 ran BF H1355, Dos Hniness. IA 50395 mm In Date FATHENT TRANSFER FDRWI PATIENT INFORMATION SELF CARE mi 5: {Check level or ability. Write Sin space 2 +1 '3 it needs superuision only-. Draw line 3 'as across it inappiimnaTums ADDITIONAL INFORMATION BB3 -- [Explain necessary detoits of care, diagnosis, medications, treatments. prognosis. teaching. habits, prelerences. etc. Therapists and social workers add signature and title to notes.) its Face. Heir. Arms v/ -- -- A - Trunk Perineum Personal . . Lower Extremmes Hygiene -- - - Bladder Program I Bowel Program 7 i_ Upper Extremities Trunk Dressing .. . - - Lower Extremities 1 - Appliance, Splint 'wxg Feeding Sitting Trensier Standing .1 I. Tub Toilet Wheelchair Walking 31 .5, $tairs 1/ BED - ow Mattress: $1 Firm Other Side Hails: :1 Nu BEHAVICIFI -J Cooperative Oflented Disruptive Eelligereni ombetive senile Suspicious MENTAL STATUS Alert tit Forgetful Confused COMMUNICATION ABILITY Yes No Able to make needs known Can speak Can hear Can write Understands speaking Understands writing Understands gestures Understands English I 1' If no. state language spoken or understood: DIET biifgguiar Ct Low Salt i'J Diabetic Bland SOCIAL INFORMATION Low Residue [it Other {Adjustment to disability, emotional support from family. motivation for Feeds Se" Needs Help self-care. socializing ability. financial pIan. family health problem, etc.) it Partial Assist 11 Total Assist RESIDENT USES CI Appliance -1'1 Catheter (date of last change r' Cotostorny Cane crutches CI Prosthesis Walker C-'heir t'_I Hearing Aid Dentures (Specify OTHEFI EQUIPMENT OWQTEIIT PATIENTS LAST NAME FIFIST NAME MI 2. SE): 3. SOCIAL - ADDRESS (Street, City, State, Zip Cadet 5; onTE_oTHIS TRANSFEH ti. FACILITY I-IAME Al;lQ Aooijss Tnfiusrennrmo IQ I J, _1 9. IN CHARGE Will this physician care [or patient facility? was I: no If]. DATES OF STAY AT FACIJELITY I1. PAYMENT SOURCE FOR CHARGES TD THANSFERHIIHG mom A SELF OR CD BLUE CROSS E. PUBLIC AGENCV 5 FAMILY BLUE SHIELD {Give nzirnel ADMISSION DISCHARGE I BI PRIVATE o. OTHER 5 5 I:Ioi=. UNION (Explain) NAME AND ADDRESS OF FACILITY TFIANSFEFIRING Fflolalj 12-B. NAME AND ADDRESSES OF ALL HOSPITALS AND GAFIE FACILITHZS FROM 9' gr'; 1 WHICH PATIEPIT WAS DISCHAFIGED IN PASTBO DAYS. (.15 I I IL-9.-APPOINTMENT DATE TIME CLINIC 14, DATE OF MST PHYSICAL EXAMINATION APPOINTMENT CARD ATTACHED GUAHUIN-JLL fr' -123' omouoses or; - I Ell? nsweo: lit was CJ NO IJTI Ir(4. aien army awmeo iagno IS OF THAN3FER 5: I DIET. DFIUGS. AND OTHER TH EFIAPY I.- 5' .1 2 at Time oi Discharge Ft BIP CHECK ALL THAT APPLY Disabfiities Incontinence Amputation fl/Bladder 2' . -- I . I: fracture Saliva CI Pressure Ulcer Aciimix Tfllerafice Limitations El'None CI Moderate Severe Impairrnents L"-l"MentaI Patient knows diagnosis? :3 Yes No Hearing lg Vision Potential for Rehabilitation (Plwsicion, pie-so sign below] Sensation Good Fair Cl Poor Inltuenza vaccination: Date I PHBUTITDCDECEII IPPV 23} DEIIE I (Stale allergies ii any} Tetanus/Totanus--Diphthena vaccination: Date 1' If I Last Date I I DIRECTIVES TB Test: Date I I Type Result I3 N0 3 COPY Attached Chest X-Ftay: Date Result 5- C.E.C.: Date 1' Fiesutt Serology: Date Result Urinalysis: Date I 4' Result SUGGESTIONS FOR ACTIVE CAFIE WEIGHT BEARING LOCOMEJTION 2 BED - nf; (1- LJ Full Partial on: Walk - I -- times/day Position in good body and on Leg change position every hrs. socIAi_ Acrwm 53 Avoid position EXERCISES Encouraget Group [1 Individual) activities Prone limesfday as tolerated. Flange of motion tirnesfday. (U Wm" omsida home' to by If patient 3 nurse Transportation: 3-Amhuianoe Car ihrs. limes/day. Stand Min. timesfday. Car for handicapped BUS I. it /in ,4-on Signature of Physician or Nurse Ii Date -I BB2 BRIGGS, TRAN ggfiffl PATIENT INFORMATION SELF CARE STATUS (Check level 0! ability. Write in space it needs supervision only. Draw tine acmss it inapplicable.) - - - Turns ADDITIONAL PEFITINENT INFORMATION Bad - 2' [Explain necessary details of care, diagnosis, medications, treatments, prognosis. teaching. habits, Activity 5 preterences, etc. Therapists and social wart-;ers add signature and titte to notes.) . I its - Independent .. . Needs It ._As'sis1ance Unable To Do 53 .. Face, Hair, Arms Trunk perineum 1, .r . i I Perfiunal Lower Extremities B|adder Program I .- .. If Elowei Program Upper Extremittes t/ 'Ru E. ti' Trunlc Lower Extrernities Appliance. Splint .Fee::lirI'g" :f I - Sitting L, . Lt 1' -I-I Standing ff Transfer - 5' -- Toilet f' vr' 2'1. '3 i Wheelchair INEIICIFIQ . BED _EfLow Mattress: Ell-'arm Fig. Other Sidet'-tails: BNO BEHAVIOR Cooperative El Oriented Dismptive I3 Beiligerent El Cornbative Senile Suspicious Ct Withdrawn MENTAL STATUS Alert Fongetful Cl Cnniused COMMUNICATION ABILITY 'f '(as No Able to make needs known ., Can speak Can hear Can write Understands speaking Understands writing Understands gestures Understands English If no, state language spoken or understood: 7' DIET Regular Cl Low Salt El Diabetic CI Brand SOCIAL INFORMATION Low Residue El Other mdiuslment to emotional support from family. motivation for .3 Feeds 33,; News Hap self-care. socializing ability. financial plan, family health problem. etc.) Cl Partial Assist D-'lfital Assist RESIDENT USES Ct Appliance Catheter (date cl last change I 1' Cl Cnloslomy Ci Cane Crutches El Prosthesis Walker E2 Chair Ct Hearing Aid Dentures (Specify OTHEFI EQUIPMENT .e5a new tetateaeeret emmt. (INTEFI-AGENCY REFERRAL) 1. LAST NAME MI 2. SOCIAL sEouRIT'r NUMBER - I- ran ix (.2. . i 03': -I. ADDRESS (Street, City, State, Zip Code] Li 5. DATE OF BIRTH 2 ,5 A 1 A 53FACILITY NAME AND ADDRESS in PHYSICIAN IN CHARGE AT TIME OF TRANSFER . - - . . g-I ll' If 1 - (-7 Will this physician care for patient alter aclrnission lacifily? Ct YES ND DATES or STAY AT FACILITY 11. PAYMENT sounce FDR CHARGES To 7_ THAI-ISFERRING I -, 5 sq' I t' A.D SELF OR CB BLUE CROSS E. PUBLIC AGENCY - BLUE SHIELD (Give name] I 5 DISCHARGE PFWATE OTHER it 5 gig; 5 jfijiji on UNION (Explain) 12-A. NAME AND ADDRESS OF FACILITY I2-I3. NAME AND ADDRESSES OF AI I AND exrertoeo oARe FACILITIES FPIJM WHICH PATIENT WAS DISCHARGED II-I PAST 60 DAYSDATE TIME CLINIC H. DATE DF LAST EXAMINATION APFOIIJTIJIENT '3 I I I Cy. AWACHED 15_ RELATIVE 16. DIAGIIOSES AT TIME or TRANSFER RELATED: l"-I .. I pg. to is Patiantifl at-mm ol diagnosisVITALS AT TIME OF TRANSFER 1 DRUGS. AND QTHEFI '{HEIqp_py r; A i at Time or Disclterge 7'30 5% CHECK. ALL THAT APPLY Disabilities Incontinence 1 I I Tutation <> {soul FQRM US PATEENT SELF CARE STATUS (Check level ol abflily. write 8 In space ll' needs supervision only. Draw tine across it inaopficabla.) lridlezpl 'ehHeni 3 Needs I_3l$5is1_an_cei ADDITIONAL PERTINENT INFORMATION Cx lain necessa details at care, dia nosis. medications, treatments. rn nosis. tcachin . habitspreierences, elr:. Therapists and social wort-rers add signature and title to notes} Tums Sits Face. Hair. Arms :17 7 .: Trunk Perineurn Personal .. Hygiene: Lev.-er Extremrties Bladder Program I Bowel Program upper Extremities in Trunk Lower Extrernities Appliance. Splint snfing 5' I irir it /7 iv as r~ Standing 'olefir>>: ax Wheelchair I -- r' . 1 Stairs BED iJLow Mattress: EtFirrn Dfieg. gm, i. Mt . .. Side Rails: Yes in No if: I BEHAVIOR El Cooperative Oriented :1 Disruptive gcombauve Cl senile El Suspicious I3 Withdrawn MENTAL STATUS Cl Forgetiul -I/{Confused coMMuNrcA'rioN AeIr.rnr -I Able to make needs known Can speak Can hear Can write Understands speaking Understands writing I Underslands gestures Understands English '1 it no. state language spoken or understood: I orsr Regular El Low Salt El Diabetic El Bland SOCIAL INFORMATION Low Residue :3 (Adjustment to disability. emotional support from family, motivation for geeds Se" 5. Needs Help sell-care. socializing ability, financial plan, lamlly health problem. etc.) El Partial Assist Total Assist RESIDENT USES Appliance El Catheter (r:lale'bf last change I CI Coloslomy Cl Cane crutches Cl Prosthesis Walker Ct Chair Ct I-tearing Aid [3 Dentures (Specify OTHER EQUIPMENT Regeis Care Center Weight Record Log .3 fl . Resident's Nagne: 5&4, A, Year: Room 5 5% 1 Ht: 5 33 CNA Nurse's Dieu'c1':1n's Signatur Sigma Signature Re--Weig Type of Date (Write Date Janu Wk- Wk-1 Wk--2 \Vk-3 Wk-4 Wk-5 Wk- 1 Wk-2 Wk-3 Wk-4 Revised 1/ 1 6/06 CNA Nurse's Dieticialfs Date rite Date Weight Re-Weigh Type of Scale Signature Signature Signature Wk-1 Wk-3 Wk--4 Wk-5 Wk--l I5 . Wk-2 Wk--3 Wk--4 Wk-5 Wk--1 Wk--2 Wk--3 Wk-4 Wk-5 October .. Wk-1 Wk--2 Wk-3 Wk-4 Wk-5 November I December Revised 1/ I 6/06 REGEIS CARE CENTER Physician Bladder Assessment I . my (4 I Residenfs Name; a- . 5' 'Dis'? Room: 5 5 Date of Admission: 5 /5 Criteria: Resident bladder fiinction 4vill be ass%secl upon admission, readmission, or if resident has a significant change in status and when catheter is discontinued. 1:1 Comatose El Imznobility El DM El Parkinsozfs c1 Para!Quadriplegic tJ CHF/Pedal edema :1 Tenninal Illness El Recent Stokes :1 Cognitively Impaired El BPH - Other: Cufigt Medications that mav affect Continence: Diuretics Antihistamines Other: Hypnoties/Sedatives/Narcotics El Anticholinergics El Calcium Channel Blockers CI Antispasmodics Risk for UTIs: El Fecal Incontinence C: Use of Catheter Cl Poor Fluid Intake History of UTI Urinary Stricture/Retention Other: Treatment Plan: Able/to use toilet I: Urology Consult Reason: Other: El Medication: EI'Refer to Rehab Sun1maxyfCornments: Check if Appropriate: Bladder Function Assessment: Inonntinent: Lifyes CI no 1/ 1 Catheter: Cl yes @114 Reason /for catheter: Neurogenic Bladder Pressure Ulcers I have determined that resident is incontinent may be due to the following predisposing factors and medical conditions: MID Signature: l/ll) Date: 3; . APPENDIX IV Physician Bladder Assessment I . Nu 3 Lg pmofgfim, A 1 __flQ' P-- . '4 If mm; 1:6' Wamlly: '40 1 cmusmxmana gcaamuimrogkoziiyIf-Damoflfifique?t 2 -Eimttujai . . 'b MD. "1 A'/Cirgsa' 1 Rqfiawad by ]Agmn Nntna Igy Nlutv-an Managawfiufinfim er Change Nuwar - 8@h_nrb: mm - rum-umnmwu nanamunaaua-awn . I - /9 (La. Residents Last Name F2752 - 686 Sex Rrn.#_ ., RIGHT EU I 234567391011 I2i3I-4|5i6 I 1. T32 3130 SERVICES SYMBOLS i or -- Missing - Fnnric - Crowned FIT -- Root or Blank 1- Youth Present 0 - Other Specify) - I - Residlant Has: I I . I. Dentures or removabic bridge . . -, . Type 2. Somefall natural teeth last. Does not have or did not use dentures or partial plalcs A 3. Broken loose or carious tcelh 4. [nflamed gums, gingivn, oral swollen or gums or ulcers. rashes Periodontal Candilion Good Fair Poor NIA 5. Oral Hygiene Good Fair Poor (Mouth Odor 1 Patient functional with prasentoral condition -- NIA nfeninnl rfi Alicrgie-5:4 Ar/'1 DATE afimrr %;M'lk COMMENT SIGNATURE I DENTAL ORDERS PROGRESS NOTES 3399 DATE COMMENTS SIGNATURE PROPERTY OF DENTSERV DENTAL SERVICES, 13.6. 00 NOT Facility Primary Care Optometry, P.C. EC 31 Procedure: Dx Room 11 Dr. Joseph N. Lieder Tel. 845 356 3156 "dent i rec-'3" ExamDate _r'caid EH4 Other initial Exam Previous Exam Date I I Admission Date I 3 []flu Order Date #35' Related Medical Dx: []Diabete5 []Sleroid Use Ocular condition: [lcataracts Glaucomaitlc HTN/Optic Nerve Disease Retinopalhy infection or inflammation PalientComplaint: Reduced vision Ocular pain or discomfort Questionable vision status[] Faiis[] History: . . . 7 ..--1 -r .5 I Opmh Meds 9 23:0 1/ e. Reviewed Gen Meds FA 4--5, rs} =3 Na: E-.-. Allergy: gulfa asa '-;entRx: 7" if 1% Cover Test: Exo Eso Cornea Sin ""0-pars' EOM: Full Iris . Flat Gross V.F. Full Anterior Chamber - Pupils: apd -'l'xr-an conjunctiva Hyperemia Lesion Posture Lens, Lids Blephrilis L_ct iot Lesion .3, Ophthalmosoopy fa-We - ore 1-1% be inoscopy: *9 K53 VA. Tonometry: Ta I VA. am Subjective VANear Test Frame Size Color PD Additional: Diag nosis rs-Q Lu. 5 .4: (L, V4 -cl Kw" --'Position Mos Determination: Liaebjective Recommended i Vision: Visual Limitations Dilficulties Visual Appliance []Side vision problem Glasses Refer: Ophthalmology impaired [].Specitic Experiences Htlo Retina Consult Moderately impaired H'NEine Legally Blind A Highly Impaired I Severely Impaired Cataracts 1 Macular Degeneration Examiners Signature Glaucoma Optic Nerve Atrophy 3 Physicians Signature bah' Facility Consultation I Optometry Procedure: Dnomii Joseph Lieder, .0.D., T.P.A. Cedifiecl uesident Mi Exam Date +1335: Medicaid If <3 8 I2 Medicare "r 4 Other initialExam Ptevious Exam Date I I (Re) Admission Date 7 I (f!u)0rder Date I up Related Medical Dx: {]Diabeles [icwx []Steroid Use {l Ocular condition: []Cataracts Glaucomai Dc HTN {Optic Nerve Disease Reiinopathy Infection or inflammafion [1 Patient Complaint vision [10cn|arpainor discomfort Questionable vision status Falls[] History; Ophlh Meds Reviewed Gen Meets =9 Ailergyf 'su|fa asa - 343 CoverTest: Exo Eso Cornea EOM: Full Iris Flat Gross V.F. Full AnteriorCl1amberD&C . ,1 Pupils: apd om. conjunctiva Hyperemia Lesion Posture Lens" R_ot iot - Lids Ellephritis I K3, L_ct 0 . Lesion I-K. Ophlhaimoscopy - "45' t. ii' x1--'T'vv 9% Retinoscopyc ":57 C3 VA. Tonometry: Ta I /33 V.A. am pm Subjective VA. Rx sv it rd VA. add Near Test Inc Frame Size Color PD I Additional: 3 Diagnosis: (3 '9 "iositioni in 1 -4-7 d' NJ. - Recommendation 8. RX .. igr7- MUS Determination: Recommended Fl i 95 Vision: Visual Limitations I Difficulties Visual Appliance {litdequate []Side vision Glasses []Yi35 Refer: []OphlhaimoEUgy rnpaired []Specific - [.aH7 gap 62;; Tflingl 'Mfr $314 - exgv ivx fix) U4 qR:uJ= ~rEH,s1.0,4% a fifimfixg xu eaF355 I 1 xCxg. In aykxbugcga Pr 0:4 ti?) 5 L3>>/vn fa k} ,fi Guam UK {Pill 1jj"UQ@'Efi'T PROGRESS NOTES CONTINUE Wniinu (710) Farm No. Podiatrist'-5 Name Regeis Care Center NURSING ASSESSMENT RECORD - Residents Name: Qt 4J gnomit Chartii 5"-5 Date oiadrnissionz i i time: 6% AMQQ By: Ambulatory Wheelchair Stretcher Accompanied ?10 Contractures: Location: Admitted from: 63,. A'"fib Ln' he Allergies: _wW_ Oral Assessment: Condition of Orai Cavity: Cfificistu Teeth: Gums: Missing Teeth? Dentures? Upper: Lower: Partial: Observed Difficulty Chewing? 1 Swatlowing?__X?Q_ Uses dentures for eating? fl Mouth Pain'? Characteristics: Fool Problems include corns, callouses. bunions. etc.) Open Lesion Other: . . r- 2 Wrist Drop: ot drop: Height: Weightq7( fie) - 1' E9 Vital Signs. T. P. quaiity quality . Behavior: Oriented Disoriented Confused t/r Alert 3: Lethargic Friendly 0th Prosthesis: Glasses EH\eari[1g Aid_flQ( Artificial Limb (specify) Pacemaker Spiint l7 Sling NU Cast Q12 Braces AID Cane Other (T Diet and Eating Habits: Diet W0 K-P Preferences U2 Assistance Needed 6' 5 NGT mt') Gastrosiorny Tube 0 Bowel History: incontinent: YES M: NO Regularity [how often} It constipated, what does resident take or do? Bladder History: Nocturia Continent: YES NO Fotey 4/0 Size Drainage /if//4 Tube 1/0 Size 14 Drainage Habits: Sleep 0 ,3 Smoking 1' Sociai History: Langua Spoken Hobbies 57 Previous Occupation: Ftellgion: Marital Status: ti" if' Reaction to Placement (agitated, signs of depression, 0 AOL Skills: (Ability to bathe, dress and transfer, etc.) Expressed Personal Preferences: Orientation: Was resident told _J4?:Name of Nurse #65 Name of Nursing Home Name of Attendant Assigned Use of Gail Bell Ftestcient's immediate expressed concerns and questions: nility To Understand Verbal Instructions? Yes Nolii Written instructions? Yes No "ledge of Educational Needs.' Treatment Plan? Written instructions? Yes No Form No. FINH-119 Nursing Care Needs: Immediate: 1/ fl7'5'3C-- 'fl' if/vol/cfow Nursing Care Plan initiated by: information obtained from resident: Family (Name and relationship) if no data obtained, give reason: Pain Assessment: Current Pain Medication in Progress: SUBJECTIVE DATA: Resident complaints of pain: Yes -t No If N0 skip to Objective Data. If YES, how intense: (Circle as indicated) Do you have pain daily? Cl Less than daily? uged 6181-Bpow uied 1310M 01 OBJECTIVE DATA: Facial grimaces Refusing to eat Cl Striking out. pulling back when any body parts is touched Withdrawal lrom activities CI Grasping particular body part DISPOSITION: No Pain: Continue to monitor for changes: Evidence of Pain. continue evaluation on pain assessment form. SKIN ALL MARKS, SCARS AND SOFIES, PRESSURE ULCERS, Nurse's Signature (4/4 Date I Signature Date REGEHS CEQRE CENTER F1 a - Doctor 'Lax goo," No_ Name Date and Time 13 cg", bk 5 . r.uk/gnr Qt/. Fiveboro Pn'nIing,LId. (M93431-9590 Form Ha. ggfifgg HEGEIS CARE CENTER NEJRSES MOVES Room No. Nurse's Name Name Date and Tim "x .jrfc4/fife-V :26 .43. tfma?ota we .5554-u, ,0 70-2. r' "nip 43.. - *OoLc?o2?Z.f1/ .5 3 7 5, 7-Cid-L' -- . 735 57-33.14' Eff 2.1' 753". zc flair"- (L. i pf -- /341'f'/'ilotb. -V5 Lf''7-z_ -3 - 5 3'5' J7 '"Li a 5' Fvaboro Printing. Ltd. 431-9500 FOITH No. RNH-16 REGEES CARE CENTER A 7 Name (3'C-Cit . :30 :17 Doctor /11 Ur ?114.? Room No. Date and Time Nurse's Name '34: 0\\5Le1 Of': F'weburoPI1nling.Ltcl. (71a)431~95oo Farm fig REGEIS CARE CENTER NISRSES Name Doctor Room No. 1? Dale and Time 0 en . r1 3'0? ra' r= Fiveboro (718)431-9500 Form fiufisglg Nafgs REGEIS CARE CENTER Name Room No. 1, I Dale and Time . Nurse's Name 3 - "ts LO I"-Wetaoro Pfinling, Ltd. (1713) 431-9500 Form No. REGEIS CARE CENTER NURSES NGTES Doctor Room No_ Nurse's Name Name Date and Time I .01(137491. 5&5 *7 I . I 15:? 211; a 0 .237>> Ju . mev. A.ox@6550 - 0 LM ow. 0, 5* 1'47'! . 06,4; wuowi uaxizmi fr ca -- ,3 -7 9C. 414; op.) Fivebnru Printing. Ltd. (718) 481-95-00 Form No. HNH-16 Regeis EURare Center nunsrne ASSESSMENT Ftesidents Name: I Roomii --5m'Chart# 're 75' 0 Date of Admission: NW Ely: Ambulatory By: Admitted from: Diagnosis: ,1 _z Oral Assessment:.Condition of Oral Cavity: Teeth: Gums: Missing Teeth? Dentures? Upper: Lower: Partjai: Observed Difficulty Chewing? C) Swallowing? Uses dentures for eating? Mouth Pain? ?531>> Characteristics: Contractures: "Location: Foot Problems (include corns. callouses, bunions, etc.) #9 0 Open Lesions: Other: I Wrist Drop: 39:1 Foot drop: Height: or (T Weight: (Ce (5 _y Vital Signs: T. 52% 7 quality Fl P. (H . quaiity_%_ . Behavior: Oriented Disoriented Coniused__L_Z L: thargic Friendly Other Prosthesis: Glasses '6 Hearing Aid Hit Artificial Limb (Specify) 9 Pacemaker {Jo Splint pi. Sling 0% Cast in Braces at Cane i9-3 Other Mi Diet and Eating Habits: Diet 9 Preferences UM Assistance Needed NGT Gastrostomy Tube 0 Regularity (how often) Bowel History: incontinent: YES NO it constipated, what does resident take or do? Biadder History: Nocturia . Continent: YES NO Foley Size Drainage -- re - arr>> re" Tube Size 1' Drainage /airy': Habits: Sleep . Smokino [Z/rt Social History: Language Spoken Previous Occupation: C/t Fieilglon: I -wbe rviantal Status: WTW- Reaction to Ptaoement (agitated, signs of depression, anger) ADL Skills: (Ability to bathe, dress and transfer, etc.) .l-f I7 Orientation: Was resident told Name of Nurse Name of Nursing Home Name ofmtendantfitssigned Use oiCallBell if Residents immediate expressed concerns and questions: I Expressed Personal Preferences: '0 Ability To Understand Verbal instructions? Yes CI N016 Written instructions? Yes Nfigif Knowledge of Educational Needs! Treatment Plan? 52 ,3 Written Instructions? Yes Ci No,Ei'/ Fivebaro Pi-intino (718) 431-9503 Form No. FINH- 119 Nursing Care Needs: lmmediate: 3/ gfadu pi'? Nursing Care Plan initiated by: Family Information obtained from resident: [Name and relationship) If no data obtained, give reason: Pain Assessment: Current Pain Medication in Progress: If NO skip to Objective Data. I lill ll SUBJECTIVE DATA: Resident complaints of pain: Yes No 1 If YES, how intense: (Circle as indicatedyou have pain daily? Less than daily? .0 .5. 35 E. OBJECTIVE DATA: Facial grimaces :1 Refusing to eat CI Striking out, pulling back when any body parts is touched Withdrawal from activities Grasping particular body part E3 DISPOSITION: No Pain: Continue to monitor for changes: Evidence of Pain, continue evaluation on pain assessment form. SKIN INDICATE ALL MARKS, SCARS AND SORES, PRESSURE ULCERS, 1 I Nurse's Signature Rx', Date 7 .. la' a RN's Signature /1 Date HEGEIS CARE CENTER NURSES NGEES Doctor Fioom No. Name Lies"-L i, /31' at Nurse's Name Dale and 59/4' 0 "l/E 1-Li . 56 cxr? J7 _/477" . 7'9 /ab' 5. 5 . 7 ca>> 1! . .272, .- (L fl/' 57!. 4 .17 3 I fl- .0242531,: ca--L. 5 95. ~76" aw /5 70 if 5.- 'flu cf r"i- . . I "7 - .-tr /1914: I -r M59 538' air /mi. MT ck-- 671.. I I- Fivetmrn F'rFnlir1g.LId. (718) 4131-5500 Form No ES REGEIS CARE CENTER NURSES NOTES Name-~~iQ--K9 Doctor Room No. Date and Time 1 3 Nurse's Name A 2' . /bf. Co 4% <> ~61'11' GM at-/Vera. Ch,-1 . I cry Cirw 1,3 -- Lam>> JQ-.3 . . -- db? 'Lit, Fzvabom 431-0500 Foam REGEIS CARE CENTER NERSPS NOTES 4/ . Doctor Room No. 32-3 Dale and Time Nurse's Name 0 5" Name lxn, eflo End cu:.u~ WEE . camxx. mg. (3 (L52 wax: "u . u-Wk J11cs>> LEI. (718) 431-9500 Faun ND. FINH-16 REGEES CAHE CENTEQ Name HG Room No. Date and Tim gawk [Liz gw Nurse's Name I ww rxm?bw Mr - L45. 'ii Fhrabom P:1nting.Ltd. (71a}4a1-am REGEIS CARE CENTER NURSES NGTES -, . .T Name (J Doctor Floom No. Dale and Time Nurse's Name FIvmomPrinting.Lld. (715) 431-9500 gag-E3 Date and Fivabmo Pumng. Lied. 17151431-am Fem: Ma. as-m--1a 17 . Name 3' fl REGEES CARE CENTER Room No' Nurse's Name -- 4 0 I . . . Lee; . Le," Kr 45-" r' Jf, A /1 REGEIS CARE CENTER NURSES NOTES I Doctor Room No. Name -x Nurse's Name . _7 --.. an the 6 Dale and Time ":banana 1 ;l.'I1.fl5N'J Form Nun. HNH-13 HEGEES CARE CENTER . I Name Doctor "Hgom No. Dale and Time Nurse-S Name It.' 15} VJ {71a}431-9590 fififiggsg HEGEIS CARE CENTER NURSES NOTES 7/ Doctor /fl Room No. Dale and Time . Nurse's Name /57; 92 59%' nun Regeis Care Center Nunstme ASSESSMENT necono Resident's Name: Floomtt 53-? Charts -52,5 . . . -71 Date of Admission: Time. as rm>> Si By: Ambulatory Wheeichair Stretcher Accompanied 9 Admitted from: n"-95L C94-3JLC-I Diagnosis: 914?' I a 5 RD HWD Allergies: .7 Oral Assessment: Condition of Oral Cavity: Teeth: Gums: Missing Teeth? Dentures? Upper: Partial: Observed Difficulty Uses dentures for eating? TLD Mouth Pain? Chest/Abdomen Characteristics: Contra:-tures: "h/6718, "JLocation: "4 i . I 9 Foot Problems (include Corns, caliouses, bunions, etc.) +0 'inf pie: and Eating Habits: Diet Open Lesions: Other: Wrist Drop: Nit" Foot drop: git?' Height: Dfl;/fie; Weight: Vital Signs: T. quality Ft. 51-0 quality B-P. EC: Behavior: Oriented Disoriented Confused Aiert Lethargic Friendly Other - Prosthesis: Glasses Hearing/Aitzt tr Artificial Limb (specify) Pacemaker Splint Nita Sling /Wfi Cast Braces Cane Other Assistance Needed Preferences NGT Gastrostomy Tube Bowel History: incontinent: YES NO Regularity (how often) If constipated. what does resident take or do? Bladder kijstory: Nocturia Continent: YES NO Foley WES Size ioflgi Drainage Tube Size Drainage Habits: Sleep Srnokinq gsociat History: Language Spoken Hobbies I . [Previous Occupation: 0 Religion: 'c69'Lfi"'d' Marital Status: Reaction to Placement (agitated, signs of depression, anger) ADI. Skitis: to bathe, dress and transfer, etc.) Ltvx, Orientation: Was resident told Name of Nurse Name of Nursing Home 5'9 Name of Attendant Assignedjw Use of Call Bell Resident's Immediate expressed concerns and questions: Expressed Personal Preferences: To Understand Verbal instructions? Yes Ct No Written instructions? Yes No.Cl Knowledge of Educational Needs/ Treatment Pian? Written Instructions? Yes CI No Cl Fiveboro Prinling (716) 431-9500 Form No. HNH- I19 Nursing Care Needs: immediate(3.: Nursing Care Plan initiated by: Information obtained from resident: Family (Name and relationship) it no data obtained, give reason: Pain Assessment: Current Pain Medication in Progress: SUBJECTIVE DATA: Resident complaints of pain: Yes No If N0 skip to Objective Data. If YES, how intense: (Circle as indicatedyou have pain daily? Cl Less than daily? El -3 3 TJ OBJECTIVE DATA: Facial grimaces Cl 3 :1 Refusing to eat Cl C) Striking out, pulling back when any body parts is touched Withdrawal from activities 0 Grasping particular body pan DISPOSITION: No Pain: Continue to monitor for changes: Evidence of Pain, continue evaluation on pain assessment form. SKIN ALL MARKS, SCAHS AND SORES, PRESSURE ULCERS, Nurse's Signature Date ET :1 RN's Signature Dail-1' O5 amass CARE CENTER -T Doctor Hoon1No. f" yams Dale and Time Nurse's Name -- 5* -WVK Lo, amp' 3, . Maw') "km. wax". Cjxca .-A kg . - - . (Q. G..- Co'? (LC: C1. gm . L2. :1 Sikwihiq '1 13.3% - qauxg ., [iv ac" L.--Z \r mm . Prtn-mg. Uzd. 5'18) 4:31 Na. RNH-16 REGEIS CARE CENTER NURSES NOTES .55 Room No. DGCIOF Name Nurse's Name Date and Time . K, L/flax"! is 1 5, - qj' 42,5' cm ..-.-.4. u. nuu an REGEES CARE CENTER Nama Doctor 1/ Roon1NQ_ 5 Date and Nurse's Name Agared? 5.31iiglxu - -L TI we . bv?c ?116/L1-rt - (715)431-9590 REGEES CARE CENTER NURSES if . Name Doctor .r Room No. Nurse's Name . LG 753 2/24/La>>? Ex - \L5l <>? 7 9 E: I ..- mamfiawfi mflfififi <> ijncm :77 CJOK xxDoct lame "Prim; Signature 1 . A32 . Family 1 patient aware in' realistic goals Q/Disciisseii with nursing stat'! Total Face to Face Time (minutes): >15 :25 :35 ;=55 >30 >liO Form "ll 401B7WCA-I 1 l!Ot3 ll'-'rt W-NU 2000 Vottra Health Services Vohra Health Services WOUND CARE ASSESSMENT Key: txl= net: (vi P05 '/Facility Dale Referring PCP. Dr CONSULTW Name Allergies Age (teen Past Medical History: Presenting complaint: Pain: verbalizes no pain Qverbatizes pain score (0-10) Social History Home killed Family Historyphys. evidence of pain withdrawn crying restless agitation Appearance 3 Cachectic Agitated Qcnniuserl Calm Arterial Doppler Ce-operative immobile Clean Content Vitals Temp: afeb BP RR Neck Supple NT No mass EMT wot Head mm, clean Anicteric Flesp CTA good AE BIL wheeze rhonci CV3 Murmurs ABD Soil No t_iur'Kidr'SpI PEG Skin Hyperpigmen Dry Pertn Foley oath. Fungus Dermatitis Excoriation Vascular: Pulses L. Pop: L. PT: L. DP: Ft. Pop: Ft. PT: Fl. DP: Cap. Ftelill 1 secs Extremities: Dermatitis Cyanosis Clubbing Nail Contractures Hair loss Edema I Labs: [3 Alt: [1 Hb>t2 HE3A1C as Peg Zinc Depression beslty Other systems rev_d weight loss Neuropathy Edema Flenal failure Tobacco lncortt. Feces Hypoxia Pain addressed contusion ven./art. Hospic Parkinsons lmmunosupp. Liver lallure Diarrhea Medications (inhib) Agitation Underweight COP Anemia Cancer immobility CAD Bed Regular Grgtip 1 Group 2 Group 3 Chair: Regular reduction Gel cushion Hoho Feet: Flegulari bunny Eadie I wattle I pillow Easy boot Multipodus boot SITE 1 SITE 2 SITE 3 SITE 4 SITE 5 Location Etiology Exam: Size (cm) at I 1/ I ,1 Under mining (Gm) . o'clock . o'clock o'clock . o'clock Exudate: serous serrfi serous serous serous Amount: Qsmall Qrnud Qtarge Qsylull Inna Qtargrl Qsmatl large Qsnlall mud Qtarge Qrnod Qlalge yellow slough I fibrin as black necrotic tiss. 'it. granulation tissue as I Additionat inlorrnation pa.-gwuund (radius 2 cm) Qorlor Qer,-th. Itliltig-f Qoctor Qeryth. Qmacfl Qorlor Qeiyth. Qmucfl Qndor Qt-ryth. Qmacll Qodar Qeryth. Qinacfl Sharp Debridement UN Post-Sx Depth I'll PO51-SK Depth Pusl-S11 Uepllt Post-Ex Depth QY Post-Sxfleptll initial stage ti MDS stage MDS Dressings objective Heating Q/Palliation Hea' Paliiation Healing Palltalion Healing Paltiation Heating Pallit g. t' it Doctor Name Signature Family I patient aware nl realistic goals Discussed with nursing start Total Face to Face Time (minutesit} Form ll' -tnrarwon-1 a WOUND CARE key; (x)=neg Vohra Health Services 5 Facility Dale Referring PCP. Dr f( @7915 UCONSULT nos rifle erg Age ost Medical History: njg_/y_Tfl7Lr: /'kgj I Pain: no pain [3 vertialfzes pain soorgo-10) Social History [3 Tobacco [3 Alcohol Skilled Ehfon-contrloulPain: 5. no pm,5_ Evidence ofpam [3 Cl crying restless agitation A pearanoe Cacheclic 'tiled Arierlai Doppler lj Cooperative Clean Content Vitals Temp: 5' ob ee Fifi -?19 Neck ?pp|E [1 No mass 1] EMT wni Head ,rclea'!1 B?dlclerlc Resp CXTA od AE BIL [j wheeze rhonci - [El Murmurs ABD Salt LivIl*ZidJSp| Coloetorny Cl PEG Skin [3 Hyperpigrnen 3'6; Perlneurn Foley oath. Fungus Dermatitis Excorlatign Pulses 1. Pop: L. FT: DP: Fl. Pop: Fl. PT: Fl. gap. Flefili 1 secs Ecyanosls clubbing 1] Nail -fij] Conlraclures [31-Teir loss El' Edema Alb 5: ,1 A ll El HEWG <8 lj Protein Cl Vit 0 1g MVI [j Peg Malnutrition broL obele Contreiciures Depression' inoonl. Urine - Obesity Neuropathy Edema El Fienai failure Tobacco incont. Feces Hypoxia [B-0/t or systems rev.d Weight loss Qziz?lian addressed confusion [j PVDA van. I art. Hospice 1] Pariclnsons Irnmunosupp. failure [3 Diarrhea mrnobillty Medications {ini1lb) [j Agitation [j Underweight . Cancer Bed Efiegular 1] Group 1 Eifiroup 2 . Group 3 Chair: [21-'leguiar [3 Pressure reduction lj Gel cushion Flgaa' '5 Feet: . |j Regular! bunny - Cradle I waffle I pillow Easy boot Qflfiuiflpodus boot SITE 1 em: 2 sure 3 one 4 em: 5 Location Q3 elorooy A/iioizr -- - (om) . o'clock . o'clock . o'ciock . o'clock . o'clock Exudate: serous .':eruus serous emu: Amount: [Ismail [3 mild l'_'i5fi1iIll Elmdd Dlaml ljmad [jiarge flrnud [llama [jmud El large yellow slough I fibrin black necrotic liss. granulation tissue 'ii: Additional information . . Cinder Cier1lh- Clmarfl Claclnr Elqmh. Dadnr ljerylh. amen! -:I1oLQe_ryzh. [j Perlwound (radius 2 cm) sharp gm.-adamant Fest-sxnezua [3 ll [1 Y,Post-sxnepoy Post-sxterrlii ljl' Fosl~SxDepih initial stage 3; Mos stage [Falliation ij Heeling [j Paiilatlon Healing Palliation [3 Healing" Paliietion [j Healing [j Faiilaifon I .13 I 4 4% and gafolzen' -725 Ar}? (Argo ojgvxa of; pjaoo r~/mo of/miaonoo ea. fol A Ecctr lame (Friar) PJWKUVE - Afr 5 go. /1/flier 0,r-I-Ir? Tr-nl liar-:1 in urr-o imsnuineb qif. I"'l Mfr; 'on r1 51 if] Form -101 IJTWCA-1 '[1/55 addressed confusion Medicaflons (inhibi Cmgilation [j Underweight . Anemia Cancer CAD Bed: I34'-ijggular Group 1 C|_Group 2 . Group 3 - -- Chair: ijfieguiar [3 Pressure reduciion [3 Gel cushion i'-jpiqo "5 Feet: :1 Heguiarr bunny Cradle 2 waflie I pillow I 5: Easy boot rgrwumpadus boot I I I I SW5 1 SITE 2. SITE 3 SITE 4 SITE 5 fa 593' 5 . - Ar-EiigamUnderrnining (cm) o'clock . o'c!ocic o'clock o'clock o'clock Exudate; scmus Cimrpus [Jseruus 1] reruns Amount: [jarnuii zjmad [jizinja Danni! Iran {jrnad ljiarqu Dsmaii Ejrnad fllarge [jsrnaii [jmod large Vohra Health Serficesj' WOUND CARE key: pog' Dale Fieiemng PCP, OHSULT i - i Aller ies - Jim 'EC?:inae am; 9 - Age i Pasi Medical" are - . I Pain: [Zf-verbeiizes no pain [j verbaiiz-es pain score Sociai History [1 Tobacco Alcohol no-term N.H0me [3 Skilled Family History: oniribui. i 1 "i . .: Pain: Eifo phys, evidence of pain wiihcirawn [j crying [3 restless Appearance |j Cacheciir: Cl Agitated ijflonius Drcalm Aflerlal Doppler - Cooperative ijglfimohiie [j Clean [7 Content Vitals Temp: mien en He 76 RR /05" Neck gr?uppie [grin [3 No mass 53 Ei-1'1" wni Head . do an Q/Anicta-Tic Resp g'CgA AE BIL wheeze [3 rhonci . HRH Murmurs AEID oft Liv/i~fidiSpJ colostomy PEG [3-fJr)y Perineum ij Foley caih. El Fungus Dermalitis '_:uiar: Pulses Pop: L. FT: L. DP: H. Pop: i R. gap. lsecs iamilges: zfi Dermatitis E-Cyanosis lj Nail Qfloniractures i3'fi'air loss Efdema 131- Alb wni ,1 HEWC <3 Appetifa :3 Protein Vit r; 1g MW [3 Flag :3 Zinc' Diet 5 H51 reviewed ementia [j orol. [j Diabetes Conireiciures Depression" lrzconi. Urine - [1 Obesity Renal failure [3 Tobacco - [j incont. Feces |j Hypoxia 0 systems rev.d [3 Weight loss Neuropaihy Edema an-I ij (3 Hospice Paridnsons lrnmunosupp. failure iefihea . yeiiow slough I fibrin black necrotic iiss. 'ii: granulation tissue Additional information DWUL Cimacfl Cludar Elmacfi Ejeryth. Elmacfl Ijodnr ijmacfl Periwaund (radius 2 cm) -3 Umicfl Sharp Debridernent i-'rai--SxDEpth [3 [j '(Post-Sx Eerie Fast-Except: [1 [Jr Pie:-sxcapai ijfl siege 8} MUS stage MUS WA MUS [jr~i1'A MES |j MDS iifii MUS i_ isings - nag,' . . Objective [j Healing ij [j Healing Healing - *1 I 1 =5 79' 0/0 r1m'% r? mm-n p@ 33 pm? AM on if?) 750 am 7'0 /fiend-'zga @/iezj V4 Eccicr . I i i I -T ADMITIED FROM: Regeis EURe_re Center Peessue ULCER ., . - are/', DATE: .43 . 57 5'7 DATE OF ONSET: fr ETIOLOGY: 41* r} DATE M.D. NOTIFIED: 0? jseverxmve SKIN CA is USED: A STAGE: - Stage I - A persistent area of skin redness without a break in the skin that is non blanchabie. Stage II - A partiai thickness loss of skin tayers either der- mis er epidermis that presents citnically as an abrasion, Stfiister, or shatlow crater. ige Hi - A fuli thickness lost exposing with subcutaneous IISSUGS - presents as deep crater with or without under- mining of adjacent tissue. Stage IV - A full thickness of skin and subcutanec5us_tissue . is lost, exposing muscie and/or bone. weex WEEK weer: DATE: ,2 357/ ULCEFI fa; STAGE -/sj fgze (L 0) . (S-M-I. 2. come) It |_coND:TioN OF SKIN ESCHAR on SLOUGH (as) UNDERNHNING-TUNNELING (LOC 23. SIZE) (A19 RESPONSE TO TREATMENT - /577 NEW TREATMENT (DATE) DEBFHDEMENT: CHEMICAL A (9 7 MECHANICAL A i - 0? em PHYSICIANS Printing ('fiat 431-9500 Farm No. Regeis Care Center PRESSUFIEISTASIS ULCEFI ADMISSION DATE: ADMITTED FROM: DATE OF ONSET: EFIOLOGY: DATE MD. NOTIFIED: PREVENTIVE SKIN CARE USED: STAGE: Stage I - A persistent area of skin redness without a break in the skin that is non blanchabie. Stage II - A partial thickness loss of skin layers either der- mis or epidermis that presents ciiniceily as anabrasion, blister. or shallow crater. Stage - A fuil thickness lost exposing with subcutaneous tissues - presents as deep crater with or without under- mining of adiacent tissue. Stage IV - A full thickness of skin and subcutaneous tissue is lost. exposing muscle and/or bone. WEEK WEEK WEEK DATE: ULCER STAGE I SIZE (L D) (S-M-I. 3. COLOR) comomom OF sussouwome SKIN ESCHAR OR SLOUGH UNDERNIINING-TUNNELING (LOC 8: SIZE) er-zseomse TD TREATMENT NEW TREATMENT ORDERS (DATE) DEBRIDEMENT: CHEMICAL SURGICAL MECHANICAL AUTOLYTIC TX- NURSES SIGNATURE FIN SUPERVISORS SIGNATURE Leeveiciws SIGNATURE Regeis Care Center . E: ADMITFED FROM: DATE OF ULCER 5; exr SKIN CARE USED: 7' at xi X, if STAGE: Stage} - A persistent area of skin redness without a break 1' in the skin that is non bianchable. Stage ii - A partial thickness loss of skin layers either der- or epidermis that presents clinically as an abrasion, or she!-idwwerater, St. fiil thickness iost exposing -with subcutaneous tissues - presents as deep crater with or without under- mining oi adjacent tissue. Stage IV - A full" thickness of skin and subcutaneous tissue is lost, exposing muscie and/or bone. -at r' c. WEEK I was}; WEEK it WEEK ms ULCER tgl' :?xHxm _v;;seATE it come) CONDITION OF SKIN {Wig I ESCHAFI on SLOUGH (era) (LOG SIZB RESPONSE TO TREATMENT I Q1 NEW TREATMENT ORDERS (DATE) i DEBFIIDEMENT: CHEMICAL (9 5 fifer>> MECHANWL AUTOLYTIC QMQV 3'2 Tx. Nueses SIGNATURE ,7 me use supsevisoes SIGNATURE iifg, PHYSICIANS SIGNATURE r2-nu M1-9500 Form No. RNH-83 Regeis Care Center PFIESSUFIEISTASIS ULCEH Ar" -"sst0N DATE: FHOM: DATE OF ONSET: ETIO-LOGY: DATE MD. NOTIFIED: PREVENTIVE SKIN CARE STAGE: Stage I - A persistent area of skin redness without a break in the skin that is non blanchabie. Stage ii A partiei thickness loss of skin Iayrs either der- mis or epidermis that presents ciinicaiiy as an abrasion. blister, or shallow crater. Stage -- Afuii thickness iost exposing with subcutaneous t' es - presents as deep crater with or without under- . _g of adjacent tissue. Stage IV - Afuii-thickness of skin and subcutaneous tissue is lost, exposing muscle anciior bone. .h TDATE: ULCER STAGE WEEK WEEK WEEK TI hs1zE(Lx D) (S-M-I. COLOR) CONDITION OF sum _LscHAe on SLOUGH (L00 3. SIZE) RESPONSE To TREATMENT NEW TREATMENT ORDERS (DATE) DEEIFIIDEMENT: CHEMICAL SURGICAL MECHANICAL RN SUPERVISOFVS SIGNATURE - PHYSICIANS SIGNATURE AUTOLYTIC SIGNATURE 4131-9500 Farm NO. FINH-33 tiegels pare I - Consultation Date: ,1 53 Rcs1'clent's Room#: is' .3 From: Attending physigianl . To: Consulting Physician: - . 1 - - Report Requested Regardmg: . . 1.. Signature: ofAttending Physician: Er -. Acuj Intenfal I-Iistoin-y: (A . .-Ki uni in an .r;3 axrgf Mental Stz\tus 1 tionzivfo 1.70/5 5; 5-: (7 353;; .- n_/M or Ag; I rm '(ll I . n._t 4 I 1 'fix' . I I Ty 4' Plans/Recommend tion[s): 12. . . . . 4-fl Eh 2-L I ("Ii 1-THE RESIDENT IS ON IVIEDICATIONS: 1. Was the dosage reduction attempted in the last months? Yes No If"No"', document reasonf J3 2. Haw: any of the foflowing side effects occurred since initiation of the Medication? Tarclive Dyskincsio .. EYES . ClNo Orthostatic Hypotension CIYBS Cognitive!Behav.ior Impairment or Deterioration resulting from the Medications? Yes El No .. .. Ez'Yes lI]No Akathisia. . .. C|Yes BN0 Other - Specify: If "Yes", Care Plan: EYE: 3. Does the Dosage Exceeds 0EIRA1nterpretive Guidelines? .. If "Yes", Document Reason: 4. Do the benefits of the medication outweigh the Yes No 5. Medication is required to maintain p:1tient'S fimctional status? .. Yes No I -- M.D.'s Sig11aturo:__ J) Date: Date: .. I diillfic Cnusultalion Fmahoro Ffinling [718] 431-9500 Fann No. RNH-2B1 'Signature ..-.- Vim -- Care Center Consultation .5 - 6 /4/of Resident's Name: Room#: From: Attending Physician: _f1, I) To: Plwsician: 5117 :14' I .T Report Requested Regarding: .--. cu. 34/. 5 /"ca 7 I ttxtas or cf Vii rt. 9 VJ Date: . A I W1 T. 63Cal}? AIU (35 (.1. ct: 1:33., LC) 7 g; i Ci'-fifl Kr32,'3\ '3 it 'run cU.h~m. be #3 :10 Mental Status Examinaticm: 113-h 1 I :33'jib 31:1; Jr"; -L. 1.. Di518'105i53 i. If') gt ii W0 4% Efwitf rt' . ta _t 3 91.3.11 . (39 V1 13?? FEM A __g,em c~w,t rte: 75 Mt} E99MEDIICATIONSH $ta: toting rm>> m/ otmat I. Was rcduction attempted in the last 4.'6 months? 2 [Was BN0 1 lf"Nu", documcmt reason: y~ 9 any oftluz followilig side initiation ofthe Medication'? Tardix-'c .. BNO I-Ijrpotcnsiolt .. {Ties BN0 lmpain11ent or Deteriorntiorl resulting from 111:: BN0 .. {]Yr:s BN0 Aliachisin .. BN0 Other Specify: Care Plan: 3. Does the Dosage Exceeds Interprelix-'6 CFL1icit:lincs? .. Documtmt F-lea.-30a: 4. Do the nzeclication the risfcs? .. UNU Mecliscutiun is rettujggd to r11zti}1tz1ir1 mti_gnt's {Lilla-e-tzgonzll status'? .. END 1 2 M.D.'s Signature: Date: Date: f/ I 1 inn Al}? fl': Wpmwi M. A cu-I~ 'fie we?-wf 'wM~ Regeis Care Center 11' it t' Ia no onsu a [On Date: 4? Resident'sNarne: . L51 From: Attending Physicianeport equeste Regarding /ti U7L Signature Physician: Wig" MD. I 1 3 Interval 5L :3 (.4 113.3%: A wc /w 45,; 2 41 it an 3" Ha}. fag 'vi' it}-Mental Status Examination"fies:-cefixvf 1 55%} iullfliak 5. 1_ I 'if:/1 11 7 am i 7 /Qyli Jr' C): . /1 *1 144 mini' Qvivf :1 FFL1 -- Tire IS on MEDICATIONS: 1. Was the dosage reduction attempted in the last 4/6 months? UYCS Gift!' If document reason: 2. Have any of the following side effects occurred since initiation of the Medication? Tardive Dyskinesia . .. DY es No Orthostatic Hypotension .. DYes No Cognitiveffiehavior Impairment or Deterioration resulting from the Medications? [Wes No Parkirtsonisnifixtrapyramidal .. DYes Akathisia [Wes Other - Specify: Care Plan: 3. Does the Dosage Exceeds OBRA Interpretive Guidelines? .- DYes 11? If "Yes", Document Reason: 4. Do the benefits of the rnedicatioyrw igh the risks? .. Utes []Medication is required to Inaintniig-gaJgnt's functional status? M.D.'s Signature: Signature: Date: Date: r! I i'AP.fmJ Psyelaiattic Consultation-O7-21.05 Regeis Care Center Consultation (:47 i Rosidcnt'S Name: gk From: Attending Physician: . Repo1'tRequeStcd Regarding: A fiiT5 =9 cam I I 2 R0om#:45 To: Consulting Physician: Date: Signature of Attending Physician: MD Interval .5/Art. AidMegtl ta 5 ~xa not: 4 ., . if, 'figs; Il_i A J3 5) F/xi' . Hal>>. 1 <> More than Once /Week - Other: - - Time ofEpisnde: - .. During Agfinprovoked Spam:/jr: Result: I_2ar1ger._t_o b. . - c. Staffs Ability to'PrUvidc.CajB cl. Causes Resident Fri ghtful Distress Deficit Capacity IIQLLK ,6 2'/i .. . ResideI'it"5'Responsc to Intervention: (Er Li States of Behavmr: __t4No _Cha'nge Episodes Decreased Episodes Increased - "Decreased Fu_neticin Increased Function I MANAGEMENT: - . Services - - Date Initiated: i1- Drugs: D'i'es E5110 BJP Sitting 7 BIP Lyi;'1Ag- . . If "Yes," indicate medication and dose:' - - - 3- D0533 RE-ductipn: ClYes. BN0 Date: Reason: Side: Effects: C!Yes BN0: indicate: Confilsionf Agitation! Postuini Hypertension! Exu'a_PyraIru'dalEffeets 4. Behavioral Maiiagemept PrograII1:__% R?sidenfs Response; - . n-an-vinr Monitoring-[D-I6-06 . I i . CARE CENTER - 7 DRUG AND BIEHAJV1 on MONJTORJNG Resident: cu. 'go C-<4-ca- Room#: Week Ending: I9 U2 - OF BIIEHAVIOR-THAT MIGHTBE OBSERVED: (Srajfmajw use one or more behaviors ma! best describe: what is 0bser_ved)- (1) Yelling (II) Smcaring Feces Biaing - (I2) _A__cting--out sexually Thfg_a[ening I . Hoarding - (143 Facing self I- - - . . nales in inappropriate areas Dangerous whecichair maneuvers" (17) Hallucfnariom {mecrfv - fl --. auditory or tactile). A (8) Bothers roomrnate's personal belongings . delusions (9) Undressing in public @Wandem to peers' rooms (10) Stealing - (39) Behavior *fi(:LL in} . 1'4'-Cfizffar 4-94' EC I Frequency: b. _g More than OncefShiI'? _At Least Once/Weelo More than Once fW?e_k Omen Time offipisodez - -- . During I Speczfir: - - Self, . b. 10 Others . c. .. Staffs Ability cl. Resident Frightfui Distress Causes-Rasid::ntDeficit infuncfiohgl Capacity' _Wm,m Staff Intervention: firs Cc: . Result: a to Intervention: fix /Q7:c..r1 LT 5:427:33? Sizatus of Behavior: - No Change: 1,/Episodes Decreased Episodes Increased - --De-cre'ased Fu_r1ction Increased Function o. MANAGEMENT: . Date Initiated: - I- Drugs: BN0 Br_fP Sitting I - . If "Yes," Indicate medication and do3e:' - . c/ 2- Dosage Reduction: {3Yos. Date: lfieason: 3. Side .- L!Yes BN0: If "Yes," indicate: Confizsionf Agitation! Hypericnsfonf Effects Maoagement ProgramR?sidcnt's Response; . - - AJE-fml pm' mm, 33}; J:-mg Bela.-nriar Behavioral Maoagemegtt ProgramResponse'5'taffSignarure Sc . REGEIS CARE CENTER - I DRUG AND BEHAVIOR MONITORING Roomll: Weekfinding: - EXAMPLES 01+' BEHAVIOR THAT MIGHTBE OBSERVED: (S tafi' may me one or more behaviors that best describe: who: is Yelling (1 I) Smizaring Feces (2) Biting . (J2) Acting--out sexually . (13) Hoarding Items/Food (4) Scratching . (14) Pagzi-jg Hits 1- (15) . - . (5) objeclg/food - (16) Urinales in inappropriate areas (7) Dangerous wheelchair maneuvers (I 7) Ifvifual. - . I audiroxy ortaczflej. (8) Bothors roornmate's personal belongings . (13) P3180053. delusions (9) Undressing in public 9) Wandfifs T0 1'09"" (I0) Stealing . (20) Behavior Observed: At Least DncEfShift More than Once./Shift Frequency: a. b. c. _At Least Oncefwoekl More than Once: Ofher: (Specffi!) 'l'irne'of1'i;pisode: . -.-.-.- DuringADI_.' Speczfir: A Result: Self_ .. . - b. Dangerfflisturbancc to Others' Staff's Ability to - cl. Causes Resident Frightfill Distress . - - e; Deficit Capacity . - - Residefitls-Response to Intervention: .-. i - a Status of Behanor: - No _Cha'ngc Ep:sodes Decreased Episodes Incmased A -Decrepsed Increased Function . MANAGEMENT: Conso]tDate:- . Services - -- Date Initiated: 1- Drugs: gnu Exp sitting . If "Yes," indicate medication and dose:' - 2- E|Yos_ BN0 Date: Reason: - - 3; sideaffecns: aria: A . - Confusion! Agitation! Postural Hypenansionl Effects . Date 2 Tirna: . I 4. Behavioral Management Program: REGEIS CARE CENTER . DRUG AND BEHAVIOR MONITORING gflceklg Notes! Resident: 5: Roorn#: Psi'? Week Ending: LT 30 O7 EXAMPLES OF BEHAVIOR THAT BE OBSERVED: (Stafirizay use one or more beI1avior.r__rhar best describes what is observed)- (1) Yelling (I1)SI11ca_ring Feces (2) Biting (12) Acting-out sexually (3) Threatening (13) Hoarding Items/Food (4) Scratching (14) Pacing (S) H1"Cs"'se'l'ffothers (15) Spitting (6) Throws (16) Urinates in inappropriate areas (7) Dangerous wheelchair maneuvers (17) Hailucinatiom (specifi; ijfviszral. auditory or tactile). (8) Bothers roornmate's persona} belongings (I3) Paranoia, delusions @7Unmessing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior Observed; C'r - At Least Oncefshift More than Once/Shift At Least Once;/Week More than Once /Week Other: (Specify) Frequency: Time of Episode: . . During ADL Uriprovolced Other Specyfiiz Danger to Self . DangerIDisturbance to Others -Interferes with Staff' .5 Ability to Provide Care Causes Resident Frightfu] Distress Causes Resident Deficit in Functional Capacity Result: . a c. Staff Intervention: Response to Intervention: Status of Behavior: No Change Episoiies Decreased Episodes Increased Decreased Function Function MANAGEIVIENT: Consultiltaie: Services Date Initiated: 1. Drugs: MA []No BIP Sittincr If indicate medication and dose: BIP Lying Dosage Reduction: . . UYBS BNO Date: Reason: 3. Side Effects: .. [Z1Yes BNO 1f "Yes,"inclicate: . Confusion! Agitation! Postural I-Iypertensionf Extra Pyramidal Effects Resident's Response: Staff Signature Title -- in .1 r;U:i' Date Ci 2 Time: AJHn'n1l Psycilolropiz Drug Bdiavior Monitoring-I0-16-O6 REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING 1 fleekly Notes} Resident: Roorn#: Week Ending: EXANIPLES OF BEHAVIOR THAT MIGHT BE OBSERVED: (Srafimay use one or more behaviors that best describes what is 0bserved)~ (1) Yelling (11) Smearing Feces (2) Bitjng (12) Acting--outsexually (3) Threatening 13) Hoarding ItemsfFood (4) Scratching (14) Pacing (5) Hits selflothers (15) Spitting (6) Throws (16) Urinates in inappropriate areas (7) Dangerous wheelchair maneuvers (17) HaJIucinat.ion- (spear:/fa ifvisuai, auditory or tactile (3) Bothers roornmate's personal belongings (18) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior Observed: Frequency: a At Least Once/Shift More than Clnce!Shift c. At Least Oncefweek 1 More than Once /Week Other: (Specifit) Time of EpisodeDuring ADL Unprovol-(ed Other Result: a. Danger to Self in. DangerlDisturbance to Others c. --1nte-rferes with Staffs Ability to Provide Care d. Causes Resident Distress e. Causes Resident Deficit in Functional Capacity Staff Intervention: Resid.ent's Response to Intervention: Status of Behavior: No Change Episodes Decreased Episodes Increased Decreased Function Increased Function MANAGEMENT: Consult Date: Services Date Initiated: 1. Drugs: BNO BIP Sitting BIP Lying If "Yes," indicate medication and dose: 2. Dosage Reduction: .. CiYes BNO Date: Reason: 3. Side Effects: .. BN0 If"Yes."int1icate: Confusion! Agitation! Postural Hypertension! Extra Pyramidal Effects 4. Behavioral Management Program: Resident"; Response: Staff Signature Title Date Time: Drug Bclmuior REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING .- - gwfeelclg Notes! Resident: Roorn#:5 )1 Week Ending: - EXAMPLES OF BEHAVIOR THAT MIGHT BE OBSERVED: {Srajfnzuy use one or more behaviors that best describes what is observed)- (I) Yelling (1 1) Smearing Feces (T Biting (12) Acting-out sexually Threatening (13) Hoarding Items/Food Scratching (14) Pacing 05) Hits (15) Spitting (6) Throws objectsifood (16) Uiinates in inappropiiate areas (7) Dangerous wheelchair maneuvers (I7) Haiiucinatiom (spectfi: ifvisztal, atzditorjz or tactile). (8) Bolhers roommates personal belongings (18) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Steaiing (20) Other: Behavior Observed: EU I Frequency: a. At Least Once/Shi it b. More than OncelSliift C. At Least Oncelweok d. More than Once fweek e. Other: (Specijjr) Time of Episode: .. _Dun'ng ADL Ea;/Uiiprovoked Va. ca, '1 Result: a. Danger to Self b. Dangermismrbance to Others c. with Staffs to Provide Care d. Causes Resident Frightful Distress 6. Causes Resident Deficit in Functional Capacity Staff Intervention: . . Residenfs Response to Intervention: R3 31' Status of Behavior: Ii No Change Decreased Episodes Increased Decreased Function Increased Funclion MANAGEMENT: ConsuItDate:_T Services . Date Initiated: 1. Drugs: ?lzfes itting Lying If "Yes," indicate medication and doseDosage Reduction: UYes Jihifio Date: Reason: 3. Side Effects: .. ClYes 1E"Yes," indicate: Confiisionf Agitation} Postural Hypertension! Extra Pyramidal Effects 4. Behavioral Management Program: Resident's Response: ti i at Siflff Signature 345 Tiilit'. Dram: C) Time; Drug it llchavior Monitoring-[ll-I6-O6 REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING - I -, ,3 Resident: ink Week Ending: "7 6 . EXAIVEPLES OF BEHAVIOR THAT MIGHT OBSERVED: (Stafima use one or more behaviors that best describes what is observed)- (1) Yelling (11) Smearing Feces Biting (12) Acting-out sexually Threatening (13) Hoarding ItemsfFood Scratching (14) Pacing Hits selffothers (15) Spitting (6) Throws (1 6) Urinates in inappropriate areas (7) Dangerous wheelchair maneuvers (17) Hallucination>> (specify auditory or tactile). (8) Bothers roomInate's personal belongings (18) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior Observed: Frequency: At Least OncelShi'ft b. than Onc:efShift c. Least Once/Week . (1.: More than Once IWEBIC ., e. Other: cspecgaauffi 0 am.' lhrl'-rfi-. no Time of EpisodeDuring ADL nprovoked Other Result: Amger to Self b. Danger!Disturbance to Others c. ,g-Inteiferes with Staff's Ability to Provide Care cl. Causes Resident Frightful Distress Causes Resident Deficit in Functional Capacity fSt.aff Intervention: . it Lo axr '81. *1 vs. -Qt' Re5ident's Response to Interve 'on: I Pi EQE Status of Behavior: Change Episodes Decreased Episodes Increased Decreased Function increased Function MANAGEMENT: Consult Date: Services Date Initiated: 1. Drugs: one BIP Sitting Lyin indicat medication and dose: gt? ?109': Uni?>> 37CLr~u~--n '0 Ki: 3- i 2. Dosage Reduction: .. DYes Date: Reason: 3. Side Effects: .. E|Yes Efl_ If"Yes," indicate: Confusion} Agitation! Postural Hypertension! Extra Pytamidaififfecls 4. Behavioral Management Program: Residenfs Response: Staff Signz1ture&TitIe 9 Date he i 3 Time: Faycllotrupit: Drug 3.: Behavior REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING --or jfleeltl1Notes1 Resident: Roornih; Week Ending: 57 "9 EXAMPLES OF BEHAVIOR THAT MIGHT BE OBSERVED: Smfi' ma tge one or more behaviors that best describes what is observed)- (1l)Smearing Feces (I2) sexually (13) Hoarding ratching (14) Pacin (5) 1 'ts self/others (15) Spitting Throws (16) Uzinetes in inappropriate areas (7) Dangerous wheelchair maneuvers (17) Hallucinatiom tfvisual, auditwy or tactile). (8) Bothers roommate's personal belongings (13) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior Observed: Cd:-fig, 3 - Frequency: .1. At Least OncefSl'tift b. I More than OncefShift c, Least Once/'Neck C1. than Once {Week e. Other: (Specify) Time of Episode: .. __During Uoprovoked _t4(5t11er Specijjt: met wk mi. U-ew-t Result: a. to Self b. Danger/Disturbance to Others c. with Staffs Ability to Provide Cam Causes Resident Frightful Distress e. Causes Reside11tDeficit in Functional Capacity Staff Intervention: 9" xte-{ix Reside-nt's Response to Intervention: 4' Status of Behnvio r: filo Change Decreased Increased HH__Decreased Function Increased Func tion MANAGEMENT: Consult Date: Services Date Initiated: Drugs: DNO Lyin go CW) BIEE I, If "Yes." indicate medication gt: . 2. Dosage Reduction: iJYes Reason: 3- Side Effects: E]Yes If"Yes_" indicate: Confusion! Agitation! Postural Hypertension! Extra Pyramidal Effects 4. Behavioral Management Program: Resident's Response: Stal'fSig11ature<9tTitle Time: 3 Drug REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING ogadiatasi . Resident: 3-5/Week "/13 EXAMPLES OF BEHAVIOR THAT MIGETT BE OBSERVED: (Stafima it one or more behaviors that best describes what is observed Scratching (5) lits selflothers Throws objects/food (7) Dangerous wheelchair maneuvers (8) Bothers roornmate's personal belongings (9) Undressing in public (10) Stealing Behavior ATE At Least OncelShift . ore than Once/Shift c. At Least Once/Week d. __?_gMore than Once {Week Frequency: (11) Smearing Feces (12) Acting-out sexually (13) Hoarding Item5lFood (14) Pacing (15) Spitting (16) Uzinates in inappropriate areas Hal]ucinan'on- (specify ifvisual. auditory or tactile). (18) Paranoia, delusions ?19) Wanders to peers' rooms (20) Unprovokcd t/(filer 6. Other: (Specify) Time of Episode: . . During ADL S.veciJfv=N Result: a. "-/-Tlanger to Self b. to Others c. 5 with Staffs Ability to Provide Care P- Causes Resident Frightful Distress e. Canse Reside tDef'1c' in Functio al apa ity Stfitgirtewenfionz xmuxifiwoa WW -. :3 1 $3 Residcnt's Response to Intervention: Status of Behavior: Change Decreased Increased Function Increased Function MANAGEDIENT: Consult Date: Services Date Initiated: 1. Drugs: BN0 indicat medication and dose: xaumx' 2. Dosage Reduction: .. ElYes 3. SideEffects: .. l'_'JYes Date: Reason: Dflo//It' "Yes," indicate: Sit1jng__ HIP Lyin $1 0% Confusion! Agitation-I Postural Hypertension! Extra Pyramidal Effects 4. Behavioral Management Program: Resident' 5 Response: Staff Signature Title A1 K: Dchu-iur Munimfing-ID-1606 Date 7'"1"h'iTirne: F5 OE jg .9-N.. REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING I ffleeklv Notes} Resident: Qonv?ao} Roon1#: sz?j Week Ending: Ix EXAMPLES on BEHAVIOR THAT MIGHT BE one or more behaviors that best describes what is observed)- 'Ye]]ing (1 I) Srnearing Feces iting (12) Acting-out sexually 3) Hoarding Scratching (14)-Pacing 't5 (15) Spitting Throws (16) Urinates in inappropriate areas (7) Dangerous wheelchair maneuvers (17) Hailucinatiom (specify auditory or Ioclilej. (8) Bothers roomrnat-3'5 personal belongings (18) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior 7 a. At Least Once/Shift b. More than Once/Shift c. at Least Once/Week d. - "More than Once {Week Other: (Specify) Time of Episode: . . During ADL Uuprovoked Specify: Result: Danger to Self b. to Others c. with Staffs Ability to Provide Care (I. Causes Resident Frightfu} Distress c. Causes Resident Deficit in Fu ity (SW I EAL NKUE J) \h Residcnt's Response to Intervention: Q3 1; Status of Behavior: ,4 No Change Decreased Episodes Increased Decreased Function Increased Function IVIANAGEMENT: Consult Date: Services Date Initiated: 1. Drugs: BNO Sitting BIP Lying If "Ycs," indies? rnedi_caIion and a; co, U20. )4 $3 $2 C: CF63 . 2. Dosage Reduction: .. ClYes Ellie/' Date: Reason: 3. Side Effects: .. DYes indicate: Confusion! Agitation! Postural Hypertension! Extra Pyramidal Effects 4. Behavioral Management Program: Resident's Response: Da:c\ Time: Al'B!ml Drug 5: Ilchuviur Monitoring-IU-I6-D6 REGEIS CARE CENTER DRUG AND BEHAVIOR MONITORING I . Resident; DCC. Week Ending: 7 EXAMPLES OF BEHAVIOR THAT MIGHT BE OBSERVED: 1' Staff 3; us one or more behaviors that best describes what is observed)- 1 (11) Srnearing Feces Biting (12) Acting-out sexually Threatening (13) Hoarding Items/Food Scratching (14}PaBiI1g (5) Hits (15) Spitting Throws (16) Urinatcs in inappropriate areas (7) Dangerous wheelchair maneuvers (17) (speczfy :fw'suaI, auditory or tactile). (8) Bothers roommate'5 personal belongings (18) Paranoia, delusions (9) Undressing in public (19) Wanders to peers' rooms (10) Stealing (20) Other: Behavior 0bservcd:( -.5 4.1% 'Kb -x'3iLC Frequency: a. At Least OncelShifI b. (More than Oncefshift c. At Least Dneefweek cl. ,Mo"re than Once [Week e. Other: (Specify) Time of Episode: . . ADL Speczfii: {Anger to Self Danger/Disturbance to Others with Staffs Ability to Provide Care Causes Resident Frightful Distress e. Causes Resident ficit in Functi nal Capacity Staff Intervention: "burg ~11-'st "ob xix KJL Result: a. b. c. d. Li Residenfls Response to Intervention: 39% Stfiills 01' BEhi1Vi01'= Change Decreased Episodes Increased Decreased Function Increased Function NIANAGENIENT: Consult Date: Services Date Initiated: 1. Drugs: Co>res/ ElNo Sitting BIP Lyin indicate medication and dos $923Dosage Reduction: UN6 Date: Renson: 3. Side Effects: .. DYes If "Yes," indicate: Confusion! Agitation! Postural Hypertension! ExtraPyramida.1 Effects 4. Behavioral Management Progrnm:__ Resident's Response: . StaffSignstuIe&Tille 9' Date 'I_'ime: Drug Monitoring-1 Do 1606 LONG TERM SOLUTEONS Coqsultant Pharmacists Lisa Venditti, CONSULTANT PHARMACIST PROGRESS NOTES RESIDENT NAME ALLERGIES LOCATION George Laflocca NKA 585 DATE COMMENTS SIGNATURE 5/ 1 8/07 Medication regimen Deinentiat Nainenda Sing daily - Monitor reviewed for restless, distress, dizziness, sornnolence, No irregularities noted HTN, HA, increased confusion or 7- hallueinatioris, or maintenance of cognition HTN: Coreg 6.25i11g BID - moilitor bp, pulse Aspirin EC 325mg daily -- monitor bleeding, bruising I reviewed /fig} irregularities noted fly," I 4 [1 ,1 Medication regimen reviewed ENC irregularities noted fl .., Medication regimen reviewed . C: 1, (ill [3 No irregularities noted 5 Medication regimen 1 I h. Lie Theresa Grandville Maribeth Lavin Carol Dispensa Rosemarie Harrington Roma Pelizza Diane Fischer Rachei Hoohhauser Karen Galasso 0 LONG TERM SOLUTEONS Consultant Pharmacists Lisa Venditti, CONSULTANT PHARMACIST PROGRESS NOTES RESIDENT NAME ALLERGIES LOCATION George Lallocca Haloperidol, radiopaque PVC markers 58-5-fir 5 3-'3 DATE CO HENTS SIGNATURE Medication regimen CAD: aspirin 325mg daily -- monitor reviewed bleeding, bruising 59 N0 irregularities noted HTN: eoreg 625mg daily with hp, pulse parameters -- monitor bp, pulse Nytatin powder rash Abx: avelox 400mg daily until 6X22 seroquel 1?..5n1g AM and 25mg I-IS - Monitor for falls, lethargy, FS, TSI-I, BPS, TD, excessive sedation, orthostatic hypotension, antieholinergic effects, altatliesia, neuroleptie maligiiant cardiac - Medication regimen I A Tfiqi I reviewed "fii i0 7 3 Hip Ci No irregularities noted fl 0.. ?173. I A uveuwwm 1 we I1 trig/nnzz,r,ip . 0 -. Medication regimen Oi reviewed ll/hf' {1_i"l_1 fill}! i951'? Arm I irregularities noted V. Medication regimen I 1 .\reviewed I. I i ii KTNAFJ a 3 ii in Ewe irregularities noted 1} ll Lie. dnditti Theresa Grandville . . Maribeth Lavin Carol Dispensa Rosemarie Harrington Ji//lgj Roma Pelizza Diane Fischer Rachel Hoehhauser 1. Karen Galasso I I Ow Wz57Lz' (Mm/1 g17aMz*m*2'7 flacwaauezf 3 [3 /fig'; {om /0/25 was mien? /Ztflig' 3% 2 VV /76455/(cc/707 /L60/paflfl?' flv?oflaafig Jim/fl/7 9% @j I L5-zw /6/r7/V0 MUUAUM ccmsu "ram" PHARMACIST moenese NGTES Lisa Venditti mm, FASCP 7 Aliergles 7 Location SIGNATURE Reviewed irregularities noted Reviewed . ElNolrregularit1'es noted two irregularities Reviewed irregularities noted Regimen Reviewed noted Karen Gallosso Rachel Carol Diepensa Theresa Grandviile /1 Home Pelizza - Diane Fischer . I . Rosemarie <1 fl ..-1-. 'as' II I Efinn-. 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Nb 4?_amoumm1 ZH mmw?>>4o: mag 304 >>umcmz_ mo_mm>>zc Hum :34 oh man >>4mcmomm mm: omz_zmm>>maz: mg: I zoHFom?m2_ wumm_ 3o_ zo_ku:nzoo mma tmmco_oLm mmdnumm m_m>_mc? UwEu_+couc: mum Jczmozmc u>Lmes:m Egg mg . puzua we on "co_mLwaw_o um*mm H5 m_mwmx "*cweeou Huog "wmm_u .. mm?m> me mm mo o_ moom_mo~o_ Ha" mwmomm.?uuom?4 NI . MEGUOIHWIO on A L. . u+:mssou M.cm- coal "mHxc pumum we vm n:o_mLmam_a we Lav .0 we m_m ukc y_\vM we <_mc? 4 mum Jczmozmc _>LmeE:m we on? ":om*mL3o mmo on "Lump me am_ ma flue; am?az?~m 2H mag :04 we om__ mm m4?s max I m>Hm2m>>xm m4m?momm sun mm um.mm mm?m> ma om_m m>m3 . mm>m3 m>_mcw_xm wm>m3 304 uD_ ?Hamcu>gcmm ufiaokuw mo 01/30!08 0fi:H1 PM EST via EampufiTrol Technolog Page 1 of 1 #29352 Patient Care Associates, Inc. Integrated Health Administrative Services, Inc. Sonographics Imaging, Inc. REPDRT REGEIS CHRE CENTER HeFerring Phgsician: BBNAD, MD OFFICE 3200 BAYCHESTER AVENUE Patient: Larocca, George BRONX, NY 10H75 Service Date: 01/23/03 Room Number: 528 Examination: Arterial S000 - RLE Diagnosis PERIPHERAL VASCULHR SYSTEM DISORDER RIGHT LUHER EXTREMITY HRTERIAL HITH MILD PLAQUE BUT HITHUUT DCCLUSIUN, STENDSIS, UR SIBNIFICANT COMMON FEMDRAL ARTERY-SUPERFICIHL ARTERK IMPRESSIDN: SEE RBGVE. Signed Electronically FDR PHYSICIAN USE ONLY The results above are acceptable For the patient's condition. No Further Fol1ow--up STEPHEN 3 necessarg at this time. 'If? fl_ Technician: M.D. Date SHILA MEHTA The results will be monitored For Further verbal Given T0: evaluation. See patients progress notes. FAXED TD FACILITY THU 07710 PH Patiejt Care FHH N0. 5555555555 03 Page: 1 Patient Care Aaeociatee, Inc. Integrated Health Administrative Services, Inc. soncgraphics Imaging, Inc. Physician's Impressions Facility: REGEIS CARE CENTER 3200 EAYCHESTER AVENUE BRONX, NY 1DQ75 Ordf: 440161 Priority: Bank: 0115049 Diet: 157970 DOB: 10/30/28 Room: SEA Patient: Larecca George DOS: 02/07/03 Tech: JWATT Procedure: Ankle Right (3 Views) Impressions: NO ACUTE FRACTURE Read By: MICHAEL SHAPIRO, M.D. 05:22 PM EST via Compu--Trol Technolog Page 1 0F 1 #31802 Patient Care Associates, Inc. Integrated Health Administrative Services, Inc. Sonographics Imaging, Inc. REPORT REGEI5 CARE CENTER Referring Phgsician: BANIK, MB OFFICE 3200 BAYCHESTER AVENUE Patient: Larocca, George .BRUNX, NY 19975 Service Date: 02/07108 Room Number: SEA Examinatiun: Ankle Right (3 Views] Diagnosis Pain,AnklelFoot Metatarsophalangeal RIGHT ANKLE: MULTIPLE VIEWS OF THE RIGHT ANKLE MILD DEGENERATIVE DISEASE HA5 IDENTIFIED. MU DISLUCATION OR OTHER ACUTE BUNY PATHOLOGY I5 UBSERVED. THERE WAS IMPRESSIUN: ND EVIDENCE OF FRACTURE Signed Electronically FUR PHYSICIAN USE ONLY The results above are acceptable For the patient's condition. No Further Follow--up MICHAEL SHAPIRU, pecessarg at this time. . Technician: 5? M. D. Date JOHN new The results will be monitored For Further Verbal Given To: evaluation. See patients progress notes. FAXED TU FACILITY FEE-U8-2008 FRI 11I4B PM Patient Care _Patient Care Aesnuiatefl. IRE- Integratad Health Administrative Sexm Sonographias Imaging, Inc. Phy5ician's Impressions Facility: REGEIB CARE CENTER 3200 EAYCHESTER AVENUE BRONX, NY 10?75 Mient: Larocca . Gecrge Procedure: Cheat NO ACUTE INFILTRATES Read By: STANLEY FRIEDMAN, M.D. . .. i FAX N0. 5555555555 see, Inc. Ordr: 440756 Bank: 0116049 DOB: 10/30/28 DOS: 02/as/as P. 02/82 Page: 1 Priority: A Diet: 158125 Room: 528 Tech: CD 02/10/08 01!: 01 PH EST via Compu--Tro1 Page I of 1 #31553 Patient Care Associates, Inc. Integrated Health Administrative Services, Inc. Sonographics Imaging, Inc. RADIOLOGY REPORT CARE CENTER Referring Physician: BANAD, MD DFFICE 3200 AVENUE Patient: Larocca, George fesoex, NY 1ou75 Service Date: 02/08/08 Room Number: 528 Examination: Chest Diagnosis Positive PPD ERECT VIEW OF THE CHEST ND INFILTRATES DR EFFUSIONS ARE IDENTIFIED. NU EVIDENCE DF CUNGESTIVE HEHRT FAILURE IS OBSERVED. IMPRESSIUN: ND HCUTE DISEASE ND EVIDENCE OF TUBERCULOSIS. Signed Electronically FUR PHYSICIAN USE ONLY The results above are acceptable For the o=tient's condition. No Further Fo1low--up STANLEY FRIEDMAN, M.U. hecessarg at this time. Technician: .. 4 9 M.D. Date CHRISTOPHER ooNnLosoN The results will be monitored For Further Verbal Given To: evaluation. See patients progress notes. FAXED TU FRCILITY {J2/13f38 09:21} AM EST via Campu--Tra1 Tlnnalag Page 1 of 1 #32139 Patient Care Associates, Inc. Integrated Health administrative Services, Inc. Sonographice Imaging, Inc. REPORT REGEIS CARE CENTER Referring Physician: S. H.D. OFFICE 3200 BAYCHESTER AVENUE Patient: Larocca, George E-eaonx, NY 1ou75 Service Date: DEHOBIOS Room Number: 528 3 Examination: Venous Sonegram -- RLE Diagnosis EDEMQ, LOCALIZED RIGHT LOWER EXTREMITY VENOUS DUPLEX COLOR DOPPLER HRS PERFORMED, FROM THE COMMON FEMORRL VEIN TO THE POPLITERL VEIN, ON THE RIGHT. THERE IS DEEP VENOUS THROMBOSIS TO BE OF COMMON FEMORAL VEIN- FEMURAL VEIN-POPLITEHL VEIN AND POSTERIOR TIBIHL VEIM IMPRESSION: DEEP VENOUS OF THE RIGHT LOWER EXTREMITY. ea?" Kr' 3' ~r '12 Signed Electrunicallg FUR PHYSICIAN USE ONLY The reEyJ1ts above are acceptable For the E3113-a lf'I"I'I'll_ LI TI I Technician: M.D. Date JOE GQMBA hixgu TD M.D. Date 588H78/01160H9/msj I1 P. [15 Page: 1 THU U5:3q PM Patient Care Fax No- Patient Care Associates, Inc. Integrated Health Administrative Sexvices, Inc, Sonegraphics Imaging, Inc. Physician's Impressiuns Facility: REGEIS CARE CENTER 3200 BAYCHESTER AVENUE BRONX, NY 10475 Ordr: 444325 Priority: A Bank: 0115049 Diet: 159362 Patient: Larocca George DOB: 10/30/28 Room: 528 Procedure: Chest DOS: 02/21/08 Tech: JWATT Impressions: NO ACUTE INFILTRATES Read By: MICHAEL SHAPIRO, M.D. zayflie 02:19 PM EST via Compu--Tre1 Tecnnolag Page 1 of 1 #34743 Patient Care Associates, Inc. Integrated Health Administrative Services, Inc. Sonographics Imaging, Inc. RQDIULOGY REPORT REGEIS CARE CENTER Referring Physician: S. BHNAD, M.D OFFICE 3300 BAYCHESTER AVENUE Patient: Larocce, George JBRUNX, NY 10H75 Service Date: Room Number: 588 Examination: Chest Diagnosis Pneumonia ERECT VIEH OF THE CHEST NU DR EFFUSIUN5 ARE IDENTIFIED. ND EVIDENCE OF CDNGESTIVE HEART FHILURE IS DBSERVED. ND ACUTE DISEASE. NO PNEUMONIR. IMPRESSIUN: Signed Electronicallg FDR PHYSICIAN USE ONLY The results above are acceptable For the patient's condition. No Further Fol1ow--up MICHAEL SHAPIRO, M.D. is necessarg at this time. Technician: 2? H. o. sate?" JOHN WATT The results will be monitored For Further iuation. See patients progress notes. Verbal Given To: FAXED TD MISS BLUE 5Q135Bi0115049/gsb /1 H.D. Date (888) 318-0300 Paiieni AFITOCCB GEOIQE .-.. .1. Hm-"y HUN "Pa ?nng292_.I: Ii: 03 1'|u5I1iI1g cze REGEIS CARE CENTER SML Code: 442099 fiH_ 3200 Bayohester Avenue g.oom:585A - Bronx, NY 10475 - - - llSpccirncn .5: Dim: Received D1110 RupL1i'i1:L1 Sc}; Auc R67012657 906020 07/09/2007 07/09/07 07/10/2007 RESULTS 9.-2112.0 0 7 0 31.9.9 PM 1-amatology White Blood Count 6.0 x10"3/uL Red Blood Count 4.20-6.00 xl0*6/uL Hemoglobin 1'2 .2 12 _5--15.1 g/dL Hematocrit 35.6 38.0-52.0 MCV 105" 78-102 fL MCH 35.8- 27.0-31.0 pgo MCHC 34.3 31.0-37.0 Neutrophils% 55.4 40.0-70.0 1phocytes% 33.8 20.0-40.0 boytes% 7.9 2.0--1D.O Eosinophi1s% 2.5 1.0-4.0 sophil5% 0.4 0.0-1.0 _htrophi1s, Abs 3.3 1.6-7.8 x10"3/uL Abs 2.0 1.0-4.5 x10'3/uL Monocytes, Abs 0.5 <1.0 .x10'3/uL Eosinophils, 0.2 <0.7 x10"3/uL Absolute Basophils, Abs. 0.0 <0.3 x10'3/uL Platelets 112 150-450 RDW-CV 14.7 11 0-16 0 MPV 9.4 8.0-13.0 fL By Auiolims on at 09:40 AM E9 Aululim.-a Clinicai lmborxifnry lnformulinn System Var. by Ncttims: 1526642--7l94982 Tue 10:01:47 718 5521022 Patient Information Larocca, Na me: George SM Code 442099 Age: 78 Sex: Male Room#:585A Requisition# Lab# 1167012667 906020 07/09/2007 02:00 AM Brooklyn Navy Yard, Building 292 63 Flushing Ave Brookiyn, NY 11205 Pl1one:{718) 552-1000 Fax: (718) 552-1022 Collected: Received: Reported: Ordered By: Dr. Rivkin Boris Regeis Ca re Center 3200 Baychester Avenue Bronx, NY 10475 7l8~320-3700 Status: Complete Report Complete Results Driginaliy Reported on 0?'l09I2007 09:09 PM Hematology Test Out of Range V\filhir1 Range Ref Range Units Range White Blood Count 6.0 4.0 -- 11.0 x10"3fuL Feed Blood Count 3.41 4.20 - 6.00 x10"6luL Hemoglobin 12.2 12.5 - 16.1 g}c!L Hematocrit 35.6 38.0 - 52.0 MCV 105 78 -102 FL MCH 35.8 27.0 - 31.0 pg MCHC 3-EURE.3 31.0 -- 37.0 Neutrophi|s% 55.4 40.0 -- 70.0 33.8 20.0 - 40.0 Monocytes?fa 7.9 2.0 -- 10.0 Eosinophils?/u 2.5 1.0 -4.0 Basophils?/a 0.4 0.0 -1.0 Neutrophils. Abs 3.3 1.6 - 7.8 x10''3{uL Abs 2.0 1.0 - 4.5 x10"3luL Monooytes, Abs 0.5 <1.0 x10"'3fuL Eosinophils, Absolute 0.2 <0.7 x10"3!uL Basophils, Abs. 0.0 <0.3 x10"3IuL Platelets 112 150 - 450 x10"3luL RDW-CV 14.7 11.0 -16.0 MPV 9.4 8.0 - 13.0 fL Eliul 3- Generated on O7"-H200-fat 09:57 AM 35, Clinical Laboratory Information 3_ystems Ver. 2.42.00 by 1542232_ AutoL|ms 7250522 7/17/2007 REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 1rocca,George EL Code: 442099 5 5 'noom:528 '3 i W"i3?5?? a R6700955N sogzjaw Chemistry 1. . Glucose (grey) 7 82 65-99 mg/dL (Fasting Glucose) . 3- mg!dL: Normal fasting glticbsel Vi. Impaired fasting >125 Indicative ofdiubetes: Rafi Diabetes Care 29:343-348. Urea Nitrogen Hg'W.gefWy1fl 20 5~25 mg/dL Creatinine 1.1 0.7-1.3 mg/dL eoFR (Calculation) >60 >60 For Afi'ica11-Aniericans, multiply EGFR'1'esu]t 1.2 3/craat Ratio 1 ;.;atq 18.2 5.o--3o.0 1 139 133-145 mEq/L Potassium 3:1 4.1 3.4-5.4 mEq/L Chloride i>>R . 107 94-113 mEq/L Carbon Dioxide 27 19-31 mE Calcium 'jf_j_g?1flq 8.5 8.1--lO.3 mg dL Protein, Total 6.0 9 8.2 g/dL Albumin d: 3.5 4.8 g/dL Globulin 1. - . -1 ,g3;x 2.9 1.9-4.0 g/dL Ratio 1 1 1 2.5 Ratio Alkaline 1 i 6 3 -140 Phosphatase 1 AST (SGOTJ 11%. ~:a,h9 21 10-40 1 3 ;3;gg1 13 5-50 firubin, Totaljf;_dd 0.7 0.1-1.5 mg/dL Chemistry . - -- - 13- Vitamin B12 g;52}g;; 349 211-911 pg/mL .5*Re?uieition Parameters** Fasting? -- Not Provided' . . A . . GcIIcr::lI:cI H-_v Autnliuns on IWHBIZDII7 PM Aulnlims Clinical Lnbur:1lar_v luforrnzitinn System I-'er. Ncllinna 1720116-8063801 Erocca,George Code: 442099 Room: 521813 . 11111L?h?m1111 4 . R6700968D 2504382 10/25/2007 $73 1%f29 PM in i . . Endocrinology Thyroxine (T4) T3--Uptake TSH 3rd Generation 39.0 Speciai Chemistry Folate Markers -ostatic Specific Antigen Hematology White Blood Count. Red Blood Count Hemoglobin Hematocrit MCV MCH MCHC 'Lrophils% ;phocytes% 'mfflOCYtES% Eosinophils% Basophils% Neutrophils, Abs Abs Monocytes, Abs Eosinophils, Absolute Basophils, Abs- Platelets 142 fiuuflihno 14.5 C3 C3 REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 COMPLETE REPORT .4.5--10.9 ug/dL 22.5-37.0 35--5.50 >5.4 ng/mL Reference Range: Deficient <3.4 ngz'mL Indeternfinate: 3.4 -5.4 ng/111-L Normal >54 rig/mL less than~4.00 ng/mL Metllodologyz Siemens Medical Solutions Diagnostics (Centaur) 4.0--11.0 x10*3/uL 4.20-6.00 x10*6/uL 12.5--l6.l g/dL 73-102 fL 27.0-31.0 pg 31.0-37.0 40.0--70.0 20.0-40.0 2.0-10.0 1.0-4.0 0.0-1.0 1.5-7.0 x10*3/uL 1.0-4.5 x1o*3/uL <1.0 x1o*3/uL x10'3/uL (0.3 x10"3/uL 150-450 x10*3/uL By Autolims on at 02:56 PM Autolints Clinical Vcr. by Nctlims 1'753355--825l153 page?? of 2 ;Mu&fl5&3?&5?251l53 'Wm; =f;uym REGEIS CARE CENTER %occa,George in; QML Code: 442099 3200 Baychester Avenue Bronx, NY 10475 Room:52l8B SHEELA r3 R6700968D I IE I I 10/25/2007: _gs 2504332 1m2ymm70m40Amf 10/25/07 i JFE Wm" 10/25/2007 %g;29 PM - Efiififiifiififl?fifi {mags an' RDW--CV 14.3 1l.O~l6.0 MPV 10.0 8.0--13.D Reticulocytes A 1.8 0.5-2.5 H1 .r lly Autulizlui on PM Clinical lnfurrnatimn Var. by Nctlims 1753366-8251153 REGEIS CARE CENTER HML Code: 442099 3200 Baychester Avenue Room:528 Bronx, NY 10475 12231/20974 Chemistry Glucose (grey) - 1 1 11-; 95 65-99 mg/dL Criteria for the diagnosis ofdizibetcs: (Fasting Glucose) . 125 mg/dL: Indicative ofdiabetes'_ . Ref: Diabetes Care 291343-S48, 2009; Urea Nitrogen 38 ,g.fl 5-25 mg/dL Creatinine 1.4 "a 0.7-1.3 mg/dL (calculation) 52 /5To >60 For African--Americans, multiply EGFR result 2: 1.2 __J/Creat Ratio . . - 27.1 5.0--30.0 Sodium 41 _wl_ 142 133-145 mEq/L Potassium . 4.3 3.4-5.4 mEq/L Chloride . 1_ 109 94-113 mEq/L Carbon Dioxide I 27 19-31 mE Calcium - 4 1 . 'o'g1 9.2 8.1-l0.3 mg dL *R?q11isition Parame-ter5* Fasting? -- - page 4114014741544 YES ti 1' 1? Hy 1-'mtulims cm IZIJIIZDIP7 at 04:03 PM i' H, Aulolims luI'orn1::tiau System Var. 2-42.09 by Ncilims l88565l--8B75027 I inf E'-uticni ir11'om1nEiu:: 1: .1 . -- as REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 1 Rocc%,George ESSN: 091220925 i -- 1 11th "7 1 Sex gt :\Ev . .4Aan41511? ?Rnfi1%n in -. 7 Tesl . -g Glucose (grey) -3 H- (Fasting Glucose)' 1 . .. fiislirlg glucose - 100-125 mg/clL: Impaired fasting glucose. i >125 1 Ref: Diabetes Care 29:343-843. 2006: I Urea Nitrogen Creatinine - 1.3 0.7-1.3 FR (Calculation) 57.' . >50 For African-Americans, multiply EGFR result 2: 1.2 5UN/Great Ratio 5.0<<30.0 Sodium" - 140 l33--l46 Potassium 1- .: '1ofi}f_ 4.8 Chloride j, 105 Carbon-Dioxide~~f1- 24 117fi5 65-99 mg/dL Criteria for the diagnosis ofdiabetes: 5-25 Calcium g-'r 9.2 8 1-10 3 mg dL Protein, Total 5.3 5.9--8.2 9/dL Albumin . 3.2i,, 3.5-4.8 g/dL Globulin 3.1 1.9-4.0 g/dL Ratio - 1.0 1.0-2.5 Ratio 71 31-140 Dhosphatase I. . -. (SGOT) 1 28 .1: (SGPT) ea 13 0.6 .1en1at0logy' White Blood Count.-7 Red Blood Count 3? Hemoglobin Hematoorit 3;41 Parameters** 4 .O-ll.0 4} .20*6.00 12.5-16.1 38. D--52.0 150-450 Q-T77 x1o*3/uL x1o*6/uL 9/dL x1o*3/uL :uu7:25 PM . 1 Clinical Infm-nullion Systenl Var. 3511.09 by Nctlims 1940410-9149001 Pzuizam iriforinzziinn 0 page - A '1 RocCa,George REGEIS CARE CENTER SN: 091220925 -- 5 3200 Baychester Avenue ii. Phone:7lB--882--O6D5 fljfiflww fli_- imoamlmfilcaomgamxm 0 I if i 00 i R7444041s 2805350 01/28./2003 09:35 Arvi /2000? 1 3000222 Nmfimwa 10$ 93095 AM Glucose (grey) 117 65-99 mg/dL - Criteria for the diagnosis ofcliabctes: in i 125 Indicative ofdiabetes; Ref: Diabetes Care 2006 . Urea Nitrogen gs Hi 5-25 mg/dL 1.3 0-7-1.3 mg/dL (oalculationl 57- if 1: >50 For Africaii-Americans, multiply EGFR re?ult 1.2 .ooNfCreat-Ratio.. 5.0-30 0 Sodium 140 133-146 mEq/L Potassium 4.8 3.4-5.4 mEq/L Chloride . -. 105 94-113 mEq/L Carbon Dioxide 24 19-31 mE Calcium 9.2 8.1--10.3 mg dL Protein, Total 5.3 2 g/dL Albumin .8 g/dL Globulin .i . I 3 g/dL Ratio 3.. 1 5 Ratio Alkaline 99'" . i"0 7 Phosphatase 5 0 I (SGOT) 20 10-40 13 5-50 Bilirubin, Total} 0.6 0.1-1.5 mg/dL Endocrinology . TSH 1-59 0-35-5-50 I Hematology 7.6 4.0-11 0 x10*3/uL 4.20-5.00 x10*5/uL 12.5-15 1 g/dL 35.2 30.0-52.0 . 7150-450 x10*3/uL White Blood Count a" _Red.Blood.Count-gg Hemoglobin . Hematocrit .. - - 1941313-9155425 Generated on 01l29I200Bat 02:42 AM By Page 2 of2 Patient Information Ordered By: La Rocca, Dr. Teich Marvin ame. eorge SSN 091220925 Regeis Care Center Phone: 718-882-0605 2' 3200 E-avchester Age: 79 Brooklyn Navy Yard, Building 292 Avenue Sex: Male 63 Flushing Bronx: NY 10475 Brooklyn, NY 11205 Phone:(718) 552-1000 Fax: (718) 552-1022 718--320--3700 Requisition# Lab# Collected: Received: Reported: status: R74440415 2805350 01/28/2008 09:35 AM 01/28/08 01,/29/2008 Complete Report Complete Results Originally Reported on 0112912008 02:05 AM Endocrinology Test Out of Range Within Range Ref Range Units Range TSH 3rd Generation 1.69 0.35 -- 5.50 ulUlmL Hematology Test Out of Range Within Range Ref Range Units Range White Blood Count 7.6 4.0 - 11.0 x10"3IuL Red Blood Count 3.41 4.20 -6.00 x10"6/uL Hemoglobin 12.3 12.5 -16.1 g/dL Hematocrit 35.2 38.0 -52.0 Platelets 138 150 -450 x10"3!uL Requisition Comments Reported to: Regeis Care Center at 01/28l08 07:51 PM Efwmr I IF1uIria_ if. nun In. Ilursul Imp-914 .-. 1940866- Clinical Laboratory information Systems ve"r'. 2.42.'bo* by AutoLims 9152495 1' . E-fiziieni earocca,George SML Code: Room:S28 442099 ffi REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 1.31: - I Duh! Sex ?5,150 7 I I 0911 among o7-35 Ami: 'm Test Coagulation Prothrombin Tim INRJ - - IV: **Requi?ition Comments** **coHefiETE 0?/Tfijnfl I Rang,-ge Units Seconds Reference range reflects Non~Anticoagulaled patientseo?ee 2.00-3.00 Ratio Recommended therapeutic range: 2.0 - 3.0 venous thronmosis, pulmonary embolism, valve, atria! fibrilialion, valvular heart disease, prevention of systemic embolism; 2.5 3.5 Mecl12mie?11" Heart Valve. An INR reference interval is 'applicable to patients' not receiving anti-coagulant medication. Aulnlims Information S3's'luI11 Var. 2.42.0!) by Ne{lims_ . l978086~93-44203 REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 ;}oCCa,George SML Code: 442099 Lab Haifa: D2110 Sex 5 Tea": T. . . Re11':rcI1ce Uniiss This Report Contains Critieal Values H. 35.2 ffi?. 0 'p MCHC 0..fiM"- 33.6 31.0-37.0 Platelets -- 5 . - - .5 0 2064 . 0; 150-450 -2 16.0 --. 11.0-16.0.. 0.. .. MPV 35 g. f5;W' 9.4. - . 8.0-13.0 fL hflanualififlerenfial 0 0 83__u Neutrophils abs 15.8 fg'Q-g -fig" 1.6-7.8 X10 3/uL tes%~DIFOe- 9. 0 . . - 1oCytes%--DIF" .-.0, . focytes abs--DIFBands 0' Occasional Macrocytosis--DIF=fi_ Slight . I Slight Toxic Granul.+DIFQ_ . "-032; 0 Prothrombin Time; VH 21.3' a*Tef . 9.9--12.9 Seconds 2 - - . . 0 Reference range reflects N011-Anticoagulated - . 5 - . patients . . . . .. . . .. .. . . TNR .0 3.29 . 2.00-3.00 Ratio . . I 0 - Recommended iherapeutic range: 2.0 -- 3.0 Acute treatn16nt.0f .. . . I - venous thrombcisis, pulmonary en1b0h5m, tissue heart valve, atrial fibrillation. 1' . --T valvular heart disease, p1'evenli{Jn of 3 9' :5 A syetemic embdlism} 2.5 9 3.5 Meefuinical Heart Valve. An reference interval is anfi-coaguhnulnedkafionLad 11131!- **Requieition Commefit?*% . F. By Autoiirns on at (H :30 Ai\'le. -. I. Aulollms Clinicni lnfurnlatinn System Vor. 3.42.00 by Na-Iliuns - 1983613-9373330 A ihiiuni ?nI'I.n'mat.iun fi Eocca George REGEIS CARE CENTER Ji.V.;;i SML Code; 442099 33, 3200 Bayohester Avenue Room:528 Bronx, NY 10475 I Ln!) 7 ilme Sm.' R749m=.R7r; 1 R01 903 7" 24.? :0 H13: nits '1"e:4i This R?port Contains Critical Values Chemistry- 1 I 0 -. .- Glucose {greyCriteria for the diagnosis ofdiabotcsz 3 . (Fasting Glucose55959 0 0 .0010 Normal fasting glucose. - ., 100-125 mg/dL: Impaired fasting glucose. _>_l25 ofdiabetes Ref: Diabetes Care Urea Nitrogen 24-_ 5-25 mg/dL Creatinine 3" 1.0 0.7-1.3 mg/ForAfrica11-Americans, multiply EGFR result >1 L2 . - BUN/Creat Ratio . 5 r,o. 24.0 . .1 5 0-30 0 Sodium 3' 143 '5 1' mEq/L' Potassium - in 4.1 - - 3.4-5.4 mEq/L Chloride 10? 94-113 mEq/L 27 . - 19--31ii-- -- 1 1mE-/Li Calcium - 8.2. 5' 8.1--l0.3 mg Protein, Total g/dL Albumin ..H.mi-HlGlobulin J.yi-' 3.1 -.-, 1. -4.0 g/dL Ratio 0.7 2 . 1 2.5 Ratio A1ka1ine_fi_nnM_HA 63 3 40 Phosphatase . f- . .. 3 (SGOT) .f 0 26 '0 10-.5.-50 .. . .0 Enalioobin, 0.5 0 1--1.5 mg/dL 5' 3rd .j f_-5 1.11 - 0.35-5.50 White Blood Count" 19.0 . '5 4.0--11.0 x10'3/uL Red Blood Count - VL 2.96 . -. 4.20-6.00 x10'6/uL Hemoglobin -- -- 10.4. -A - - g/dL -- Hernatocrit: 31.0 - - 38.0-52.0 MCV 105." . V. - . 78-102 fI.: ;:3cncraIlc1IByA.ut0lim5 on at Aulniims Clinical Var. by N0l1im.'i1983613-9373330 ?':1Ei:2r1l REGEIS CARE CENTER 3200 Eaychester Avenue Bronx, NY 10475 _iHRocca,George SSN: 091220925 Room:528 E. Sex I Auk llaliu ifiealliiarluzi ifrnii: 13:11:: i 274955172 gnangaa - amigo? ea?" 'i"e.g1 Olil 0 'L_l1'1ii'S This Report Confiains Critical Values . 0 Glucose (grey) 116j 'iIj -. .0 - - - mg/dL: Normal fasting glucose Indicative clfdiabctesj o_ 0. Urea Nitrogen 49'TgfUTf 5-25 mg/dL Creatinine 1.5.3fifo-Qf 0.7-1.3 mg/dL (calculation) 43 0 . >50' For African-A:11ericans, multiply EGFR. result BUN/Great Ratio 32.7 . 0 . 5.0-30.0 Sodium ;i'i'5 143 0 l33--146"" '"mEq/L Potassium I - 'i -.255 5.4 - i 3.4-5.4 mEq/L Chloride 3 .- 1101 0 94-113 mEq/L Carbon Dioxide - . 3 23 19-31~-- -in-0 mE Calcium _fi; Ljjg:?g' 8.2 5f 8.1--10.3 mg dL Protein, Total 0 2 g/dL Albuminfir' mu: Globulin g/dL Ratio 0 61 ""1sphatase of - . _i 28 10-40 (SGPT5-50.. 77 . . - - go. 0.1-1.5 mg/dL Henmtology - White Blood Count. HI 4.0--11.0 xlO"3/uL Red Blood Count" VL 2.35 ugfa; 0 Hemoglobin l0.2.'y3Tf.l - 12.S~l6.1 g/dL Hematocrit 'Io; 38.0-52.0 Platelets" 195 150-4500 xlO"3/uL"" Coagukuknl ov"V Prothrombin Timel . ism Ratio 09.9-12.9 Seconds Hy Aululims an at 05:34 PM 3 V: 7 Clinical Information Systerrn Var. by Nctlims A }Rocca,George SSN: 091220925 Room:S28 Phone:718--882--D605 2 of 2 sNum@8me@ewe399052 REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 Tfiwaiwa emrr"h DR. TEICH MARVIN 5-ip:-cirncu igm 7 eci 02/20/2008? 79 R74965178 2000954 02/20/08 1 Ffifififif. Asyh i Tesi INR Fasting? -- (mg 2 Limits Repofeedofiteihs Critidelnfielues Reference range refiects Non-Antieeagulated - patients 2.98 V//3f 2.00-3.00 Ratio R_eeo;n1_nend_ed ;"11_er_apeutig; Vraz1ge:Z2.ZO 13.0 Acute prophylaxis treatment of venous thrombosis, puinn:-nary embo1i5n1._ tissue heart valve, atrial heart bf" systeluie embolism. 2.5 - 3.5 Mechanical Heart Valve. An reference interval of0.8-1.3 is applicable to patients not receiving anti-coagulant nuedication. **Reqfiisition Parameters** [By Autnlims m_I at (15:34 PM Aulolims Clinical _lnfm-malliun System Vcr. by - flute Pzmiciit hlftarlnafintl REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 _Arocca,Ge0rge SML Code: 442099 Room: 52 8 MARVTFR7496522F 2200770 "79 1 "cs! Out 0fRzir1ge Range Units This Report Contains Critical Values Coagulation 0 Prothrombin Time 24.1 9.9--12.9 Seconds Reference range reflects Non-Anticoagulated pati?ncts_ 0 . 0 . 0 -- This assay was confirmed in extended made. INR VH 4.20. A 2.00-3.00 Ratio Recommended therapeutic range: 2.0 - 3.0 Acfle M.I., pr0p11y1a5(is treatment of venous thrombosis, pulmonary embolism, tissue heart valve, atrial fibrillation, valvuiar heart disease, prevention of systemic embolism. 2.5 - 3.5 Mechanical Heart Valve. This assay was confinned in extended mode- FD fig. wglaggzg? COMPLETE Auleiims Clinical Laboratory Var. 2.41.00 by Nctiims Rt': [By .-Xululirns nn :1t05:37 PM E':1i'c1:'::122tEm1 }oCca,George QML Code: 442099 R0om:528 7 1" . 153 Lula 2200770 i ?2x Emu-. J'.haii- REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 Hm.' Duly 2 . Q2Aa212an?;F R7496522F 02/22goa Out 01' I Ram This Repbft'COntains Critical Values liizarigrs {1_i_l.fi I I Coagulation . 7 .. . Prothrombin TimeT 9.9-12.9 Seconds Reference range reflects 7.. . This assay was confinnecl in extended mode. 2.00-3.00 Ratio Rccolnmended lhrarapcutic range: 2.0 - 3.0 'A'c1'1t'e venous thrombosis, embolism, tissue heart valve, atrial fibrillation. valvular heart disease", p'1''ev'entic'm''ofA' systemic embolism. 2.5 - 3.5 Merzhambal Heart Valve. This assay was cnnfinned in extended nlode. fin ?4?1 f' INR L"vfi Ru gr.-Inc-ranted mt 05:37 PM- 1. Autulims Clinical Vclj. I1-y_ 1992593--9423542"" .- --Z 1 '2 . .533 :occa,George . 5ML Code: 442099 Room:528 REGEIS CARE CENTER 3200 Baychester Avenue Bronx, NY 10475 MAPVTN 02/25f2008?= "w 2 -Lge -I of -7 94 42 ixzsia Dzatc Rcpu:"ie1i Sex I ?MfiW? aamzm This Repbrt fiofiEains Criticai Values Coagulation .. .. Oui: Lh1iiS Prothrombin Tim 7 VH . 107.: Ref'erence range reflects Non-Anticoagulatcd This assay was confirmed in extended mode. INR . AVH 5.23--1.0g1= 0 - 0'1 30 2.00-3.00 Ratio therapeutic - 3.0 Aciite &"tf0at'fi10I1t' cm 0 0 0 0 venous tlirombosis, puimcmary tissue heart valve, atrial fibrillation, VriIvu1ai'110'aI't di'se'a5c:', pi'eV?'11li01i or' systemic embolism. 2.5 - 3.5 Mechanical Heart Valve. This assay was confirmed in extended mode. - bpCJ" By .\ut0lin1s_an Lu 03:55 PM . M. .. .- Autalims Clinical 'fur. Nelli:_11s_ I ??fiEfi? C121: [3 5 PM Critiealn Values Coagulation 1 - Prothrombin Time 2Seconds -. 7 . 7 1 Reference range1'eflects . patients . . This assay was in extended mode. VH. -TIT - I ..RatiQe" . - -- - Reccmunendcd therapeutic range: 2.0-3.0 Acute prophylaxis 3: treatment. of i-'zsiiealt Eocca,George REGEIS CARE CENTER Code: 442099 3200 Baychester Avenue Rc)om:528 Bronx, NY 10475 nvaasapnw i 9qnn7qs 7 n9/Qagna n9j9Gj9nn2fi- 570 fififi venous tluombosis, pulmonary embolism. tissue E-lfrial I I valvular heart disease, prevention of systemic e1nbc--li5mThis assay was confirmed in extended mode. - Comme:1ts** Reported to: Regeis Care Center at 0285/08 02:40 PM By Ant-nlims an (JZIZSJZINIH at 03:31 I i 1 3 Autnlims Clinical Netlims l996523--9-'-140609 Regeis Care Center 32.00 Baychestar Ave Bronx, NY 10 47 718-320-3700 Medicine'& Rehabilitation Consfiltafion I- Historv Illnas 'find. Chief Con'ip1a.iuUROS: -Cfo: Last Name FEirstName Roomfif Refer;ri.11g Physician Date: ofCon$u1tLatiou. . 7" fivl?aifi The is a year c_$Id M33 admitted_t_o Regeis care center on' .1 '7 I - . rm"' I7 T, ,1 - - The reviewpf system was non contribution! significant for. Thanks fgrlieferrai . History: M?dicafions: 5,5' I [0 2r" 2 Livw alone! ives witI1Fan:?ily in agar Licup Eievaior I - - Iudzpepdeutlneedsd assistance - ADD -'ea - A.mbuIatign_- needed assistance a - assistance! Independeuf with gait aid I 7 . 5 Alert . Follows a Hea:t-- 31 FL. 'Lm1gs- Ai>domeu-- BS fl It - - MMT-- . I-Ioffmam Bab1nsk1- . g/3 9 64;; f. - I if ?/03733;" . . A . . Plan: Evaluation aud;Tt<32it1uent I 13 1+ WBAT Prognosis --_Exce1lent, Cfiafi Fair, Poor, Guarded If I, Ot.l1erRcco1nrueI1dations- .4 - . I [95-2 W0 man NH) Sign tKI}r'e 0 Primary page. Board certifieq in and EMG . OCCUPATIONAL Tmmuvy EVALUATION fcsidcnl's Namc: Ronni . Dale of Birth: 5/ this Therapy Diagnosis: 7455' I - ICD-9 Code: 6* Reason -. Onset Data: '44- - PLOP: :75? air.' D:'CP1ahs1 Precautions 41.? . Bed Motiiszsy: _Mcnt:a1 Status: I. I. /Qw Range of Motion 0. No Limilation 1. Limitation on out sidi: 7. Limitniiou on both sides Voluntary 0. No Loss' 1. rgrzial Loss 2. Full Lass Muscle ROM BUB BUB RUE LUE 0 0 9 0 Balance: Transfc-.rs: Coordinafiun: . Fina Dexterity! No Loss: I Loss: Specify: LE Dre?siug'. - Personal Hygiene: 71405.1? Feeding/Drinking: await Mobflily: Olh?Shan?c or . .. 414'-' . -. er" 2 F: zgfi .4 /fun 22' - E'-naluation and Plan ofCan: established by the tin /U49-i-9 (:79 fin'-J ?122? .5 4514:54- Rehab 'um: '7 4'1?zE?Vy 9' Tmrmem Plan: 247/9% ,4 W6 Rcstumlivcz (21 Maintenance: .. Frequency; :5'/12 ?fi? &mfion: 1 Pl_zu1 of cm Dimussod with Resident aw Plan ufCarc Discussed with COTA: .. M. in NL_Lr5ing: r/(ff (- - Pi with the physician: 4'9' I )1 st/57? 1 M.D.'s Sigualun: 19 Fiveboro Pnntinn Form Nn. RNH-fin'! 5.11.3. DEPARTMENT op OCCUPATIONAL THERAPY PROGRESS NOTES Program: Weekly Cl Bi-Weekly PATIENTS K4: <> 3e"S?r1' Training:7j"'31 fig? "4 Ir I. x'/'Rafa. /GramRESPONSE TO TO DATE: 5; (I29- !?75F,gf_ A 2 1 Er:_Tr/ -. 3.- - 57?' -4- if I - UPDATErfizw-' 6367;? *2 Resident making measurable progress towards attainment ofgenls: ofCnre discussed with of Care discussed with supervising Occupational TherapistCnmmentS: [3 Yes No" Comments: [3 yes No Comments: DATE: SIGNATURE OF THERAPIST: 71/ SIGNATURE OF PHYSICIAN: fgx? -1 SJ Fivebaro Printing (718) 431-9500 Form No. DATE: I DEPARTMENT OF REHABILITATION OCCUPATIONAL THERAPY PROGRESS NOTES 5 Weekly l3E~Wecld1' 13 NAME: - mg: DATE: Program: El Restorative' Mifintenance Frequency: . Pain Complaint: [3 N0 [1 Yes Location: tfi IntensityHOFPERSDNIS PROVIIJING ASSISTANCE: 2 HnirGrOomingMAX TOTALDEP Faciaiflygicnc: IND I3 sup CGA. MOD El MAX El Ornll-Iygienc: [1 SUP CGA MOD El TOTALDEP Toiletingz IND SUP CGA El MIN MOD [3 MAX [3 TOTALDEP Bathing: 1141TOTALDEP [TOTALDEP Dressing: IND SUP GOA El MIN MOD MAX TGTALDEP Wheeichs-.irMobiIityMAX [gt DEP EATINGIDRINKING: PROVIDING ASSISTANCE: 0 2 Graspivi.-Ui TOTALDEP Fi|IgerI'oodTO Mouth: CI IND SUP El COAT MIN MOD MAX TOTAL DEF Utensil Grasp: IND lj CGA MIN I3 MOD MAX TOTAL DEP Utensil ScoopTOTALDEP El IND SUP CGA -MIN El MOD El MAX CI TOTAL Drin1ITo Mouth: [3 CGA MIN MOD NIAX TOTAL DEP #05 PERSONIS PBGVIDINGASSISTANCEImuc El TOTAL DEF BED MOBILITY: movnama ASSISTANCETUTALDEP BALANCE: Sitting: [3 Normal Pun-r El Zero Standing: Normal CI Good Fair Poor Zero THERAPEUTIC EXERCISES: $21" 8' 51.3' rags': i' . OTBZERS: fnrlodaiitiw, Orthatics. Prosthetics, ADL Adaptivemusitioning Devices, Cognitive Training, Sensory Training, etcF'-fix I 1 fir'; I K-8 3' r-Ta I I . TO 1' PROGRE TO DATE: 1 . t. I .75.. I ff' 7'41 <51 MIN [3 MOD MAX TOT-A-LDEP UtensilGraspMOD MAX TOTALDEP UtensiIScunpTOTALDEP [3 SUP CGA. E1 M01) MAX El TOTALDEP DrinkTa MouthMAX TOTALDEP TRANSFERS: #01? 9 I 2 3319MAX TOTALDEP BED FERSONIS PROVIDING ASSISTANCE: 1 2 477- El IND SUP El CGA Al] MOD MAX TOTALDEP BALANCE: i Sitting: [3 Normal [3 Fair 23970 Normal El Good Fair' Poor [3 Zero THERAPEUTIC EXERCISES: +3 OTHERS: (Modalities, Orthotics, Prosthetics, ADL Devices, Cognitive Training, Sensory Training, etc.) ;Mv kart.' %?fl RESPONSE To PROGRESS PLAN I GOALS UPDATERnsident maicing measurable fix towards attainment ofgoals: with Yes No Comments: '3 on THERAPIST: 9755/ DATE: 0 SIGNATURE DATE: 0 Printing (318) 43149500 Form No. RNH-158 REHABILITATION INTERIM NOTES NOTES. - 24/<>mn, - Coordination: 4022 #5 /7 Fine Dcxizriiy: No Loss: Loss: ., 4* Specify: 4&1. aw UE Dre:ssiug: vzmz?' /24; LE Dressing. 77$! Persona} Hygiene: ffmy Mobility} 4/3 011165: r" Problem (lisi): jg; 9/4' /zfl Tgzir 17Restorative: Maintmance: Frequency: 13213;" :1 Duration: /xi/A Plan of Can: Discussed with Rcsidcnt (E: ff': man of Care Discussed with com; -. - to Nursing: /i 1:5 . ., and Plan OFCJII: tstabiishcd by the 'f;4:on qfi?u ah the Mater U. - Signalurc: - Dater'r-10' firnn DEPARTMENT REHABILITATION OCCUPATIONAL THERAPY PROGRESS NOTES El Yes N0 Cummenm: I [3 wecmy Bi--Wwi> [3 CGA [3 MIN El MOD TOTAL 131:? pmsows pnovmmc: ASSISTANCE: 1 2 Fingerfood GraspMAX TOTALDEP Fingerfand To MouthTOTALDEP UtensiIGraspTOTAL DEP Utensil ScoopMAX TOTAL DEP Drinkfirasp: [3 my sup :3 CGA MIN MOD MAX TOTAL 131:? DriukTo MouthTOTALDEP TRANSFERS: #01? PERSONIS PROVIDING ASSISTANCE: 0 1 2 El 311? CGA [3 MIN El MOD IVIAX [3 TOTAL DEP BED MOBILITY: ASSISTANCEMIN MOD MAX TOTAL DEF BALANCE: . Sitting: CI Normal fig Fair Pour CI Zero 5% Standing: CI Normal CI Good Fair Poor Zero THERAPEUTIC EXERCISES- X17326, 6x293-S Cbdravf'. OTHERS: (Modalities, Orthotics. Prosthetics, ADL Devices, Cognitive Training, Sensory Training. etc.) fly; I RESPONSE To Roqg__Ess PLANIGOALS UPDATE: 45% war? v3r{~gLg . Restd :1 measurable grass Yes Progress/Plan of Care discussed with YES No Progres.sfPlan of Care discussed wit E, Occupntionai es 0 Comments: 1419i73o>>. Comments: Comments: I -6.- SIGNATURE OF THERAPIST: DATE, - 4 SIGNATURE or PHYSECLAN: (ii) 1' ,1 BATE, Fiveburn Printing (P13) =13!-9500 Farm No. 3 ..-- 'u 13.1931 OEPARTMENTOF REHABILITATION OCCUPATIONAL NOTES Er Wcelcly Z-A 5 DATE: ggfiflfi Program: Restorative [j Mninterrgime t'0Cll13"CY5 Pain Complaint: No Yes LactationACTIVITIES OF DAILY LIVING: #4 OF PERSONS PROVIDING ASSISTANCE: 1 HairGrOO:niI1gTOTAL DEF mo sur CGA MIN MOD [1 MAX TOTAL DEF Ornii-iygiene: sup 5353TOTAL DEF Toiletingz [TOTALOEP BathingTOTALDEP Upper Body Dressing: [3 IND Cl SUP C1 CGA MIN MOD MAX TOTAL DEF Lawerfludy Dressing: IND SUP [3 CCA El MIN MAX TOTAL DEF Wheelchair MobilityMOD MAX TOTAL. DEF EATINGIDRINKING: my maasowzs PROVIDING ASSISTANCETOTALDEP Fingerfuad'I'uMoutIITOTALDEP Utensi!GraspMAX TOTAL DEF Utensilscoapz IND SUP MAX TOTALDEP IND [TOTALOEP Dr-inkTo MouthMAX TOTALDEP TRANSFERS: #017 ASSISTANCETOTALDEP BED MOBILITY: #09' PROVIDING ASSISTANCEMOD MAX TOTAL DEF BALANCE: Sitting: CI Normal Good Fair Paar CI Zero Normal [3 Good Fair Poor Zero THERAPEETIIC vi' Frke OTHERS: (Modalities, Orthotics, Prosthetics, ADL Adaptivemositioning Devices, Co uitive Training, Sensory Training, of 3:3:-wag is' 13% RESPONSE TOT ATMENTIPROGRE - . . A29 a. 5337: 4'53' I/gs' iv'- ?30 5237 g' A. A, . UPDATE941;; 5; A 'mg 7 A esideut making asurahle progress tS_ towards attainment ofgoals: Yes 0 "lumen" ProgressI'Plnn of Care discussed with residentfpatient: No Comments' Progressmlan of Care discussed with I 8 EEK Yes No Cammenm SIGNATURE THERAPIST: DATE, I) Hi SIGNATURE OF PHYSICIAN: DATE, Fiveboro Printing (NEH 431-9500 Form No. OF REE-IABILITATION OCCUPATIONAL THERAPY PROGRESS NOTES Weelcly El Bi-Wccidr n-Ionuny NAME: ?aafmfl zuvw: DATE: Program: Zfiflestorative I I Pain Complaint: No CI Yes Location: 'WnsityACTIVITIES OFDAILY LIVING: #017 PERS ms PROVIDING ASSISTANCE: 0 2 HnircroomingTOTALDEP Facial Hygiene: [3 SUP ECGA [3 MIN MOD MAX TOTALDEP [3 mu sup cm MIN [3 MOD .MAX [1 TOTAL map TuiletingTOTAL DEF BathingMOD MAX TOTALDEP Upper CI IND Cl SUP CGA MIN MOD MAX TOTAL CGA Mm MOD MAX TOTALDEP Whcelchaii-Mobility: my sup [1 cm: El MIN M00 MAX #09 PERSONIS 1-novmma ASSISTANCETUTALDEP Fingerfood To MouthMAX TOTAL Uten5ilGrasp: [3 IND SUP CGA [3 MIN MOD MAX Utensil ScoopMOD MAX TOTALDEP DrinkGrasp: mu) 511TOTAL map Drink'I'o MouthMAX TOTALDEP puovmmc ASSISTANCETOTALDEP BED MOBILITY: IIOFPERSONIS PROWDINGASSISTANCETOTALDEP cu BALANCE: Sitting: Norma! 1] Good [3 Fair Poor [1 zero 51.: El Normal Good Fair Poor CI Zero I THERAPEUTIC EXERCISESEgg Uh': OTIERS: (Modalities, Ortlloti-us, Prosthetics. ADL Devices, fiognitive Training, Sensory Training, etc.) -JL-H91 (1 La 3 RESPONSE TO TREATMENIIPR TO DATE: {cszb K. 3 . -Rae . A ivcaiaffis . 25?' ?3 . 82?, we 51, Q-2.9 .- /For" EUR 4 . sill I .L Cow' I . gm FD flwg{2// 7'3' 99%' 2 ("exam ,4 tz?/W 9: . 7" I 555% Resident malang measurable Pragress Yes No Comments. towards attainment of goals: Pragress2'PI:1n of Care discussed with E. Yes No Comments' Progressmlan of Care discussed E, Yes No Comments: Occupational Thernpi SIGNATURE OF THERAPIST: /95SIGNATURE OF PHYSICIAN: [1 i _7 Fiueboro Printing (718) 431-9500 Form No. RHH-153 DEPARTMENT OF REHABILITATION OCCUPATIONAL TIIERAPY PROGRESS NOTES /xfifrwcekly Bi-Weekly nionthi}. PATIENTS NAME: 6 Cfl/Fifi PM 5 if DATE: "1 I I Frequency: Lu Progrnm:ERestorntive Pain Complaint: No Yes Lucafion: llni?rlsityz ACTIVITIES OF DAILY LIVING: IHOF FEES NI ASSISTANCE: (lg? 2 HnirGmon|ing: IND SUP CGA IVHN MAX El TOTAL DEP SUP CGAEUWU MIN MOD CI MAX TOTALDEP -Druiflygicne: IND [3 so? CI MIN MOD MAX TOTALDEP ToiletingTOTAL our BathingMOI) TOTALDEP Upperflodybressiugz TOTALDEP DressingMIN E<.Mon MAX TOTALDEP Wheelchair'-MobilityMIN Emu TOTAL PROVIDING ASSISTANCETOTALDEP To Mouth: CGA MIN [3 MOD MAX TOTAL DEP Utensi!Grasp: mm jzisur CGA MIN MOD Cl MAX [1 TOTALDEP Utensil Scoop: El IND Efsw CGA MIN El Mon MAX 8 TOTAL DEP DrEnkGrasp: Ilfifsur CGA Mm M01) MAX [3 TOTAL DEF DrinILToMouthMon MAX TOTALDEP TRANSFERSTOTALDEP BED MOBILITYTOTAL DEP 5 Taiwan: Sitting: [3 Normal Good Fair Poor Zero Normal Good Fail' CI Poor Zero THJ3: EUTIC EXERCISES: e4:.E I, Me? ,-aac - OTHERS: (Modalities, Orthotics. Prosthetics, AJJL Adapiivemnsifiouing Devices, Cognitive Training. Sensory Training, etc.) Iqlgfi I RESPONSE TO TREATMENTIPROGRE 0 534 35.4% 53' 5239 %Ji i fixiffi?kw 1* "7 5441-573 5" . PLANIGOALS MW: 5, ca I 1.. Rest eat making measurable progress /g towards attainment of goals: Yes No Commenbh of Care discussed with residentlpatient: Yes N0 C0mmEflfS<< Progress/Plan of Care discussed with supervising Occupational Therapist: (E Yes N0 Cemmenm SIGNATURE or THERAPIST: DATE: SIGNATURE PHYSICIAN: In-' Fiveboro Printing (NE) 431-9501] Form No. RNH-158 DEPARTMENT OF REHABILITATION OCCUPATIONAL THERAPY PROGRESS NOTES I ?44 Weekly Bi-Weekly Monuny I NAME: ?wmp Rm: 5795 DATE: QZSZ Program: Restorative Frequency: PninCompl:1int: No Yes Location: A I Int?nsityACTIVITIES OFDAILY LIVING: #01: PERSON PROVIDING ASSISTANCE: 0 1 2 HnirGronmingTOTALDEP Fncinlfiygiencz IND SUP CG MD MIN M00 MAX TUTALDEP [TOTALDEP ToiietingTOTALDEP Bathing: [3 r_r~n) gmTOTALDEP UpperBodyDressingTDTALDEP rmTOTALDEP Wheelchair-Ivlobilityz TOTALDEP EATENGIDRINKING: PERSONIS PROVIDINGASSISTANCE: 0 II 2 Fingerfond Grasp: SUP El CGA (TH MAX TOT-ALDEP Fiugerfood ToMouth: SUP CGA MIN (3 MOD MAX TOTAL DEF SUP CGA MIN MOD MAX '3 TOTAL UtensilscoopMOD MAX TOTAL omTOTALDEP DrinkTo MouthMOD MAX TDTALDEP TRANSFE PERSONS PROVIDING ASSISTANCE: (I 1 2 335/ El IND sumMAX TOTALDEP BED 0 I 2 3,36MAX TOTALDEP BALANCE: Sitting: El Normal Good air Poor Zero Standing: Norma! Good Fair Poor Zer (45, Reg; farms: 91?/aw' OTBZERS: (Modalities. Orthotics. Prosthetics. ADI. Adaptive'/Positioning Devifes. Cognitive Training, Sensory Training,' etc..) 4' - I RESPONSE TREA T0 ATE: . /5575. 0 as ri - 7: e'7?'9'7 Ci - ATE: . . 3% Resident in ng measurable pr grass towards attainment of goals: of Care discussed with Progi-essfP!an of Care discussed with supervising Occupational Therapist: or THERAPLST: SIGNATURE OF PHYSICIAN: ~22 .22 /g?gxgn?fl 'fxarfigl? 5 21" Yes Comments: Comments: r"c> 2573-rarfl Comment.-s: DATE: DATE: Fix.-eboro (713) r$31--95D0 Form No. RN {+158 7 4 r" i - a afi?g" REHABILWWON DISCHARGE SUMMARY fior -DPT Name Firzl l'LJrr-: Room: - I Laardcga/, 35$' LEVEL ATIINITI LUNIQION FUNCTIONAL LEVELATDI RGE Date: Date:' .43 wax S+5gfiC' 11751:2-rx . cm ME .. . .4.) D9905 -L7 . Di" 3 - 0.65 u?i??jfizgwfi _fl' --oh - LE H. MBA (R) Puma oi/L It Fwd" -., . C3 rirxiima. SUMMARY OF SKILLED TREATMENT PROVIDED: Ea-a"w 'r5 40:39:; - mtg"? . ANALYSIS OF PROGRESS MADE TOWARD GOALS: Indicate reason for and if goais are met; If not met, indicate why not) Ran 057'? PIT: - ~52 - Liwi?-9 SUMMARY OF DISCHARGE PLAN: A 1. Discharge Location'. 2. Summa of Caregiver Training: (Include cuinlenl of training. lafg ed and summary of resyits: I2-3, I feckr . c-V 3. Equipment ordere-zilissued; 4. made: Fiveboro Pfifiling (718) 431-9500 Form No. 5. Other referrals for foilow-up Care 2 agfigizyfizkr>> REHABSLE ATEON DESCHARGE SUMMARY OT. E1 PT SLP [rd r-larmz 1 l'l.IIl'I.2 Ml Room 3 I FUNCTIONAL LEVEL ATTINITI L-EVALUATION FUNCTIONAL Dale: Dg-ate: . 4.4.-am. JFKB I - (ma --rmIm -- me: Arse I,Ea1r<<3 7 pint +7 - .. mm-(R) Iqu- 5 -I L59/fa': - Ct 5% 9-D we- :43. 41% ME mg ca/@ -. Qfi' 25?- SUMMARY or TREATMENT PROVIDED: I324 71-. d-7' wt" 75: ANALYSIS OF PROGRESS rnet, indicate why not) MAD pi TOWARD 745% me; I. I A Ma xi-2 /Wrf GOALS: Indicate reason for and if goals are met. If no SUMMARY OF DISCHARGE 1.. Discharge Location; C- fid fit'--C51 4. Fweboro Form No. RNH--209 OF 3. waxSummary of Caregiver Trainingt of Iramlng, v" 2" /we cw: 74DATE-: I . audufg e, and summary of reau 5. Other rcibrrali; for foliow-up care: cg flag' - I . rift' _7 A I-Inf--1 Its: W4 REGEES CARE CENWR OCCUPATIONAL THERAPY Name: Room #2 . EFQUARTERLY CIREFERRAL: M-D.: Diagnosis: f. 1. Cognitive Status: Folioinrs Yes El No 2. Physical Funciiuningt Sump at Hap CODES .2, um and 2: 9' 2+ meow I Self-Perfonnance Support Dressing {Ii 5'7 Ealing 1 Drinking Toiieting .2 Personal Hygiene 4 2 Bathing ?1 3. Functional Range of Motion: (in Ha Lira-Elafiorr: go) No Loss cones on one side (1) Parfiul Loss an rm. side: mm um . Range of idotion Voluntary Movement Contractures Neck (j 0 Am Shoulders Elbows 4. Wrist . Hand 0 2 Fingers 4. Task Segmentation: gEYes BN0 5. AOL Fulictianai Rehabilitation Poienlial: Resident believes hefshe is capable of increased independence in at ieast some ADLS. - El Direct care staff befieve resident is capable of increased independence in at least some ADl.s. Cl Resident able to perform tasksiaclivity hui is very slow. Difference in ADI. Self-Peifonnance Support, comparing mornings to NONE OF ABOVE. 6. Change In ADI. Function: IEIND Change CI irnproved CI Delerioraled lg Wheelchair Gerl--rediner Other: Chair T)rpe!Posilioning fieflces: 8. Wheelchair Mobility: Toigasiwf CI Partial [3 Independent 9. Yes No Type: Weaiing Schedule: 10' El Resident is a candidate for Occupational Therapy. Resident is fundioning at maidrnum level of independence. Resident is us! a candidate for Occupational Therapy. CI Resident on an active Occupational Therapy Program- I 11' rfeifii r: A I . Therapist Signature: Fivebnro Printing (718) 431-9500 Form N0. RNH-205 Date: ii -1 REGEES CARE CENMR eccuennanzxt THERAPY SCREEN Name: Lia' ROUTE - M-D-3 I Diagnosis: (R) LE 5, PTPW5, - NEVVIRE-ADMET UQUARTERLY CJREFERRAM 1 . Cognitive Status: Follotus Instructions: [3 Yes N0 2. Physiea! Functioning: (G) - Nu 3:1-up 0: Help (1) H) nap (23 1 .Ms:.isi CODE Extensive AniaNat occur Dressing 4 7, Eating I Drinking Toiieting Personal Hygiene 4. Bathing 4 1/ 3. Functions! limitations -in Range cf Motion: COUES zida Rifle - Range of motion Voluntary Movement Cantractures Neck 0 'Ir Shouiders - Arrn 0 C3 Elbows Wrist . Hand 0 - 3 7/ fingefi 4. Tasksegmentation: C]Yes Ema 5. ADL Functional Rehabititation Potentiai: Resident believes hefshe is capabie of increased independence in at Least some ADLS. Direct care staff believe resident capahte of increased independence E1 at least some ADLS. Resident aide to perform but is vent stow. Difference in ADE. Setf--Performanoe or ADL Support, comparing rnamings to evenings. CHE QF REOVE. 6. Chen a In ADL Funcliont E40 Change Improved Deteriorated 'wheelchair Geahecliner Mb .. Chair TypeI'Pcsi1ioning Devices: 5. Wheetchair Mobility: Total [3 Partial [3 Independent 9. OrthotidPm5theticJ'Feeding Device: Yes [3 Type: Wearing Schedule: 16' Resident Be a candidate fer Occupationa? 'i'herag:y. Resident is functioning at tznaxlrnurn tevel of independence. Resident is not 3 candidate for Occupational Therapy. [1 Resident is on an active Occup?tionat Therapy Prog am. 1 1. Recommendation: +9 flit x/mama . i . - . "therapist Signature: {'1/tx /Fr )1 Date: fiveuom Printing (718) Form No. RPIH-206 of Care discussed with supervising DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES [Elf Wecldy Bi-Weekly PATIENTS NAME: An ragga 6-egrqe, RM (3 5 DATE: '32- 0 2 Program: Restorative Maintenance Frequency: . . Pain Complaint: No 'Yes Location: IntensityGAKTIAMBULATION: yorrnasowsrnovmm ASSISTANCE: a Q) 2 Assistivc Device: [3 None [3 sw law sc [1 NBQC [3 Other: Weight-Bearing Status: WHAT I rwa I Nwu I Distance: Utilized: Yes N0 Assistance Needed: CGA TSISIST [3 TOTALDEP Deviations: Present I00 "xi. ofthc time. Description: J2 Flag; STAIRS NEGOTIATION: #5 OF FERSONIS PROVTDING ASSISTANCE: I 2 No. afsteps I Flights: SUP C1 CGA MEN El MOD MAX TOTALDEP TRANSFERS: movmmc ASSISTANCE: 0 Q) 2 sitc->smnd: mm sup Eras MIN El MOD MAX El TUTALDEP Bed INTTOTAL DEP Bathroamffoilet: 1ND 13 SUP CGA I3 MIN MOD MAX TOTAL DEP BED MOBILITY: SSISTAI-ICETOTALDEP Stunting: IND El MIN MOD TOTALDEP IND SUP El MOD El MAX El TOTALDEP BALANCE: Stand (Static): Norman! Good IE/Fair [3 Poor Zero Stand (Dynamic): Cf Normal Good 8' Fair.-' fz'W'Ij Poor Z-era THERAPEUTIC EXERCISES: .31: ($975, Balmm, +9 arjamefaz 360/ OTHERS: (Modalities, Ortlzotics, Prosthetics, Chest PT, etc.) PATEENTI CAREGIVER TRAINIPHQG-EDUCATION: 4- RESPONSE TO TREATMENT I PROGRESS TO DATE: F7 75, PLANIGOALSUPDATE: %1_l/yz /fie/GM, Resident making measurable progress inwards attainment of goals: El/'Yes No Comment of Care discussed with E/Yes No Comments' ,1 av SIGNATURE or THERAPIST: I 04/5 I F7 DATE: -1,2 5' SIGNATURE or PHYSICIAN: . hf 7 Fiw;-lmru Printing (718) =131--95tJ{! Farm No. WC '5 QT 5% 2:-ma? Distance: -1.2 Utilized: Yes No Assistance Needed: El IND SUP RESIST [3 TOTAL DEP Deviations: Present /ggz ofthe time. STAIRS NEGOTIATION: Ivor PERSONIS pnovmmo ASSISTANCE: a I 2 No. AssistanceNoeIlcdTOTAL DEP TRANSFERS: nor rsnsows movmmc SSISTANCEMAX TOTAL DEP El SUP El MIN MOD El MAX TOTALDEP Bathroomffoiletz IND so? con. [1 MIN MOD MAX [3 TOTALDEP BED MOBILITY: aorponsom PROVIDINGASSISTANCETOTALDEP Scouting: IND CGA Cl MIN MOD MAX TOTAL DEP El IND so? [s21'cGA Cl MIN MOD MAX El TOTALDEP BALANCE: -- Normal [3 Good Ef Fair 7 if [1 Poor Zero Stand [Dynamic]: Normal CI Good Fair Cl Poor Zero DEPARTMENT or REHABILITATION PHYSICAL THERAPY PROGRESS NOTES C-A-R-E Bf Weekly El Bi-Weekly PATIENTS NAME: 45, fogrm RM DATE: I7 2 3 2' Program: Maintenance Frequency: ?x Pain Complaint: No "Yes Location: IntensityGAITIAMBULATION: IJOFPERSONIS movromc ASSISTANCE: 0 Q) 2 Assistivcflevice: None sw sc [1 NBQC WBQC 1] Other: Weight-Bcuringstatusz WBAT I PWB I NWB I THERAPEUTIC EXERCISES: )4 39 3c gh?flu ggamegag 9' MM OTHERS: (Modalities, Ortholics, Prosthetics, Chest PT, etc.) PATIENT I CAREGIVER Vfififl gr frayau fin/5 I RESPONSE TO PROGRESS TO DATE: Ace: mcm? arm: ate Fr PLAN 1 GOALS UPDATE: cyaf wk Resident making measurable progress towards attainmentof goals: G/Yes No Comments" of Care discussed with No Comments: of Core discussed with '1 supervising Physical Therapist: cW; I residentfpotient: SIGNATURE OFTHERAPIST: fi?'Vl?{ DATE: 5' SIGNATURE or PHYSICIAN: \-Iii; i DATE: 9&0 Fiveburo Printing (TIB) Form No. RNH-159 a TERAPY EVALUATION Resident's Name: 'Eat-czar GE O2-as: - Room 12:; 5593 Dulcuof Birth: fa! BUIIQEB Date ofAdmssio Therapy Diagno?is: Code; '7 Reason for Referral: 05 - i Onset Dale: /37 .cs!P Ciaf-3-'C-3 VI cm F. fib I. -Lrm, AA-A PLOF: 'V-Jczs on 33:97 pfinr emf? f' we Plans: Onnoino . Prcacautionsi 1 Mcnt:zISt:Itus: Crbk' Range. of Motion Voiuziiary Movement' No Limitation Loss 1. Limitatiori on one side 1. Partial Loss ROM 2. Limitation on both sides 2. Fall Loss BLE BLE RLE LLE - RLE -LLB Hi? 3/3 Knee - 'wfi. Ankle 3,53' 3? WFL w1=: TW5 0 3V3 Other limitation or loss .3. Baiance: k3"'D 5 P4- Bed Mobility: min GE) I 'if Gait: using 21-' mar} 1 Other: ('E7-fimolfi (E) 4 enduranv-3 Problem Gist): 4 - - ci ~93'U/Idi ac balcmce, .L Short-term Goals: .r'm'n bu - CECE) '+Ul mm xi 'Tmm Inns able weft 7 using Eu! "5 (Q eflduzance RchahPute:nt1'al: C-2-mni TrI:atz11cntPIan: ting. Beef '8c::lc:anc:e Rmomtive: Maintenanotz Frcquerlcy: - 2 Dmfion: Plan ofCarc Discussed with Resident '#93 weeks Plan ofCarcDiscus5c:d with PTA: Rccommendationstu Nursing: 006 jp ADI, Evaluation and Plan ufCan: csiahlisl1m pin#iQcomImtiou with the physician: 3 :T"ltc1"apist's Cit? . Dale: 'fig. . x, - V. Date: Fuveuoro Printing (713)431-9500 Form No. DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES IE Weekly Bi-Weekly C-A-R-E GEORGE RM mm _>-wvritci Pm Utvnbuilcrfitm +rm.'n.m 25: -resrdarn RESPONSE TO TREATMENT I PROGRESS TO DATE: flu Ctmivumss icy in otgpc-Ci"; 62;: bed Si balance. Qi?upxom umrrer nevi ang9a'hg. Tbitrmfid itx mu. PLAN I GOALS UPDATE: 0 FT ix pimn 4-0 magi am am. dam; 41%: J1 dmvirgg) . Capcix, mmifnegg fr' Resident making mcasu le progress towards attainment of goals: Yes Comments" afCare discussed with E, YES No Comments' afC1ire discussed with sup:-rvIs' ing E'E|ysicalThernpist: A, Yes Dmmeflm? SIGNATURE or THERAPIST: DATE: 1 SIGNATURE OF DATE: :3 gm Flat.-Lmru srrenunq ma) Form No. rmu-159 9 DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES Ea Weekly I :85" DATE: glgilfi Program: Restorative Maintenance Frequency: Pain Complaint: No 'Yes Location: Intensityll} GAETIAMBULATION: 0 (1) 2 Assistiw.-Device: None sw aw sc NBQC wnoc [3 Other: WeigItt--ElaariugStatus: awn 1] WHAT 2 vwa .r NW8 :1 I Distance: Parallel?-ars Utilized: Yes No Assistm1ccNet':ded: El IND El SUP CGA iigifsj. TOTAL DEF Deviations: Present 1} ofthe time. Description: aorpmsows movmmc ASSISTANCE: 2 5 No. of Steps I Flights: Assistance Needed: mm sup CGA El MIN MOD MAX TOTALDEP TRANSFERS: 1: or mason/s movmrwo ASSISTANCETOTALDEP new-:-cnainrwcTOTALDEP Ball1room!ToiIctTOTAL DEF BED MOBILITY: gov mzasoms movmmc ASSISTANCE: (ifTUTALDEP ScoutingMAX TGTALDEP Supine<-> SitTOTALDEP BALANCE: Stand (Static): El Normal Good Fair Poor Zero Stand(Dynarnic}: Normal El Goad Fair Poor Zero Mafia of tine mono IE WE !_3'fii| Cm THERAPEUTIC EXERCISES: HQES an LE '5 Q-aka 'mag ycfiifilril 'ih5'l'r:tb:Jurd OTHERS: (Modalities, Orthn-tics. Prosthetics. Chest PT. etc.) ammo Baal Qt Tf?liflm (37mtl* -E7miE'ina'in' PATEENT 1' CAREGWER TRAHVING-EDUCATION?tifly ca di?ausscd Ftiidcmb fiat RESPONSE TO PROGRESS TO DATE: -inmn St amlaulmohlm But progrEUR5.Sing eitccolily an aannb malaifiry of Core discussed w' it . I Physical Therapist: {bed 9a Simiolc ciuirim, PLANIGOALSUPDATE: Cmtivmfi pr 'i'Itli\{ SE8 . flit C) ciarifg "Ca Ema' i dcvrafim JO) imp V0110 mficitamfcg Resident making measurable progress towards attainment of goals: Yes No Comments' Progress!Plan of Care discussed with residentfpaticnt: Yes NJ Comments' SIGNATURE OF THERAPIST: viabqvicauoto DATE: cur DATE: 55' Flveboro Ptintirnj} (113) 43143500 Form No. rum-155 - DEPARTM ENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES J3: Weekly El Bi-Weekly El TE: QH Restorative Maintenance Frequency: lg Pain Complaint: No CI Location: IntensityGAITIAMBULATION: PROVIDINGASSISTANCE: ii kill 2 Assistiveflcvicez None SW RW El SC Cl NBQC WBQC I3 OtherNWB Distance: Pnrallelflurs UtilizedCGA TSISIST ASSET [3 TOTAL Deviations: Present '?00 oftiie time. Description: Cgiiff, \.Li'l'l3l 1 STAIRS NEGOTIATION: OF PERSONS PRDVEDING ll 1 2 No. ofsteps I Flights: AssistnneebleededMan mi:-i El TOTALDEP TRANSFERS: PROVIDING ASSISTANC (TOTALDEP Bed TOTALDEP icil-BED MOBILITY: nor Pisnsows PROVIDING ASSISTANCE: 0 1 RollTOTALDEP ScoutingTOTALDEP ivwr; TOTALDEP BALANCE: I Stand (Static): Cl Normal [3 Grind Fair El Poor Zero 5 Stand (Dynamic): Normal Good Fair Poor I:l Zero THE ,-'rlid Cl' I iggig, i,w3. OTHERS: (Modalities, Orthotics, Prosthetics, Chest PT. etc.) 'i rrviri I (2 10 lmliki PATIENT .1 CAREGIVER ('firm Pm-mirrio I RESPONSE TO TREATMENTIPROGRESS TO DATE: M- (W . jnziyl lama" Q"U'r"1([75 . N0 tum, PLAN I GOALS UPDATE: a C954 Gm-i"i /ishig C, Vi (R) lb 1'.T'i Resident making measurable progress towards attainment of goals: [3 No Comments' of Care discussed with residentfpatient: Yes Commwm Progress.'I'lSn ofCarc discussed with .. . Yes u:flA_ supervising 1"hysic:1lTheriipist. -. SEGNATUREOFTHERAPIST: DATE: 4" SIGNATURE OF PHYSICIAN: /fl 7 DATE: 0' i'iW=boru Form. No. RNH-159 35$ DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES . Weekly El NAME: DZATE: 03425 Program: Restorative El Maintenance Frequency: Pain Compiaint: 'Yes Location: IntensityGAITIAMBULATIONI ASSISTANCE: 0 I 1 Assistive Device: None SW RW SC NBQC WBQC Other: Weight--Bearing Status: (E FVVB ID WBAT I PWB I Distance: Utilizedfirst?!" TOTAL Deviations: Present ofthe time. Description: . .-- STAIRS NEGOTIATION: #01? ransom/5 rnovmmc 0 1 2 i' No. FlightsTOTALDEP TRANSFERS: Pnovmmc ASSISTANCE: 2 El mo so? ECGA El MOD [3 MAX TOTALDEP Bed ClmirfWCTOTALDEP Bathroon1IToiIetTOTALDEP BED MOBILITY: rnovmmc ASSISTANCETOTALDEP ScoutingMAX TOTALDEP El IND so? Recs 1] MIN MOD max TOTALDEP BALANCE: Stand (Static): Normal Good gm' Fair?" Poor Zero Stand (Dynamic): Normal Good Fair Poor Zero xfegclsaiim no zfrer or vie'? {3 OTHERS: (Modalities. Orthotics. Prosthetics, Chest PT, etc.) (QW ?5131'? - xi" .5 Dikt?t" [(1-finial PATIENT I CAREGIVER Cerf" Wkfifmw RESPONSE TO TREATMENT 2 PROGRESS TO DATE: ft T7~'btr i "ml -- - i - 11%" I DQIE 41 rfib 7? 77"" Mr. no new Co mrbm Iv" PrIJgresslP|nn ufCare discussed with supervising Physica|Therapist: Yes ft; ={3'auTr FW7. Mzmovmo 3; mr( 7.35"" 70 GOALS UPDATE: A-_r . war 1: I91 Grflur raua 4- {Kw it 95" LTC 1' Resident making measurable progress RY towards attainment of goals: as No Comments" afCnre discussed with residentlpatientz -J2:-Yes No Comments' SIGNATURE on TIIERAPIST: I DATE: "((371 SIGNATURE 01:' PHYSICIAN: DATE: Fwet:-oro Printing (718; -131-9500 Farm No, n_m1_159 DEPARTMENT OF REHABILITATION TI-LERAPY PROGRESS NOTES 'Ag/Weeldy El m-me: LfirWOCC.fi 2: RM .3: 0" 5 DATE: sag 07?- Progrnm: R/Rcsiorativc Maintenance Frequency: Pain Complaint': N0 El Yes Locfliionz IntensityGAITIAMBULATION: PROVTDINQASSISTANCE: 2 Assistiveflevicc: [1 None [3 sw .81: aw SC NBQC El WBQC [1 Other: Weight-Bearing Status: ma [1 WBAT 2 [1 FWD I Distance: 1 ?71' Parallel Bars Yes -fiflwo Assistancemeeded: El sup EISESIST CF TOTAL IJEP Deviations: Present ET) ofthc time. Description: 4 UPC) 1 MU scams NEGOTIATION: aoxr mzovmmc ASSISTANCE: 1 2 A5sist21nceNcededTOTALDEP TRANSFERS: PERSONS PROVIDLNG ASSISTANCE: 0 2 [3 mm sup ,a'cGA El MOD [3 MAX [3 TOTALDEP Bed El IND Ij SUP El MIN MOD MAX TOTALDEP MIA nammumrruiletTOTALDEP BED MOBILITY: :io:=1=1:Rsows r-novmmc ASSISTANCEScouting: rm) Jgjsup cm. [3 Mm MOD MAX TOTALDEP TOTALDEP BALANCE: Stand (Static): Norma! CI Good Fairfir CI Poor Z-era Stand (Dynamic): Nurmal CI Good Fnir CI Pour Zero xi OF )1 mm >. PLAN I GOALS UPDATE: :97 '9 -'ro Resident making measurable progress towards attainment of goals: No Comments' ofCarc discussed with E: yes No Cadac, rcsidentfpatient: PrugressII'lan ol'Care discussed with . . . . \'es r|%1 Br! SIGNATURE OF THERAPIST: H97 DATE: /0 )5 or 0' I DATE: 3' (G I 7 Form No. RNH-159 REGEES CARE CENTER PHYSICAL THERAPY SCREEN Name; EUR160 Room ii: -523 M.D.: Diagnosis: El ANNUALISIG- CHANGE Ll NEW I RE-ADMIT EQUARTERLY1 REFERRAL: 1. Cognitive Status: Follows instructions:E:Yes N0 2. Physical Functioning: Independent (D) No setup or Ham (1) supanman Setup Help Only CODES (2) Limited (2) 1 Pusan ham 6" Emnswa wk: 21- Persons Assist mm Depwdam in} Did Not Occur in) ma nuioccur Self-Performance Support Bed Mobility Transfers 2 Walk In Room Walk In Conidor 3 jg Locomotion On Unit 4 2 Locomotion Off Unit 4 3. Functional Limitations in Range of Motion: (0) Nu l_in-ilntions (0) No Loss CODES (1) Unitations on one side Partial Loss Na (2) Limitations on both sides (2) Full Loss Ra nge of Motion Volu ntary Movement Contractures Hip Leg Knee 0 2 Ankle Foot Toes 2 Trunk (others) 0 4. Modes of Locomotion: CANENVALKERICRUTCH E1 WHEELED SELF Bowen PERSON WHEELED PREMARY MODE OF LOCOMOTIDN El NONE OF THE ABOVE 5. Modes of Transfers: Bedfast ail or most of time Efified rails used for bed mobitity or transfers Lifted manuaity Lifted mechanicaliy CI Transfer aid slide board. trapeze, cane, walker. brace) El NONE OF ABOVE SITTING: STANDING: 12 CODE: Maintained position as required in test Unsteady but able to rebaianca selfwilhout physical support (2) Fartiai physical support during test or stands but does not tollow directions for test (3) Not able to test without physical help 7. Resident is a candidate for Physical Therapy. CI Resident is functioning at maximum ievei of independence; Resident is not a candidate for Physical Therapy. 'j?J'Resident is on an active Physical Therapy Program. B.Reoon1rnendation: CDfl~i{nDLe - Therapist Signature: Date: 631/! 01/ CI *7 Fiveburu Printing (718) Form ND. HNH-205 DEPARTMENT OF REHABILITATION PHYSICAL THERAPY NOTES C-A-R-E . /Bf Weekly B-i--'WeekIy NAME: DATE: Program: Er Restorative El Maintenance 1 Frequency: Pain Cornpiaint: No Yes LocationGAITIAMBULATION: movm GASSISTANCE: ca 2 Assistivc Device: None El SW RW SC NBQC WBQC Other: WBAT I PWB R11. [5 NWB Distance: 'Pi' Utilized: Yes [3 No . - MOD MAI-I Assusumceweeded. um sup taco>>; ASSIST CI ASSIST E1 ASSIST TOTALDEP Deviations: Present ofthe time. Description: G7'5'i'-i ifio sums NEGOTIATION: #09 Pmsowrs rnovmmc 1 2 No. uf Steps I Fiights: Assistance Needed: my [3 sinTOTALDEP TRANSFERS: Hsnsows PROVIDING ASSISTANCETOTAL DEP Bed ChairfWCTOTAL Bathroumffoilet: sup cap. MIN Ij MOD El MAX TOTALDEP BED MOBILITY: ASSISTANCE: 0 Q) 2 [1 mm 1330? CGA [1 MIN MOD El MAX Scouting: IND ElTOTAL DEF IVEAX El TOTALDEP BALANCE: Stand (Static): I:i Normal Ci Good 3/ _F41ir Poor [3 Zero Stand (Dynamic): El Norma! Grand E/Fair Poor Zero 'mmn 3 mm. elm mu or ~awCr2~v- mmuc), gm Cafifl OTHERS: (Modalities, Orthotics. Prosthetics, Chest PT. etc.) |Q;mi;--Jx {Lu PATIENT I CAREGIVER UCATION: 9&3 . ig'fiiD" RESPONSE TO TREATMENT c' OGRESS TO DATE: rw- rm; Ce tutu 1" it Fr" XL /507? ii.xta'CiL'Jy'iJ'f /gotprw VC TL 113 5'3-nrg I0 A No I-Qgzxi in;-F797. PLAN 1 GOALS UPDATE: mesa-ria 1: FT 5%-Doiwrfin C2 xc 2: ]u iaui} LTC. (I Resident making measurable progress towards attainment of goals: Yes El No Comments' supervising Physical Therapist: of Care discussed with residentfpatient: N0 3 - fi Progress/Plan oi'Care discussed SIGNATURE 01-' THERAPIST: 009-) '57 DATE: 067/ lg', Q3 s- 31-' i DATE: 5? SIGNATURE PHYSICIAN: Fflinling ('um 431-9303 Form No. RNH-159 Nu. ufstepsf Fiiglits: DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES C-A-H-E (K CI Bi-Weekly lj KTUVZCOU RM DATE: Program: Restorative Maintenance Frequency: . IQ. Pain Complaint: No [3 'Yes Location: IntensityGAITIAMBULATION: ASSISTANCE: 2 Assistivc Device: Cl Nona El SW RW SC Ci NBQC WBQC Ci Other: Weight-Bearing Status: CI VVBAT I PWB NW3 Distance; Pttrallelflars Utilized: El Yes Er No MOD MAX Assistance Needed: El INT) [3 say CGA ASSIST Cl ASSIST ASSIST TOTAL DEP Deviations: Present %o[tl1c time. Description: Q-617 -JJPO STAIRS NEGOTLATION: OF PERSONS PROVIDING AS I ANCE: 1 2 AssistancehleededMAX TOTALDEP TRANSFERS: pnovmmc ASSISTANCETOTAL 0139 SUP CGA [3 MIN Ci MOD MAX TOTAL BEDMOBILITY: #01? PERSONIS 0 1 1] 11-11; 'jgfsup CGA El MIN Ci MOD Cl MAX TOTALDEP ScoutingTOTALDEP BALANCE: . Normal Good Poor El Z6111 Normni Good Ex Fair Pour CI Zero . nigmiagbml Iilknr EDF =m=3 dew:/Imfi OTHERS: (Modalities, Ortlnofics, Prosthetics, Chest PT, etc.) kw-"Ar mm}. PATIENT I CAREGIVER TRAINING-ED UCATION: [flan RESPONSETOTREATMENTIPROGRESSTO . A 1 T0 mrsucasgari merpvs Am Fwim WW QALUW fic mm umivimrom C3U1f1:i!uC v' . (1 on Nov <> can [1 MOD MAX TOTALIJEP TRANSFERS: #017 movmmc ASSISTANCE: 0 2 IND 3151' El CGA MAX TOTALDEP IND SUP .-E1 CGA [1 MIN MOD El MAX TOTALDEP Balinroamffoilctt TOTALDEP BED MOBILITY: ms Psnsows Pnovmmc ASSISTANCETOTALDEP Scouting: El 311TOTALDEP [TOTALDEP BALANCE: . Stand (Static): Normal Good Fair Poor Zero Stand (Dynamic): El CI Good Fair CI Poor El Zero mg rsfl-:1: or 19070 OTHERS: (Modalities, Orthotics, Prosthetics, Chest PT, etc.) J57 Lgu/mm mum "Cw PATIENT CAREGWER TRAWTNGEDUCATION: wrrm-<> Tn wrmu mm? flue umrtci. PLAN I GOALS UPDATE: I j@7fi_ NJ Resident making measurable progress - towards nttainmentof goals: Eyes Comments' I rugrcs5iPian ofCare discussed with a Yes [3 Na 1' residentipnficnt: ofCarc discussed wiIt\i) f' . . . . supervising Yes fa is SIGNATURE /91 - DATE: - .5 I - SIGNATURE 01? PI-IYSICLAN: Form No. RNH-15-3 . ,3 . A . REHABILETATEON SUMMARY CTE-N-T-E-R am-A Mr USLP A A RWEH - FUNCTIONAL LEVEL EV - FUNCTIONAL LEVEL AT Dl_ Date: rfimr <3 7* 13% Lora, LUFZ, 'mmrf WWI imam 3+/if @705' gm 5 Ergo |mix. U-'not 1/Cm 5 N100 "Tim "rmmfirzr HWDI SUMMARY OF SKILLED TREATMENT PROVIDED: A . L75. e_(jrr, %;5U~1l Ema 'fig; mzsh?>> ANALYSIS OF PROGRESS MADE TOWARD GOALS: Indicate reason for DIC and if goais are met. If not met. indicate why not) 10/9 ~47/avfigfi i, ix 1,1 gm TQH {aim (3 @2774 iffwutl Cs (Lu) 5,1 SUMMARY DISCHARGE PLAN: Frog .22) 1. Discharge Location: 2. Summary of Caregiver Training: (include conlent of lraining, targeted audience, and summary of results: 3. Equipr1rci1tordcre 4. made: P5. Other referrals furfollow-up care: 1* Fweborn Printing (713) 431-9500 Form No. RNH-209 If I I or-' I 5 3{ 1 REGEIS CARE CENTER PHYSICAL THERAPY SCREEN Name: Q90 Room M.D.: pl' . Diagnosis: ANNUAIJSIG. CHANGE new; Reitomir EQUARTERLY3 REFERRAL: 1. Cognitive Status: Follows No 2. Physical Functioning: (0) Independent (0) Ha setup 3 (1) Sot- up Help Dnty CODES 1 . 1F'cr:un Assist E7li.flI'ISNl! Assist (3) 2+ Parsons Assist Total Dependence I Did Not Occur ca} Uld Hot Occur Self-Perfonnance Support Bed Transfers 3 2 Walk In Room 2 Walk In Conidor 3 Locomotion On Unit 4 2 Locomotion Off Unit 4 3. Functional Limitations in Range of Motion: (0) No Linitations (Cl) No L055 cooes on one so. [l)P:ir1lal Loss (2) Limitations on both sides no Loss Range of Motion Voluntary Movement Contractures Hi Leg Knee ?3 2 Ankle Foot Toes 2 (others) 0 2 4. Modes of Locomotion: El Ci WHEELED SELF PERSON WHEELED PRIMARY MODE or LOCOMDTIDN Cl NONE OF THE ABOVE 5. Modes of Transfers: Bedfast all or most of time 'flfled rails used for bed mobilitysor transfers Lifted manually CI Lifted mechanically Cl Transfer aid slide board. trapeze, cane, walker, brace) El NONE OF Aeove 6. Balance in SITTING: 0 STANDING: CODE: Maintained position as required in test Unsteady but able to rebalanco self without physicat support (2) Panial physical support during test or stands but does not follow directions for test Not able to test without physical heip Y. Resident is a candidate for Physicai Therapy. Resident is functioning at maximum tevel of independence. jafiesident is not a candidate for Physical Therapy. El Resident is on an active Physical Therapy Program. B.Recommendalion: GEm_finHe, m-fer 0.3 Therapist Signature: Date; if 53103;'. Fivctloro Printing (7.18) #231-95lJtl Form No. RNH-205 PHYSECAL TMRAPY EVALUATION =?Residcut's Name: 08/ I - Date of Birth: - fl) l<<3?F2 If i Date of Therapy Diagrm?is: Eff? - - '7 Reason 2 'Kb; 5' mrififih Onset Dale: mi% 42a rm s- PLOF: jam gm we Plans: Lg": . Precautions": 92 37?! Mental Shztus: - 2' fir cf; 1 Rangchof Motion 0. No Limitati 0. La - 1. Lignitafiori one side 1. Pzgnialslioss ROM 2. Limitation on both sides 2. Full Loss BLE BLE RLE . I Us - -- - HIP gig) - am ?15 I 27Lam? 01:11:21' lirnitation nrloss Balance; rm' fix? 2314: I p_ 'gaed Mobility: . flflaw afiqhifjrz. ca-0 jzf/1 if [3553 I 'Transfers: Ti 0 I, I - Gait: 1: \1i')5'F I Other. . gr fa' Problem (list): H: max>> I 1i? r. hif-in: . .,r-17 Q: 'ls. . :2 flifr: 15'31; 1 pf I 59 Ind?! if" Rehab Potential: t' .1 a,.u c. FCCEL Treatment Plan: (in. 'fl-fl 5.: Restorative: t/ Maintenance: Frcqucficy: I A 5! Plan Resident xx Plan of Care Discussed with PTA: bx: - Rcconupendatinns to Nursing: 1 flag fill? Pfirvx, 0' __V-Evaluation and Plan of Can: established by the therapist in consultation with physician: (2 . Thcrapist's Signuturc' Date: 2' - Date: hyiadr Fiveboro (718) 431-9500 Farm No. RNH-208 Riizoets CARE CENTER PHYSICAL THERAPY Name: -, '35 #3 5:117' Diagnosis: I 5 G- CHAN NEWIRE-ADMIT El QUARTERLY REFERRAL: 1. Cognitive Status: Follows El NO 2. Physical Functioning: (D) No Set-up or Help (1) Set-up Help Only CQQE5 (2) Umifld (2) 1 Person Assist (3) Extensive Assist (3) 2' ham Tm} Depmdenm (up on Not Dcnir (3: Did Not Dunn' Self-Performance Suppoit Bed Mobility j? .3 Transfers 4. Walk In Room Walk In Corridor 5 5 Locomotion On Unit Locomotion Off Unit 2 3. Functional Limitations in Range of Motion: Na Llnitalions No Lesa CODES Llrritafions unone side (1) Partial L05: on both sides (2) For Less Range of Motion Voluntary Move ment Contractures Hip Leg Knee 7 ?7 53 Ankle Foot Toes :2 Trunk (others) 0 0 9 4. Modes of Locomotion: CANEJWALKERICRUTCH El WHEELED SELF DDTHER PERSON WHEELED EWNHEELCHAIR PRIMARY Moos OF LOCDMOTION NONE OF THE ABOVE 5. Modes of Transfers: Bedtast all or most of time CI Bed rails used for bed mobility or transfers El Lifted manually Lfilifted mechanically [3 Transfer aid slide board. trapeze, cane, waiker, brace} CI NONE OF ABOVE 6. Balance in SITTING: STANDING: CODE: (0) Maintained position as required in last. i (1) Unsteady but able to rebaianoe set! without physical support (2) Partial physical support during test or stands but does not follow directions for test (3) Not able to test without physical help It'. 1] Resident is a candidate for Physical Therapy. El Resident is functioning at maximum level of independence.' is not a candidate for Physical Therapy. Resident is on an active Physical Therapy Programecommendamn Qua rifriy wiu 3; visa-sgzteaf Therapist Signature: Date: 3- Fivehoro Printing [718] 43143500 Form No. RNH-205 Distance: (EYT ParallcIBnrs Utilized: Yes No Assistance Needed: El [> can MIN 1" MOD El MAX TOTALDEP TRANSFERS: yon: risnsows movmmc ASSISTANCE: o_ 1 (3MAX 12/ TOTALDEP Bod IND 3012 can MAX TDTALDEP BED MOBILITY: movmma ASSISTANCETOTALDEP ScoutingMAX TOTAL IND SUP CGA El MIN [1 MOD [3 MAX DEP BALANCE: Stand (Static): Normal El Good Fair Poor IE Zero Stand (Dynamic): Normal CI Good Fair Pour Zero THERAPEUTIC EXERCISES: 51,2. Pr wizt/1., MIPIWML. ProgressfP|an of Care discussed with LET Yes No Comments. ofCare discussed with I supervising Physical Therapist: YES Comments' SIGNATURE on THERAPIST: i\J{ DATE: 57*. 0 5 . SIGNATURE or 72 DATE: *3 DEPARTMENT OF REHABILITATION PHYSICAL THERAPY PROGRESS NOTES C.A. . '1 3 I 0 Weekly Bi-Weekly El NAME: ,r mo: 53% DATE: Program: ':12/Restorative [3 Maintenance _Frcquency: (SK Pain Complaint: No 'Yes Location: IntensityGRIT AMBULATIONZ OF PERSONIS PROVIDING ASSISTANCE: 1 2 Assisfiveflevico: CI None SW I3 RW SC Cl NBQC WBQC Other.v5izP fl'wfiIwr'--'f I I mjfiyifi -'mm V1134) OTHERS: (Modalities, Orthotics. Prosthetics, Chest PT. etc.) PATEENT I CAREGWER TRAUYINGEDUCATION: vboofi RESPONSE TO TREATMENT I PROGRESS TO DATE: A3 Mam PLAN I GOALS UPDATE: emf-n .4 1,1: Resident mnliiug measurable progress towards attainment of goals: Yes No Comments" Priming Ulfl] 431-9500 Form No. RNH-159 NOTES OT tviyf - SCI SLP 5:7. 315 . . 1' mes"? cr2"2..: 3:5 3 rJ- 5 fiWfiP'TD *2/-1/ob :2 5 :9 5} 0* 7,50wax' HP 06 fl0H/-5: 2' 1 ET SWALLOWING EVALUATION AND PLAN OF CARE- I Room DOB: 10- 30. 4 3M.D.: Primary imedicalflistorg 51,. 'djamm-521$ 1, - . . I Gen e'raI Patient Profile Cognitive Statusiorientationz - ('31/m /Zp I Nutritionm Comprehension: 5, 52,13; .. . . 1 . Oral 5'1 I14 Respin.ItorjyS?atus: ND *1 Swallow Function Profile$n'a,ff'Lma a cfigmfifl 01mm!' I 13:2' 9 ffiie. miasfic - 5 P|;asefSignlcsgessment Lg - 1:1 61" '?13 rap. '?mlalg MA D:'etRecommendatious: I I I 47mg? ff L2?/aukflz Feeding Slrategits: Plan of Caremecommendations CI Swallow Therapy Indicated: . . Swallow Therapy NOT Indicated. CI Rec0;nmei1d Modified Biirium Swallow Study (MES). Resid cut is on Aspiration Precautions: Evaluation and Plan of Care tabfished by the in consultation V-with the physician: Thefapisfs Signature: Iq Xi Date: j- I fir" Date: "ff! /0 SWALLOWING EVALUATION - AND PLAN OF CARE- Room [0 35 D-V 'Qi1r'Ki"Primary Medical HistoryGeneral Patient Profile - Cognitive Star.usl0rientalion: . (A-VL I I Nlutritionalflgiiet Status: . A omprehcnsion: A .2 9,1, Oral Peripheral Examination; 3' L5, Respiratory Status: :3 I i'TCw _S_waIlmv Function Profile I jeencics Tested: Oral Phase: - I21 ti': Lid'? .Pn.i_g If-nxi: EM ml 9 am'; "who M: i - GU: z-P. $314 0113 1 _f:ment Oral I Pharyngeal) [3 (.3. '?12 - Dielflecommendations: if Gwcifl'-wimp" i If -mu Feed i ng Strategies: Plan of Carelftecommendations El Swallow Therapy Indicated: Swallow Therapy NOT Indicated. Rem-rnmend Modified Barium Swallow Study (MES). Resideui is on Aspiration Precautions: IDEA Evaluation and Plan of Care stablished by me tlnerapist in consultation \ivith the physician: The-rapist'5 Signature: DateM.D.'s Signature: 3' DHUEI bi? ii 7 - I - Cognitive Stalusifirientaiinnz . we AND PLAN OF CARE- -flame; gamma ??Eug,7,g 1 3/5 . Primary Medical I I. I Ejrl . . I 6<<'0wtmovvwL% WM (41 /in om} . .dl-tzlduflory Comprehension: - A - Assessment Oral Peripheral Examination; Respiratory Status: AhlA AJ J63, I 8 9w Function Profile I Tested: fill? . Oral l;rcparatior:lOral Phase: WE AJ mn:__0L embfi offispiralionz [1 Rf 4. WU film? 'rjf Feeding Strategies: Plan ofC3re/Recommendations 5 Swallow Therapy Indicated: . L-"Swallow Therapy NOT Indicated- Recolnmencl Iflodified Barium Swallow Study (MES). - I 1' Resident is on Aspiration Precautions: 1:7 2" in consults ion with the physician: Evaluation-and Plan oft; blished meragiist Signature: KR Date; 02/41' GU30 I 3137i"? REGEIS CARE CENTER SOCIAL SERVICES DEPARTMENT QUARTERLY ASSESSMENT (Page 1 of3 Pages) Resident Name: LO Medical Record Ro0r11# 0 . Assessment Type: DQ1 BQ2 DAnnual Due Date 7 Significant change []Sl1ort --Tem1 Rehab Tenn Placement Last CCP Meeting (date): i" I Significant changes in Medical Condition/Status during this Review Period: []Yes No Comments: Mental Status Assessment: Impaired Comments Cognitive Status: Intact Person .. Time .. Place .. 1 Memory J, Long Term .. Short Term .. Insight and Judgment .. 3 Is Resident Able to Make Needs own? .. [Wes Eizl?a Describe/Specify: J. maggots Sensorv/' Communication Status: (Note use of specific devices) Primary Language: nglish [JOther (specify) ElResident is non-- verbal "Intact Impaired Comments Vision .. Hearing .. Speech! Language 5 Mood and Behavioral Patterns: Mood L/lqone Verbal Expression of Distress Sleep Cycle Issues Sad, Apathetic, Anxious Appearance Loss of Interest Withdrawn! Isolated None Verbally Disruptive/Abusive Physically Abusive Wanders Socially Inappropriate Hallucinates Agitation Infantile Behavior Affect appropriate? figs UNO 2 Quarterly Assessment (cont'd) Resident's ace; Medical Record 5-73 3 0 Histoevt .. BNO (D/Yes F. . . i; or 13-9. r\ -9: Date of last EvaluationList of Medicationsf Treatmerits: 510 3' E7. Mi' Services . . . . ElYes El receives weekly Individual receives weekly Group therapy Maintains Spiritual Beliefs, Pracfipes or affiliations: . .. es BN0 Comments I mvfilt Family Involvement'}Relations: Family Involvenient (Check all that apply): No involved faniilyfsignificant other/' family not expected to be involved in plan of care. El Resident does not receive regular visits from family/friends. Face Sheet Contact Information (Names, Addresses and Telephone Numbers) reviewed this quarter with: []Resident ElDesignated Representative - A (1 Current Designated Representative is listed as: Han ax, pk . 5-3; (N am e) (Relationship) Contact! Designated Representative information remains unchanged. Resident! Designated Representative requested changes to Resident contact information as follows: Updated Contact information forwarded to the Admissions office on (Date) Name of person forwarding information InteractionfSocialization Patterns: Soeializes with peers of choice: ElYes .. Comment: it/L Participates in Recreation" 1 Activities: ElYes Comments: ri A, Quarterly Assessment (co11't'd) Resident's Namezm 3.70 Medical Record #557? 3 Meats: Resident receives meals in: [3 Main Dining Room . Own Room Day Room Resident has a Feeding Tube Comments: Resident'5 Rights: Reviewed rizis QLtar.r.'er1w'tIz.' Resident czmily Advance Directives Is resident able to understand Advance Directives: ?]Yes END If no, explain: Advance Directives Status form Updated? . Eifes -- i]No Currently in e' ect: None DNR Living Will Health Care Proxy Durable Power of Attorney Comments: Discharge Potentialf Plan: Reviewed this Qua -terwit/1.' Resident Family Resident appropriately placed? BNO Comments: {Wore any plans in progress and preparation 0fresz'denrfl:Ir discharge) 1. 1 A ?3 'saw. vuelfil/07 Signature Title Date Qunaly Savitrs REGEIS CARE CENTER SOCIAL SERVICES DEPARTMENT Resi(lent's Name: L) 'i I .. Meeting Type: A aha Date: tr} (1 Li}, (L was invited to attend the (nesxdeizri Farnily Party) Compmhensive Care Plan Meeting on 0 urn' fletter. Attended: Failed to Attend: 1/i (Social Worker's Signature) REGEIS CARE CENTER SOCIAL SERVICES DEPARTMENT Residenfs Name: Meeting Type: Date: was invited to attend the (Resident/ Family Ariember/Resporzsible Purify) Comprehensive Care Plan Meeting on via phone/ letter. Attended: Failed to Attend: (Social Worker's Signature) REGEIS CARE CENTER SOCIAL SERVICES DEPARTMENT QUARTERLY ASSESSMENT (Page 1 of3 Pages) Resident Name: F4 PO QCL Medical Record 5- Room# I 1 Q2 DQ3 DAnnual Due Date if 0% Assessment Type: Signific nt change . Significant changes' in Medical Condition/Status durin Last CCP Meeting (date): 0% ong-- Term Placement this Review Period: es BN0 --Term Rehab Comments: Mental Status Assessment: Intact Impaired Comments Cogiitive Status: Person .. Time . .. Long Tenn Short Term Insight and Judgment .. ls Residei1tAble to Make Needs Kiiown? .. DYes Efi Describe/Specify: Sensorvl Communicafion Status: (Note use of specific devices) ElResident is non-- verbal Primary Language: Other Intact Impaired Comments Vision .. . .. - -_-apeechf Language Mood and Behavioral Patterns: Mood: . None Verbal Expression of Distress Sleep Cycle Issues . Sad, Apathetic, Anxious Appearance Loss of Interest Withdxawnl Isolated Behagior . None Verbally Disruptive/Abusive Physically Abusive Wanders Socially Inappropriate Hallucinates Agitation Infantile Behavior BNO . Comments: Affect appropiiate? es Qu arterly Assessment (cont'd) Resident's Name: Lo Medical Record aiofi .. BN0 Ei?es Diagnosis: Cm' Date of last Evaluation: List of Medicationsf Treatmerits: hecffi. I 211%' Services .- receives weekly Individual receives weekly Group therapy Maintains Spiritual Beliefs, Practices or affiliations: .. El'{es BNO Cornnlents Familv Involvementllielationsz arnily Involvement (Check all that apply): No involved faniily/significant other/ family not expected to be involved in plan of care. [3 Resident does not receive regular visits fronifarnily/friends. Face Sheet Contact Information (Names, Addresses and Telephone Numbers) reviewed this quarter with: Elljlesident ElDesigriated Representative - Coninients: - Current is listed as: 3 mama) (Relationship) . . 'All Contact/ Designated Representative information remains unchanged. El Residentf Designated Representative requested changes to Resident Contact information as follows: Updated Contact infonnation forwarded to the Admissions office on (Date) Name of person forwarding infomiation teractionlsocializafion Patterns: Szializes with peers of choice: Comment: Participates in Recreational Activities: Q'?'es EINO Comments: BNO . . - Quarterly Assessment (cont'd) Medical Record Residenfs Name: I Meals: - Resident receives meals in: Main Dining Room Own Room Qfiit Day Room Resident has a Feeding Tube Comments: Resident's Rights: Reviewed' Quarter Resident Family Advance Directives . Is resident able to understand Advance Directives: ElYes Mm If I10, es-5 Advance Directives Status form Upcfithed? . .;l3Yes BNO Currently in effect: I . None DNR Living Will Health Care Proxy Durable Power of Attorney jlominentsz 'arz'er with.' I Discharge Potential! Plaixiz jemewed rm Resident appropriately placed? 13 es BNO Comments: (Note any disc/zargejilans in progress andprepamtfon discharge) .. D. Date Signature Title .TLa'n:l Dummy Anannu:-Social Sc:-visa -- i_ socm SERVICES NOTES C-E-N-T-E-R Resident . @4-vL;jg/ Roomfi 5757.3' /51 - Lzrsinamc, First n:nn::?.f/duw. 9' 913,1>>, 5 it 'Dirk Kata. inf cr we /42 I ff?fln ?4 7. Lg 'u tfav?i' Jlf?f/9x4L .4. r' - at/KL w/ 901V as#71 2% C-E-N--T--E--R I SOCIAL SERVICES NOTES Resident' - Lnsinamc, FE"-stn - . aiz,/" aim mg: Room _IH-Jfla /9 Mqdical Record f? XL (M34 . as raw rm' AL mm I J'-mm rim;M>>/ 1 SIGNATURE DATE a-11' . socw. SERVICES NOTES I C-A-R-E C-E-N-T-E-R Resident Room V5 Me_dica1 Records: . First manor? -- in 0' hflf: 4' flV\/ 3 47//'ira . . .3 - .-- GEN-T-ER Resident Roomifi IVfe_dica1Rc=corE1# - Ifistmma - mm: 1,929,: I an ?10 nan.a.zrxw1m. av%wumz mm: ,4m, IMAM 91? pl Jflfim rill" fie; U%w Wwfiwu Jun x7' i/gm Mi I i vz- /< F. Inc:-E3 A 9-., Q93SIGNATURE . . Resident la/D - Root-I1 if ?rfi Medical Recordff La?t Fast iguana /uzfi?c . 7L0 f9'nm 515-' K131)-m . on rm. /J??ca Vlorv Gmfixfiirj/ffgf mfh"I2' Amcaiuz>> j?flrf?f H-Ofilgn?pfl "fig. /4,977/m,zflL 14/ Quay 1 DATE ?fpf /07 SIGNATURE \g6 . . C-A-R-E Resiaeutpxfimgcfii. Room# 59?? Medical Record# 5933' Lam-'tuznmc, F"n-st manna?' 'Fm 5? .V f)/U SL) Yjfo q7/pal!' 1' :9 1/9 MK - Qua Smges--a I 'ts Jail cdaatv (43: i(d15:n x- I DATE SIGNATURE . . . .- - C511 fer Sfi?iai Hespitai T':'aIIsf:r Fcrlu 5? filesiflerkt: Ronni .5933 . (J - Adrnissidti Data: Date; '1 I D.is-charge to: . - Reason -- . - 1: . /Ofiiw ?f1m<1T He./2 R.e3ident'5 liesporlse to ., A 4' is readnfissfme Arlticfpated T65 N0 Is resident on Luedhold. 'sfes No' 4, 4.7' Scurce OF Insurance reaction to u'an5F?z' /Lg Wale all bed. 119 Id issues addressed: :1 Ciutstanciiug Social . - I I /4 051 Social Date - Regeis Caro Center NUTRITIONAL ASSESSMENT . --.. Name; ROOITI. . Sex Male Female Adm. Date: 3 6.1% D.O.B.: .15) ..1 If#12 /ti; *4 asst/53 . .57 0 I - Diagnosis Diet Order: -gufi L. Medication with Potential Type of Interaction: Nutritional Interaction: ft .41 . - I gig) (.9 Labs I 5' . Z. L. Ht: :r7-'fr Des. Range: A fisoai- .1 .. . 1 . Estimated Nutritional Need for: /5132? Cals: Pro {gms} Fluid . -- Mental Status: 3 Alert Confused Method of Communication: verbal Nonverbal Oenti tion: Teeth flb-529 Denture Edentulous Feeding level: Indep Assist Spoon Fed Adaptive Equipment: Yes No 'rypetif yes) Check any Impairment or Problem in the following which affects or is affected by Nutritional Status: Vision :3 Hearing: Elimination C: Mobility' I: ?lcin I: Food Hydration :3 Swallowing Chewing Language Behaviorcj Resident {if mentally capacitatedl or designated reprosentative informed of diet? gm, 5021? Limited Why Not (if No): ctr' Level of Comprehension (if yes): Complete Nutritional Education Desired: Yes No Food Preference;/Food Dislikes W13 "if Ethnic, Religious or Cultural Food - 4' ax' T3 Illa ASSESMENT /5 -r z5?7iI on HISTORY pr' fix. '5 ii; 1/ '?EURj'ii5i'l'3 if/lob SUMMARY: LEVEL or NUTRITIONAL CARE ft Lab data essentially within weight within range. Food intake well --balanced and Basic: normal range. Medical condition sta.ble., in' varied. bkxierate: Height fluctuates. Lab data conaiaiteut with potential for malnutrion- Hedical condition unstable. Food intake fluotzuates. Intensive: Excessive weight loss or gain. Lab datnfdiagnosis consisitent: with potential for or presence of malnutrition. Food intake poor. Resident recieves tube feeding, has pressure sores, or is in critical medical condition. See Comprehensive Care Plan.' - if I Signature: Data: trig' I Fiveboro Printing. Ltd. (718) 431-9500 Form No. RNH-144 0 . memm PRGGEESS mras gm REMARKS SIGNATURE Cum aim hit C. ii: Regefis Cam Center NOTES SIGNATURE REMARKS -- - <> /1 0 Resident-Nanie I tit.>> - The resident has attended programs . Regeis Care Center Recreation Dep ent Progress Note! Rea 'ss'l)n Note Room Is" this a progress note'? 'ir"es__ is it Other . . in Is this a_ readmission i/no Ifyes, date of readmission (92! 'ff Oil" - Was the previous goal achieved! Does the resident attend religious services! often: tithes in the past 7 days. The resident is usually an active . or The resident responds best to the following types ofactivity: games (spelling, finishing rhymespr proverbs, sorfingflash cards, etc.) games (balloon, volleyball, basketball, bowling, etc.) (sing-a--]ong, name that tune, passive listening etc-) actifity (sorting, matching, staclcing, assembling, etc.) '/flreative activity (drawin g, painting, sewing, gardening, etc-) activity (parties, field trips, special events, etc.) 8. 10. ll- __Dornestic activity cooking, ironing, folding clothes, sorting laundry, etc-) activity (is, current events, discussion groups, educational programs, etc.) _,40ther. raerpg arm in') The .esid eI1t's level ofparfircipatioti increases when: are segmented according to__the residentis individual ability. are based on social or occupafional experience- purpose of the task is clear. - _,_The resident istconfidect that what he/she is doing will be of benefit or help to someone tmctionsgare given at small steps and demonstration offered: - Instruction are repeated as oftenas necessary. Adaptive equipment is provided (is. large print, amplilying device). if. Verbal encouragement is offered. - Excessive noise and distraction are controlled. Z/The resident is seated close to_the leader. v. resident is seated in a comfortable social group, or with specific resident ofhisfher cl Does the resident engage in independent activity! -9 If ,es, indicate which activities are preferred 1 _Watching TV __Socializing with fiiends I family "Reading I writing outdoors in community Other Is the resident a candidate for individual activity visits! If yes, who provides these visits? ifiecreaticn staff Musician. Therapy _"__Hu1nor Therapist How frequently? Resident is: __Intolerant of' peers of peers _initiates social contact _ma.!cesflceeps friends __more likely to participate if friends are with them- Frveboro Printing, Ltd. (718} 335-79?9 Form No. FINH-136 14: Resident is: candidate for daily participation - (Specialized Groups, ifany)- - - 15- Skills: Initiates social ec_1ntact_;_ Displays helping behavior__ Plain Of Care:' . Please refer to the Comprehensive Care Plan of (0 21 . ?om an e/fie./3+ cue M) mafi Qeflalwn cups. freely but does not initiate __MinimaJ response, socialization is severely limited >_Is01ated by choice 0 Please reflect specific content in the care plan. 12- verbal cues './Iangible propsf Visrial engage the residerit: 13. Stefi'p1'evides: programs. Comp1etes._tas1c5: independent1y__with intermittent requires Requires tasks segrnentedllesportds to verbal tangiblefvisual props K, . . me/nma Am goo/MIA cam . . as/T7 '/9/6,707: (him r' ya 772 25' ff mm (add mo 77:' I . I - Signature: Ufl@, Dete: Signamre: Date: Resident*Nan1e i Regeis Care Center - Ijafcreation Department Pro te I Readmission Note Room 1; Is' this a progress note? lfyes is it Quarterly_ Other /7730 The resident has attended programs . Is this areadrnission note?,Yes no If yes, date of readmission Was the previous goal achieved! Does the resident attend religious services! Yes_ How oflen: tirnes in the past 7 days- The resident is usually an active . or Passive participant .The resident responds best to the following types of-activity: games (spelling, finishing proverbs, sortingflash cards, etc.) games (balloon, volleyl:iall, basketball, bowling, etc.) u'sic name that-tune, passive listening, etc.) Task activity (sorting, rnatchin stacking, assembling, etc-) eative activity (drawing, painting, sewing, gardening, etc.) - activity (parties, field trips, special events, etc.) . activity cooking, ironing, folding clothes, sorting laundry, etc.) acti 'ty (is, current events, discussion groups, educational programs, etc.) _,f1,U7 gt' rm - TEeresident's level of participation increases when: are segmented according to__tl1e residenfs individual ability- are based on social or occupational experience. purpose of the task is clear. - %he resident is-confident that what he/she -is doing will be of benefit or help to someone Instructions_are given in small steps and demonstration oifered. are repeated as ofienas necessary. . equipment is provided (Le- large print, amplifying device). 95.. 1/ Verbal encouragement is offered. Vlixcessive noise and distraction are controlled. The resident is seated close tU_the leader. resident is seated in a comfortable social group, with specific resident of hisflaer cl Does the resident engage in independent activity! -r lfyes, indicate which activities are preferred 1 TV __So-cializzing with fiiends 1' family _Reading I writing outdoors in community Other 10. Is tile resident a candidate for individual activity visits! Ifyes, who provides these visits? filtecreation staff' ifgtrolling __Pet Therapy _L{_Hnn1or Therapist How frequently? 1 1. Resident is: "intolerant oi' peers ":Tolcrant of peers "initiates social contact friends __more likely to participate iffriends are with then'1' Ftvebcro Printing, Lid. (713) 3353979 F'iJr'm NO. BNH-135 fieely but does not initiate socialization is severely limited __IsoIated by choice -- Please reflect specific content in the care plan. 12- Stzfifufilizes verbal oues'I'angib1e Vistial coesl?tzo engage the resideot: 13- Staff provides: progzgams- 14_. Resident is: candidate for daily paiticipafion - (Specialized Groups, if any)- - - 15- Skills: Initiates social contact_;_ Displays helpiog behavior_ independentl intermittent - Requires tasks segmented Respoeds to_verba.l cues~_ tangibleh-isual passive: Plain Of Care: Please refer to the Comprehensive CareP1an of 7,5 /719 - CommentsLil/. earns 7'-to (Fm .33.. Jm r",nmL,mc,zz lo? 1,0 . 12251}? 7/13 704' 75773 (.4574. - - f\ - - Signature: Date: '72 1' Signanlre; Date; Rage-is Care Cei1?e_1_' 3200 Ave Bronx, NY 10475 Physical Rehabflitation Consliltation . Last Name - First Name Roomfi Rafeuiug Physician Date of - L4 L9/farce; E. 9'7 of Present Illness and. Chief . - Cf0= -- cfia/was 2, 74 bution! significant for: fr"! The. patieqd: is a admitted_to Regais care center 01:1' ?0764>>; fir>>/1 - The reviewpf system was non contri Past Medical Historv: M?clications: :25: =31, 3" Lives alone! Lives with Family_ in a walk up Bldg! Elevator '1?1dg . - . .Cufrre-.11t ADD for assisfianccf Independent git aid "Pr?irious ADD Indepepdentl nccdad {assistance - Ambnlatiou: Independent! uceadcd assistance. Amjbulationr PERRLA I 2, Alert . Follows command. Abdomcn--LBS Tenderness -- 3 -27 Scnsat_iot1- 1! (L Babins1ci- /J/a?qjd I . - - "mp resmn G5, 54:37' Plan: rafiv 2' ST Evaluation andfrealtrnent . .- I . . - - -ya; r- Max Buman Br:1_I1111b 2111, MD - Signature qfPri_n1a'r5r Date'. -- Univ?rs Pulmonary, Tom; mp Precaulion, NWB, PWB, wax: Prognbsis Poor, Guarded I - Other: Recom1I1eudat1cn1s- I fl?__m g?jfl, "Shaman; Board Certified in PBIR and EMG - - Regeis Care Center .. 'creation Department Pro Note Readrnission Note Resident-Name - Room 15% L9 25 Is this a progress note'? ill?' es yes is 't Quarterly Other (ad? 2- Is this areadmission no Ifyes, date of readmission 3- Was the previous goal achievedi Yes No Does the resident attend religious services! Yes__ No__ How often: The resident has attended programs . tirnes the past 7 days. The resident is usually an active . or participant. The resident responds best to the following types ofactivity: Cognitive gan1es(spelling, finishing rhymes or proverbs, sortingtlash cards, etc.) Physical games (balloon, volleyball, basketball, bowling, etc.) ZMu'sic (sing?a-long, name that-rune, passive listening, etc.) _7Tasl{ activity (sorting, matching, stacking, assembling, etc.) ,'EURreativ_e activity (drawing, painting, sewing, gardening, etc.) _ZSocid activity (parties, field trips, special events, etc.) . __Dornestic activity cooking, ironing, folding clothes, sorting laundry, etc.) tellectual activity current events, discussion groups, educational progams, etc.) . B. The esident's level of participation increases when; are segmented according tothe residenfs individual ability. Tasks are based on social or occupational experience- ZThe purpose of the task is clear. - The resident is-confident that what he-fshe -is doing will be of benefit or help to someone els- instructionsjare given in small steps and demonstration offered; are repeated as oftenas necessary. __Adap'tive equipment is provided (Le. large print, amplifying device). "Verbal encouragement is offered. - Vjixcessive noise and distraction are controlled. - The resident is seated close to_the leader. -. __The resident is seated in a comfortable social group, or with specific resident of hisfher 9. Does the resident engage in independent activity! If es, indicate which activities are preferred: Watching TV __Socializing with fiiends I family I writing outdoors in community Other 10. Is the resident a candidate for indivi 'ual activity If yes, who Vpflovides these visits? _Recrea-tion staff' Musician. Therapy utnor Therapist How frequently? - 0 11. Resident is: of' peers _\/folerant of peers __initiates social contact friends likely to participate if friends are with thera- Fiveboro Printing, Ltd. (713) 3384979 No. RNH-135 __Responds freely but does not initiate response, socializafcion is severely limited "Isolated by choice - Please reflect specific content in the care plan. 12. Staffufilizes verbal ouesx?angible props l/6iStla_l engage the 13. Staffprovicles: 1nvitatio11__ Reminder 'to programs- 14- Resident is: candidate for _a daily participation - (Specialized Groups, ifany)- -- - 15- Skills: Initiates social contact_' Displays helpirng Completesjiasksi mi al intermittent superv'ision_ requires - Requires asks esporzds to verbal cues" tangiblefvisual props_remai1is Plan Of Care:' Please refer to the Comprehensive Care Plan of 9 2 D2: - Comments: . - . . - ta', 1' -9 'Pf 1,0 /ls/fix} -/imm/lg/1 fl {oh may: 7 ML . (L501 232>> fir/14?: Amway . Signature: af1b*L@ . 8 (lg Cl?' . . Signature: Date: sidentName 9 - - Regeis Care Center - Recre tion Department a eadmssion Note Room 5. Is this a progress Ifyewt Quarterly? 'pther. Is this a readmission note? Yes no If yes, date of readmission Was the previous goal achieved! Does the resident attend religious servings! How The resident has attended programs time? the past 7 days. The resident is usually an or participant. The resident responds best to' the following types ofactivity: garnes (spelling, finishing rhyines or proverbs, sorting flash cards, etc.) games (balloon, volleyball, basketball, bowling, etc.) J4'l'vf[nsic (sing-a~long, name that tune, passive listening, etc.) __Taslc activity (sorting, snatching, stacking, assembling, etc.) - ireative activity (drawing, painting, sewing, gardening, etc.) 10. 11. activity (parties, field trips, special events, etc.) e. cooking, ironing, folding clothes, sorting laundry, etc.) activity (is. current events, discussion groups, educational programs, etc.) _3/_Other: i The reside-nt's level participation increases when: asks are segmented according to the resident's individual ability. _X:Tasks are based on social or occupational experience. purpose of the task is clear. __'Ifl1e resident is confident that what he/she is doing will be of benefit or help to someone else. Instructions are given in small steps and demonstration offered. are repeated as often as necessary; _Adaptive equipment is provided large print, amplifying device). encouragement is offered. ircessive noise and distraction are controlled. he resident is seated close tothe leader. __The resident is seated in a comfortable social with specific resident of hisiher choice. Does the resident engage in independent activity! Yes No \If}es, indicate which activities are preferred: "Watching TV \__(Socializing with friends @319 _Reading I Writing outdoors _Shopping in community Is the resident a candidate for indivi ual activity visits! Yesld If yes, whp/provides these visits? __Recreation staff. Musician Therapy '_Humor Therapist How frequently? weelrii L4 Pet Resident is: _'Intolerant of peers _\f1"olerant of peers social contact friends _more likely to participate if friends are with them [Responds freely but does not initiate response, socialization is severely limited __Iso1ated by choice -2- Please reflect specific content in the care plan. 12. Stalfufilizes verbal engage the resident: 13. Staif provides: to programs. 14. Resident is: candidate for daily participation in (Specialized Groups, if any). i 15. Skills: Initiates social contaet__ Displays helping behavior_ Completes tasks: independently__ with yiimal sL1pervision_ intermittent supervision_ requires Requires tasks segmentedi/Responds to verbal cuesjftangiblef visual remains. Plan Of Care: Please refer to the Comprehensive Care Plan of I I [7 - I tame ts. Emcee lest m4 is extra}! its/'m 1/my 97%-zw, 72 Cz5717?a9 ram G2) omit ma as/M5 my crsafiveo WM 7'21;2 or/TH V392: gar /zece zawf Signature: 4 Date: Signature: Date: Regeis Care Centef, 1, g_ . creation oepaaraeat - Pro res ltesidentlfame . Room a 'Idt_h_is a progress ante? is Oth_er, .542: 2; a readdiission note'? Yes. no, Ifyes, date of _read.n.1ission 1 3; xiv.-and previous g-goal achieved! . i How often: i psisrams; . 1.: pages' the resident religious services! Yes . as Past 75 diiysg tree re?itiest 'agave or Passive 7 issues has to the fonowhls tiip??i I - - (spelling, otproverbs, sorting flash cards; etcjl -. 911" grains; (balloon, volleyball, baslgetlnall, boiavling, etc.) that tune, passive listening, activity" (sorting, matching, stacking, assembling, etc.) a - reativ? aiitijvity (drawing, painting, sewing, gardening, etc.) activity (parties; field trips, special events, etc.) . activitjr (is. cooking, ironing, folding clothes, sorting laundry, etc'). 4 . activity current events, discussion groups, educational programs, etc.) a - :3 -Other: agexeectco-l a i - s- tr'ly'fesideat=s level otpatacipation increases when: are segmented according to the resident's individual ability. based on social or occupational experience. . ZTbe purpose of the task is clear. -A - . that what hefshe is doing will be of benefit or help tosoriiecne else. Instructions are given in small steps and demonstration offered. . are repeated as often as necessary; Adaptive eijuipinent is provided (is. large print, amplifying device). ,Verb'ai encouragement is offered- xcessivc noise and distraction are controlled. The resident is seated close toythe leader. i _wTl1'e resident is seated in a comfortable social group, with specific resident of hisfher choice 9. Does the resident engage in independent activity! No If" as, indicate whic ctivities are preferred: '_'watc1ang TV __Socializing with fiie'nds raspy I writing outdoors __Shopping in community 10. Is the resident a candidate for indisii/dual activity Ifyes, wbyrovides these visits? _RecreaI:icn staff __Strollin Musician __Pet Therapy "__T-Tumor Therapist How frequently? HJLU - A. Resident is: of peers of peers social contact friends likely to participate if friends are with them fieely but ddes not initiate __Minima1 response, is severely limited choice - - Please reflect specific content in the care plan. 13. Stafiprovidesz Invitation Reminder-V Transport fro programs. 12. Staff utilizes verbal eues Efiangible to engage the resident: 14. Resident is: candidate for daily partieip ation in (Specialized Groups, -if any)'. 15. Skills: Initiates' social conta'ct__ Displays helping independent1y__witI1 al intermittent Requires iaslirs Responds to verbal cues__tangib1elvisua1 . props" remains - Plan 0fCare: I I 7 Please refer to the Comprehensive Care Plan of 371/ (5 3 . Comments47/" /.7635? 44mm /1152 - 7471.0>> ??%a01 5"Z;rz flay/rxm- _,0,0/11 . 3 0 MM /um 772M away - m;o0:3- /92: 14:10 /mg: /7:249? :52: 75:4 #24 9 (low ,nfz9,g,e flawSignature: MAIL I Date: Signature: Date; s-i the _resi_c_lent geese religious services! '2 The ?ft?fidsfi 1 the best to the following we Qfhfififitisi. RegeisCi1_Ie Ce'_e'f. Ree_reationDe Progress Note/Re" "es __nN::_ite A apiogr?ss neie? 'i'3es__ yes is it .2. . i . far?adftmissiijn note? Yes. 3 5 I10. Ifyes, tifte?idnlission Ill iH~iQ& :i Waj?ns pfeviotas gen a_e_h_ievjedl . 1. often: ftnishi rhjinies sortingiflesh cards; etcn) r' oggiiztiv? wll?ybali, basketball: etc.) tisic thet tune, jjassive . .a?tiV?itjt (sorting, naatelling, stacking, asseinlsling, etc.) - J2: eiitiv? aiitiyitgi (dfanringtpainthigi, sewing, gaideliing, etc.) . . some activity events, etc.) A e. ironing', folding clothes, sorting laundry, - 5 . fritfpose of the task: is clear. 10. - 1ntellet':tu'a'l ourrei1t'events,cl iseussion educational progtafiis, eta). - . . level of p?racipason increases when: 3 are segmented according to the residefitis individual ability. 1;sa?ed on social or ei-rperience. A be fesident is_eoh[f_idei1t that what hefshe is doing will be ofbenefit or help tosoitu?oiie else. are gisten in small steps and demonsttatinn ofiered. - . . are'repaa'te'd as often as necessary; . ._dapt?_ireeE1uip1fient is provided (is. laxge print, amplifying device), eiicspgagement is offered. noise and distraction are controlled. he resident is seated close tothe leader. resident is seated in a eonjf?irtable soeial specifie resident oflijs/her einoiee. Does the 'resident 'engageinindepei1dent activity! Iy?s, indicate whielfetiyities are preferred: _Watc]iing TV Socializing with friends I family 2' writing outdoors in community _Other Is the resident a eanididateifor indixigfal activity Ifyes, whyrovides these visits'? eereation stalf _"_Strol1ing Musician __Pet Therapy _Humor Therapist How frequently? ,1 . Resident is: _'_In_tolerant of peers olerant of peers social contact fiiends "more likely to participate if friends are with them i 1.5 esponds freely but dries not initiate response, socializatirm is severeiy limited __Isolated by choice - I Please reflect specific content in the care plan. 12. Staff utilizes verbal. eues_\_/ an gible prop 50 engage the resident: 13. Stafi' provides: Remir1der;_ Transport__ to programs. 14. Resideni is: candidate for daily participation in (Sp ecializedu Groups, if any), .15- Skills: Initiates' social contact" Displays helping Completes. taslmf with $513131 supervisioJ:1_ intermittent requires 1:1 Requires _segmented'__ esponris to verbal cues__ tangiblefvisua] props - _]E']a11 Of dare: . . Please refer to the Comprehensive Care Plan of (>21 /5 (9 3 - Commentswas org/'E/a as /2126 Imam <>t.ftee centisicatioa nae nacaatisieacatica {Skilled taursing Facility' 63% (HEALTH INSURANCE CLAIM NUMBEFII IPATIENT) CERTIFICATION of patient admission. Required at time oi admission. of continued SNF in~ patient care. On or before the 14th day. I Certify that SNF services are required to be given on an inpatient basis because of the above named pat- ients need for skilled nursing care on a continuing basis tor the for which he/she; was receiving inpatient hospital servicegrior to his/her transfer to the (PHYSICIANJ 8. I certify that continued SNF inpatient care is necessary for the following reason(s): testimate that the additional period of SNF inpatient care will be days {or weeks). Pians for post<> A care. On or t_ the 44!" dv- - kl}-Julia 9.31111 MA, I estimate that the additional period of SNF inpatient care will be days (or weeksl. Plans for pcst--SNF care are: CI Home Health Agency Office Care Other {specify} Continued SNF care is for same conditiontsl for which patient received Inpatient ho pita! services: El Yes No Date Due 7 5 07 5% ls:-iTiFlcATlGM I certify that continued SNF inpatient care is necessary for the following reason(s): of continued SNF in- 'ient care. On or /Tl I fore the 74th day. It I I estimate that the additional period of SNF inpatient care wiil be days {or weeks). Plans for post-SNF care are: Home Health Agency Office Care Other lscecify) Continued SNF care is for same ccir1diti0r1(s} for which patient received inpatient pitahservices: Yes No :2 IPHYSICIANI tome) MBULANCE SERVICE I hereby certify that ambulance service was medically necessary for the above named patient. (DATE) nsv. axes Fiveboro Printing. Ltd. (718) 4131-9500 Form No. FE-273 Ciutstax-mug Social Work -- . Rageis Ca re C21: fer Sfi?iai 6 [12-mm' . ft} 91- Data: Discharge E0: . Reason 5: L, Hcspitai 'Penn 3? 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L. . ocqooam _2.2.mzm_fi ooprm . ufim no 5 _z4mmmm$m:n_ ufiowmfima . . . Emma ma: Qmm: man um . 0 4:3 mam uomaoa 0m._.mE_ 9. <> 2 amam. . .zm= wmmu m:o: Emma; .2 . . 2.. mssam . 2. ms. . Eoznon an . z..m2;.znzzaim A A .. . .. I -..q.-oultlu nl-Ir.-. . .. . 4 . lluor . -. . . .. - . a . . .m.En_ 25? . . .o . OPWH . o>mm _u_LpZ . . . . zmamn fir mmooa vffi mm 3003 9 av o.o>n_3_ma8 cam" iwfi mum. Umzw flux] AH: "rm >__ma_mm Kim I H. o_>ozom_m 4. Ex fi.N>a> .. . Dimm 8 ?a Uflm: G32 .C m. ..Um5 .m omumgm 2. Em Em: 3 amp>>. U> m. Dam o_ Dm_m Q. momma? 5 3 umniumznu Em :2 Em: 2 nma _U335: . >cac:EE_ was . mam.? 5:3 5.5330: mum" 4. bx." gm. 55:3 EFE . u. 5% E1mm:m..Ec: mm ..E. am 2Qm.Eu_ w3..nrc:dEQ E5 :3 5385 Cam . . C. an Kenn Emficusccm . .3. and C..mo.EmE . .r . cm ZE..mm 345 3358 10:: Zn. nzxama 1 Resident has a permanent catheter. 2 Resident requires intermittent Cattieterization. 3 Resident has diagnosis of urinary 4 Resident has diagnosis of urinary .2 retention. 5 Resident has fecal incontinence. 5/ 1" . 6 Resident has urinary incontinence. 1/ REGEIS CARE CENTER RISK ASSESSMENT: URINARY TRACT INFECTION . Resident Q??daix 5' Admission Date: Criteria: Resident will be assessed for risk factors for UTI on admission, quarterly, episodieally andfor if the resident has a significant change. ANY check mark will identify the risk factors and triggers the implementation of a specific and individualized care plan. Date I 1393,": D313 Date I Date Date Risk Factory 57256237 1/sy 'r 2' 7 Resident has poor grooming and hygiene. 8 Resident has history of Keg Points: Risk factors identified will be reviewed at CCP meetings and the care plan will be revised as needed. - Signatures of Con_1_nletion: Date: .- 7 Signature: Date: Signature: I Date: 7 Signature: Date: 3 Signature: I Date: Signature: APPENDIX near I-'onn-Risk Assessment 2-I3-D1 :3 toast 5 time a week for totai ofat least I50 minutes TEi':l Beneficiary: Date: - Hospital: Contact: Phone Number: - yes flit-s ti-ic patient Have a oficr ior one oi tfie*i3 tfierapics iSpeecfi, Fliyslcal Uccupaftonall at 2. Does the patient have a physician's order for one oFthe 3 tiienspies(Speecl1, Physical Occupational} at least 3 times a week for a total of at least 45 minutes and _wiil sflic receive at least two types of nursing at least 6 days a week? (Definition for nursin rehabilitation rovideci on osite side.) it answerto oither ott questions in is section is yes. then the case-mix, category is and you may stop here. Otherwise, continue with this worksheet. - EXTENSIVE lost 14 days, has the patient received: Yes 1'35 4. Mfldications A 2. ftacheostomv Care A . in the last 7 dnvs. did the patient receive 3. Ventilator respirator treatment 5. Parenteral feeding If the above answer to any of the questions in tliia section is yes, then the paticnt's cnse~mix category is Extensive and you stop here. Otherwise, continue wgvitii this worksheet. -CIAL CA Does the natietlt currently have: Yes I, Qiiadripienia ADI. Sumi0+ 8. Resni a - dai ver 2: onto duitinle Sclerosis and ADL Sum 10+ or since admission if less than i'ni.3v and 13+ . the facility. .'-iver with dciwrlration. nnenmonia. or vomiting. in davs. did the patient have: or weigth loss feeding. 9. Radiation treatments 5. A Stone 3 or 4 pressure ulcer or ulcers - (nnv tvoei across all Stages if the answer to any of the questions in this section is ye: ?.fiA feeding tube and Anliasia A then the patient's case-mix category is Special Care and 7. Surgical wounds or open lesions Eijh one of the you may stop here, Otherwise, continue with this following'. wound care or skin care treatments worksheet. INICLL COPX A I4. Clternolhcrapy . [Diabetes with daily-_ii1jcctions examinations and for order changes at least 2 'days answer to any oi' questions in this section is yes. then the pntienfs case-mix is NOT MEDICARE COVERED BY CASE-MIX CRITERIA patient does not lttwe at least one nTtiie nbovr: indicators then the patient cio?rh' nut ami-et tin: IVIEDICARE BRADEN SCALE - For Predicting Pressure Sore Fiisk HIGH FilSK:Toiai scorer <12 MODERATE RISK: total score 13-14 K7 LOW RISK: Total score 15-16 It undo: 75 years old OH 1518 ii ovor75 years old. I {f Fncroirr -. senomr I I I 1. coetaisraor Li 2. an uieireo- 3. LitlliiTElJ- one - Unriisporisive (does not i-'ieepenos only to painiui Responds to verbal Responds to verbal com- to raspund moan, flinch. or grasp) silo1uii.ca.ntiotoomrnu- commends but cannot rnaiids. has no sensory to to minim dug to nicata discomfort except always communicate deficit which would limit . .-erred diminished in-rel oi oon- by moaning or restless discomfort or need to no ability to feel or voice dlecomton sciousness or sedation, ness. turned. Dill' 0' hasa sensory impairmerri has some sensory impair- '5 which limits the ability to man! which limits ability loot pain or disoomioit to loot pain or discom- oiier 1J2 oi ttody. ion in 1 or 2 extremities. MOISTURE 2. i'iit3l1'~ Skin is 3. 4. Sitin Degree to which skin Skin is itspt moist almost cinch but not always moist. Side is occa~ is tint: 01113' is oirpoaed to moisture constantly by persoiia- Linon must be changed slonally moist, requiring requires tsianging at lion. urine, etc. Dampniiss at least once a shirt an extra linen change routine intervals. I is detected every time approximately once a day. patient is moved or i. to 1 to it WALKS at.i?iAl.itE FltEiitiEil'ii.Y- Dagraa at physical trod. walk severely limited or walls occaslonallii dur- Walks outside tha mum activity ngnaxlsignt, cannot hear mg day but for very short at least twice a day and own itioigitt a.l1dl'cii' must distances, with or jlrithoid inside room at least once he assisted into er rislanoespericis maturity of every 2 hours during wheel in oach shiu in tied or chair. walking hours. iitoaitirv 1.i.'l3iilPLEiE1Y avert? Liit1l'l'EIi-Miiltes l.ilillT?iJ- Ability to change and not occasional slight changes Metres irequent though Makes maioi control body position maiiu even slight changes in iiody or extremity pcsi- slight slight changes in changes in position - in body or extremity line but unable to incite body or extremity posi- out assistance. position without essls-- irequent or significant tlon independently. tanco. changes independently 1.iiEPl'i' - Never 3. ADEQUATE - Eats over 4. Eats -- Usual loco intake pat- eats a complete meat - Raraiy eats a complete hall' or most meals. Eats most at every meal. Never tam Rarely eats more than meal and generally eats a total otai servings of retirees a meal. Usually Uzi at any iood oiierad. only about 112 ct any protein (meat. dairy eats a total of 4 or more Nothing by Eats 2 services or less iood oltered. Protein products) each day. servings of meat and mouth at protein (meat or dairy intaiie includes only 3 Occasionally will refuse a dairy products. products} per day. Talias servings of meal or dairy meat but will usually take Occasionally eats between 3N: intravenously lluids poorly. Does not products per day. a supplement it olisred. meals. Does not roquirs . take a liquid dietary sup- Occasionally will take a on supplementation. 31?t-l: Total parenteral pttiinani. dietary supplement. is on a iulre reading or nutrition. UH lifl TPN3 ronimen. which is andior main- raceluos less than opIl- probably meets most oi rained on clear iiquids or mum amount ofilquld nutritional needs. for more than 5 days. diet or tube feeding. FRICTION Allin - Requires 2 PHiiBi.Ehi- 3. till moderate to maximum Moves teoliiy or requires Piitiflifld - Moves in is assistance in moving. minimum assistance. trail and to chair inde- cornoiete lilting without tluring a move, skin pendentty and has suiti- slidlrie against sheets is slides to some cierit muscie strength to impossible. Frequently extant euainst sheets. till up completely during sides down in bed or chair. restraints. or other move. Maintains good chair, requiring frequent devices. Maintains rola- position in tied or chair repositioning with mesh tlveiy good position In at all times. assistance. chair or tied most oi the spastieiiy. contractures. time but occasionally . or agitation leads to slides down. i. almost constant irictiori. . i I . Strtirta til I2 t;li loss li'opi'esi:ii1ts i-'iigit. Rislt - I ass. Date Evaluate; Access. Data Evaluator Name - Last, First, Middle Attending Physician: ID Number gi t"2M/g or 9 5%/w .-- 0 nrnaglim Form SGALE BRADEN SCALE - For Predicting Pressure Sore Risk scoot: slides down in bed or chair. requiring lroquent nepoelttonino with maxi- mum assistance. Spasticlly. contracturos, or agitation leads to almost constant friction. choir, restraints. or other devices. Maintains rela- tively good position in chair or one most ot the time butoccasionelty slides down. move. Maintains good position in bed or chair at all times. HIGH score <12 MODERATE FIISK: total score 1344 OF LOW FIISK: Total score 1546 if under 75 years old DH 15-1B if ovar?5 years old. ASSESS.- 'i'~itSl< -- SENSORY 1. 1 VERY 3. Mill IMPAIRMENT - unresponsive [does not Responds only to paintui Responds to verbal Responds to verbal com- Abillty to respond moan, or grasp) stimuli. cannot cornmu- commands but cannot moods. has no sensory rneaninplully to to ztalniul stimuli. due to nlcato except always communicate deliclt which would limit pressure related diminished level at cm- by meaning or rest|ess- dlscomtort or need to he ability to test or voice dlecomiort sclousness or sedation, "mt llfiifl di5G0lIli0|1- . on has it sensory lmpaimaent has some sensory impair- which limits the ability to meet which limits ability '15' 5" 9- lest pain or discomfort to feel pain or discom- over 122 pi body. tort in 1 or 2 extremities. MOISTURE -2. OFIEII bttils'l'- skin is 3. 4. I'ittIl3'i'-- skin Degre to which skin Skin is inept moist almost otter: but not always moist. Skin is occa- is usualy dry; linen only is exposed to rnoieture constantly by perspire- Linen roost be changed sionally moist, requiring requires Giiarlginp at lion. urine. etc. Dampness at least once a shift. an extra linen cltanpe routine intervals. is detected every time approxlmatelyonce a clay. patient is muuail or turned. to 2. to it at Degree ot physical bed- walk severely limited or walks occasionally dur- Walks outside the room nonexistent. cannot hear int: day out tor very short at least twice a day and own weight andlor most distances. with or willtout inside room at leastonce he assisted Into chair or caermsoeods minis 9! were 2 hours durlno wheelchair. each shift in bed or chair. walking hours. MDHILWY 2. VERY tlhiItED- lit! Ability to change and not occasional stighi: chanpes Makes iroquent though Makes major and frequent control hotly position metre siren stlgittohennee in body or posi- slight slight changes in ohanpesln position witi1- in body or extremity use but unable to matte body or eartrentity post position without assis- trequent or lion independently. lance. chances independently NUTRITION tltititt - Never 2 PROBABII 1 - Eats over 4. Eats usual teed intake pat- eats a complete meal. - Rarely eats a complete hall on most meals. Eats most oi every meal. tam Rarely eels more then meet and generally eats a total at 4 servings oi roiusos a meat. Usually 113 ot any food otterod. only, about 112 or any protein lmeat. dairy ate a total or -t or more Nothing by Eats 2 servings or less teed uttered. Protein products} each day. saniiopsof meat and mouth ol protein (meat or dairy lnlnira includes only 3 Occasionally will refuse a dairy products. A products) per day. Taltes servings oi meat or dairy meal but will usually take Occasionally oats between . 3' intravenously fluids poorly. Does not products per day. a supplement ti uttered, meals. Does not require 5 latte a liquid dietary sup- Occasionally will take a tilt supplementation. 3TPN: Total parenteral pioment, dietary supptmenl. is on a lube loading or nutrition. on on 'l'Pl'i3 which is andlor rnain- receives less than opti-- probably meets most oi tained on clear liquids or room amount oi liquid nutritional needs. for more than 5 days. not or tube taaone. FRICTION AND -- Requires 1 PUIEIHM. 3. H0 RPPAHEIET SHEAR moderate to maximum Moves ioebiy or requires Patltitfiin - Moves to assistance in moving. minimum bed and in chair inde- complete llitlne without During a move, skin pendently and has suin- sltdinp against sheets is probably slides to some cient muscle strength to trnposslinle. Frequently extent against sheets. tilt up completely dorlnp Total Score til 12' or less ruttrosonls Fiaslt Assess. Dale Evaluator Slgnaiureftitie Assess. Date Evaluator Slqnaturemtie - ""Name - Last. First. Middle Attending Physician: ID Number FiwI'bor-o enneng Form No. FB-199 BFIADEN SCALE 4 TAKES 3 - 4 oi these medications currently and! or within last 7 days FALL RISK ASSESSMENT Upon admission and quarterly (at a minimum) thereafter. assess the resident status in the eight. clinical condition parameters listed below {A--l-ii by assigning the corresponding score which best describes the resident in the appropriate assessment .5 column. Add the column of numbers to obtain the Total Score. ii the total score is 10 or greater. the resident should be considered at HIGH FIISK for potential falls. A prevention protocol shouid be initiated immediately and documented on thercaregylan. I If i ASSESSMENT DATE :sc,o A- LEVEL OF ALERT - (oriented at on COMATOSE MENTAL DISORIENTED 3 at alt times If INTERMITTENT CONFUSIDN 3. HISTORY OF FALLS N0 FALLS in past 3 months 1 - 2 FALLS in past 3 months (east 3 months] 3 on MORE FALLS in past 3 months 0 1 C- P-MBULATIOW ELIMINATION . i STATUS CHAIR BOUND - Requires restraints and assist with elimination AMBULATORWINCONTINEMT Ll- ADEDUATE (with or without glasses) POOH (with or without glasses} LEGALLY A g_ To assess the have him/her stand on both feet without holding onto anything; walk straight forward; wail-i through a doorway; and make a turn. Gail/Balance normai Baiance problem while standing 1 1 I Baiarice problem while walking I Decreased muscular coordination Change in gait pattern when walking through doorway i' Jerking or unstable when making turns Requires use of assisiive devices cane, w/c walker, furniture) I I I N0 NOTED DROP between tyin and standing Drop LESS THAN 20 mm Hg between lying and standing 0 (D Drop MOFIE THAN mm Hg between lying and standing Mgpicnnons Respond below based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives. Antiseizure/B_enzodiazeplnes. Cathartics, Diuretics, Hypoglycemice, Narcotics, Sedattves/Hypnotics. 0 NONE of these medications taken currently or within last 7 days 2 TAKES 1 - 2 cl these medications currently andfor within last 7 days D. VISION STATUS F. BLOOD PRESSURE 1 it resident has had a change in medication and/or change in dosage II1 the past 5 days score 1 additional point. Ll' H. PHEDISPOSING Flespono below based on the following predisposing conditions: i-lypotension. Vertigo. OVA, Parkinson's disease, Loss of Seizures. Arthritis. WSEASES Osteoporosis, Fractures. 0 none PRESENT 2 0 1 -- 2 PRESENT . . . . a . 8' Hie!" 7:5' I 5 - sieunrueemrteroriia i .- Ass: 1 I A i . {a.oD,NAM -Last First Atton Ic_iari chart Na_ CL 1606-51 CE fir Irv 3 Printing, Ltd. iio. i-'e-195 FALL piggy; ASSESSMENT Clcorltinued on Reverse FALL RISK INSTHUCHONS: Upon admission and quarterly (at a minimum) thereafter, assess the resident status in the eight clinical condition parameters listed below by assigning the corresponding score which best describes the resident in the appropriate assessment column. Add the column of numbers to obtain the Total Score. If the total score is 10 or greater. the resident should be considered at HIGH RISK tor potential falls. A prevention protocol should be initiated immediately and documented on the care plan. ASSENTA 1 . i ADEQUATE (with or without glasses) POOR (with or without glasses) LEGALLY BLIND E. To assess the resident's Gait/Balance, have himfher stand on both feet without holding onto anything: walk straight forward; waik through a doorway; and make a turn. 0 Gait! Balance normal Balance problem while standing Balance problem while walking D. VISION STATUS _-scone 9- LEVEL otsl.:IEI::I::e I it if AT MENTAL STATUS a a was i 4 INTEFIMITTENT CONFUSION FALLS 2 1 - 2 FALLS in past 3 months - (Past 3 4 3 on MORE FALLS in past :3 months AMEULAHON, AMBULATOFIWCONTINENT 2 CHAIR BOUND - Ftequires restraints and assist with elimination 4 2 4 Decreased muscular coordination Change in gait pattern when walking through doorway Requires use of assistive devices cane, w/c, walker. furniture) F. SYSTOLIC BLOOD PRESSURE NO NOTED DROP between lying and standing Drop LESS THAN 20 mm Hg between lying and standing 4 Drop MORE THAN 20 mm between lying and standing G, Flespond below based on the toltowing types of medications: Anesthetics. Antihistamines. Antihypertensives, Antiseizure. Benzodiazepines, Diuretics, Hypogiycemics, Narcotics, Sedatives/Hypnotics. 0 NONE of these mectlcatiorts taken currently or within last 7 days 2 TAKES 1 - 2 of these medications currently and/or within last 7 days 4 TAKES 3 - 4 cl these medications currently and/or within last 7 days 1 if resident has had a change in medication and/or change in dosage in the past 5 days score 1 additional point. H. PREDISPOSING Fiespond below based on the tollowing predisposing conditions: Hypotension. Vertigo, CV5, Parkinson's disease, Loss of limbisl, Seizures, Arthritis, Osteoporosis, Fractures. NONE Pnesenr 2 1 - 2 PRESENT 4 3 on MORE PRESENT 1 'l 1 1 Jerking or unstable when making turns SIGNATU FIE ITITLEI DATE ASSESS FIE I DATE First Middle Attending Physician Chart No. FALL RISK ASSESSMENT I MALNUTRITIOH RISK ASSESSMENT rnetaorurn tact F125 - I Upon admission and quarterly (at a minimum} thereafter. assess the resident status in the eleven clinical condition parameters listed below (A-K) by assigning the corresponding score which best describes the resident in the appropriate assessment column. the column_ of be Risk for main on. A QFBVEDIJ numbers to obtain the Total score. it the total score is 10 or greater. ilhe resident should considered as'HlG 'r-jirotocol should be initiated Immediately and documented in the care n. A-I-E: SCORE I I 4 LEVEL 0 Alert - oriented 3 I Slow to respond -- disoriented 1 - . STATUS Leihargic - disoriented 2 I 3 Comatose. depressed, constant wanderer - disoriented it 3 Feeds self . Feeds self with verbal cues Feeds self slowly and only part of meal Fed by staff or tube fed El. SELF-FEEDING ABILITY Via Stable within last 3 months n_fl__ C. WEIGHT STATUS Explained weight changes li.e.. edema. diet. surgery, etc.) >50/o weight loss in 1 month or >10% in last 6 months ORAL HEALTH condition STATUS Lost dentures or several missing teeth Edentuious Difficulty swallowing/'freouent choking C3 Excellent - eats 75 - 100% most meals Good - cats 50 - 75% most meals I I I Fair -- eats 25 - 50% most meals Poor - eats less than 25% of most meals. Refuses some meals E. FOOD INTAKE weight loss in 1 month or <10% in past 6 months FLUID INTAKE 1000 - 20D0cc daily 500 - 100Elcc daily Less than 500cc daily 200Dcc or more daily I Takes as offered - Takes most ct time -- greater than 50% Takes occasionally but less than 50% 'f Refuses to take supmemenrs Few food dislikes Many food dislikes/complaints 0 Specific food-related allergies. intolerance-s 0 Limited access to culturally accepted foods Flespond below based on the following types of medications: Chemotherapy. Steroids. Cardiac!' giycosides, Diuretics. Antibiotics. overuse oi Antacids or Laxatives. 0 None currently taken Takes 1 of these drugs I H. FOOD PREFERENCES MEDICATIONS Takes 2 of these drugs 1 2 3 Takes 3 or more of these drugs LAB VALUES 0 Albumin 3.5 - 5.0. all other lab values within normal limits 1 2 Albumin 3.2 - 3.4; 1 - 2 other lab values abnormal Albumin 2.9 -- 3.1; 3 5 other lab values abnormal 3 Albumin <28; 5 or more other lab values abnormal uofjto esponc below based on the following IISI of diseases: Osteoporosis. Diabetes. CDPD, Arthritis; PREDISPOSING Anemia. Cancer. Kidney disease, Malabeorplion Alcohol abuse. GI surgery. Prolonged CONDITIONS nausea. Diarrhea. Vomiting, Depression. 1 1 present 2 2 - 3 present 3 4 or more present . -SE58 ASSESS gum 7 2 - 7 I --same Last First Middle Attend] Physician ct, uaczrar, 3 I 3' 1 1 MALNUTRITION RISK ASSESSMENT Fivaboro Form No. Fa-am El Continued on Reverse MALNLITRITION RISK ASSESSMENT INSTRUCUONS: Upon admission and quarterly (at a minimum} thereafter, assess the resident status in the eleven clinical condition parameters listed below by assigning the cornea ondin score 'on best describes the resident in the so roprlete assessment column. the column of numbers to obtain the Total score. it he tota score is 10 or greater. the resident sh dared as i-ltGl-i for malnutrition. A prevention protocol should be initiated immediately and documented in the care plan. - i I SCORE RESIDENT LEVEL OF Alert - oriented in 3 low to respond -- disoriented it 1 Lethargic - disoriented 2 Comatose. depressed, constant wanderer - disoriented 3 1 MENTAL STATUS B. SELF-FEEDING Feeds self Feeds salt with verbal cues Feeds seit slowly and only part oi meet Fed by stall or tube fed Stable within last 3 months C. WEIGHT STATUS Explained weight changes edema. diet. surgery. etc.) weight loss in 1 month or -5.10% in past 6 months I >5?i'o weight loss in 1 month or in last 6 months condition Lost dentures or several missing teeth A 2 Edentulous 3 D. ORAL HEALTH STATUS Difficulty swallowing/frequent choking Excellent - eats 75 - 'i00?!o most meals E. FOOD INTAKE Good - sets 50 - 75% most meals 1 2 Fair -- eats 25 - 50% most meals 3 Poor - eats less than 25% of most meals. Fteiuses some meals 2 F. FLUID 2000cc or more daily 1000 - 2UO0oc daily 500 -- 1000cc daily I 3 Less than 500cc daily . snacks; 0 kes as ottered SUPPLEMENTS 1 star than 50% 3 -1 a Takes most of time - gre Takes occasionally but less than 50% 1 Fietuses to take H. FOOD PREFERENCES __i:ew food dislikes Many food disiil-teslcompiaints Specific food-related allergies. intolerancee 3 Umited access to culturally accepted foods Respond below based on the following typu oi medications: Statoids. Cardiac olycosides. Psuchoactives. Diuretics. Antiblotiu. overuse oi Antacids or Laxatives. - 0 None currently taken Takes 1 of these drugs 2 Takes 2 cl these drugs 3 Takes 3 or more of these drugs . .1, Lag wu_u1=_s 0 Albumin 3.5 - 5.0, all other lab values within normal limits 1 Albumin 3.2 - 3.4; 1 - 2 other lab values abnormal Albumin 2.9 - 3.1; 3 - 5 other lab values abnormal Albumin <25; 5 or more other lab values abnormal PR-EDISFOSMG Respond below based on the iollowing list of diseases: Osteoporosis. Diabetes. Guru. 3. Anemia. Cancer. Kidney disease. Malabsorption Alcohol abuse. Gil surgery. Prolonged CONDITIONS nausea. Diarrhea. Vomiting. Deoresslort. 1 1 present 2 2 - 3 present 3 4 or more present --ASSESS I 7' #35535 First Middle Attending Chart Nu. max ASSESSMENT . Cane CENTER ELOPEMEINTHVANDERING ASSESSMENT GUIDE Residents to be assessed within of Admission, Re-admission, Quarterly, Significant Change in Condition and Annual Assessments. - Enter for "Yes" and for If you answered, "Yes" to most of the questions, considering placing a signaling devioelwanderguard. . . -- Wandering behaviors can increase with changes in residence, so consider inifttitoring the resident ';until the next assessment period or until you determine the elopernent risk has decreased. I . Resident: Roorn1.997 3/,5/0 5 . Date" Date Date Date Date - /0 xi" 1. Is this a new resident? 2' 2. Is the resident ambulatory? a. Able to walk with walker or other assistive device? /ix' b. Able to propel a wheelchair independentlyAble to leave unit, ifdesired? . 3. Is the resident resistant to being placed in a Iong-terrn I I oare facility? /0 /0 (ix 4. Is the resident verbalizing desire to go home or leave ., the facility? 5. is the resident attempting to leave the unit uneseorted? I -5. Is the resident attempting to leave the unit through the 4_ exit door or elevator? 7. Does the resident have a history ofwartdering? 9. Final decision on use ofwanderguard. Are there am' indications ofdementia? /y Signatures of Completion: . . - '5 Date (initial Admission) -5k_"g 5- 7 Signature: 5 5' 7 Date: Signature: Date: 5-7 Sigtarure: - A I the: 2 El Signature: J. Date: Signature: GP-'ml T. T. T. T. Fwsfiflwm T. . Numboc._.ooamT . Efim mafia Efim. on can aim. _T.omm . 3m_aIlnmfiamozw IIOSPT Re T. mco: mm". .T T. T. zmzfi .33 oamamaon T. . T. 82.3.. mungE9.a_? 83.3 mumofin - .3 new 2: Emmacann amzsma .. mumnfin Wu 103 . . umfiaam Sax .- >>mmTT sowqancmfiuquava . I gmao? Sum T. . 0 3 Tamfi ymm" 3% main qmuuaza .2 =3 o1mm_um2.mT. man 3 BB magma TN.mxu3mm_..5 . . T. . TT %mTa T. 33.. R30 o3._oB3nm__Eou_m3mTIbumaos bug TEE T.. . . . . . 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E06 xmm_.ozm_m_.m fiamw Ex 3 .. .. 230% La. 83 .mo._3..fim.n Em: . . . .9225. 4.3.s..2u2E.u_au . .. . . .. . . . . . 9an opmm 252.. omzamm obmm fiuffl Q. 9; 2.5.9 . umowrma zmmc. on n_ mmaama o_umm2ma 3 :96 SE $2.3 iman nmnmam mag a_mm:om_m 9. 3 mmgama 23% na>. . xom maaocanm Emaoaxo :3 2.mR2 Ea .3 .. Rmxfim amaam ?8 .oo3mn.. <23. Buuoamm. . a .6 m.2=2. - .. . ESE mocaam. . o3m.3.o=m 5% Ebb .3 oafinfi. 2.53 5.3: Ea 3% 3 9.5 :33 $33 Fm; 3.2.. . am. =3 8 anew. u. 2.5 8 25 $32.mauofimnm qmmamzfi 8. 233.5 3 .9 mnuaomosmm monoasn 3 Euamzfi. Emnazmm am m. onion. . am. 2 9 wmaaom ammaw ?3 53% mo__m.nm. 3.. 2 2:2: oE3m_ .m>x 4 arm, Qfim n>EQVBA . .. mooza." an N. omfi mmocmoogm .. . . . . . . mo>$ .>ox033 2.20.. ice 5 uma Ema. nu? . . . 9..z$.moma? _3n.m3=aa . . 2522 nmfiEaster . . . .. aocmamsa .. . Sam 3 . ..ll U_mo_.um_. . ll .209. amzs. _u_m3_u_ma_m..1w.a_uEmma . Qmmahe . . Baa . . . mm: . 35.3325 1 ice . 3.: . '\\_3um_3n :3 . . . .032man. 2% xm) . I1 nus" . . 222 <., . . .. .. . . . . . . .. . . . moozfi mr.N% W. . .. umocqoogm . . . . . I .. _2:uE Efi..m umomrmamfizmmummammzmaxm .. . . .95253$ . u_.E.3m . . Bangui 38:. %am_ .. . Basic: wzaunoam on 9. 9.3 . . .. Emficm. . 5 ca. mm amaaQmwmam .225 Ea .59 .. . . . 3.95925 . . . . . 3% 31.. ea mega. man? .223 . . it .23.. mmfica m. .3: um_..2aEo3u..am__< .. $3 mm .333. . . . ojmaofimqmuw . . Em sea cam. . . is 39.5 om..awe: scam. . 33.2." . 3,5 ..Ios% . .. . use mom:3o_5_o:pmmu . . A . . aaznuwmwazamm man In _oamm_ 92.0% 3.3. . L. mfiama 2.: 5&2 . . 8% o_mm:m_:m moms. wages. . _u_.mum_._nm Siam 3. . I: Esau mam _:m.m1 .3 . w_._n_nm . . aux" .. Em 3.o3__.a H33 . .. .. . massEmmalam 9.3m E3 .. 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Sam" 533 as amfioo3u_m_a a $3 . n?cmfi 2:5 0. 2mm ll Ooummummoa u6m_.an_umm__ mum .33333<m.m nmfimx . . I __..fim_umzd . W- .. . mooum<. . . . .. ofiaozm . H. Sam Ub._.m . 98Edmmamzdozm . Emanmwozmio . . . . ormm . ems . aka 333%.. . opmm amp . .. . . .. . .. 3m.m.o>bfiw . MLyam fishy . . .. I...I.. ..--. .JoflfiAI'..I.--.IIVI I..II I ..LIIIL. .131 .. urn .. . . . . - 5m . . mpmuin ammo? 99.202 . . . umoo?um_Am5_azxT510 .HSo>>o AS E: dung. nfqoazmxu . . . ..m.u?.uel Rim! .ozmm.. 1 . moprm cram ozmma . . cram Emo_E._zm TaB.m.. . . ua.Emama 2: am 9. nm.d_mn . _z .5 .. 3&3 am mafia: Qo . . Ea :95. za 2 mE..23m_ 2.23%. . 3 o:mm_um_: Hmom . . A . a an cam<36: 3 A. mu EU 9:333 no.5. :0 2 3 mamam .. . . . .4 4. . . . nounmgun . fix nm?mo Zn. ofimn. . 1.. . AL m?ooum . up Km and . xxdungum. . . . . . \>n_33Em: $52. um. Eocoamn . . .odmmfim 3.. macmamm 2150 . . om_.n__mn . wax maqmamm <4<> mm . . . 233. . . Egan? Ba 2% mama m. .3 xm 2.3 mm? . Ffifixnvma mooafi N. . . mmc. . 9.28am am. Eam >nx>. .. . . . . . . .. .. . . . mu a. nu 6.. huusd . aim: .. . . . amu un_..2_c_ma. . . 2 2222$3355 mmum <> 39.2 no maoziu 3.8 8 u_.om_E_.m on mioflma . . 1. m_mu_u3> manna. aonmfiw Hogmam111.1 1% 1 . . 4.1nnan Numatic identifier 5030 MINIMUM DATA SET (MDS) Vt. 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE scneemno DISCHARGE TRACKING FORM [do not use for temporary visits ham 3] sermon AB. DEMOGRAPHIC INFORMATION AA. IDENTIFICATION INFORMATION temp," my was man 1' days] 'Mmu.(.mar1 pom' 5' In mes' "59 2' GENDERG Litiialo 2.Fornala I 1 l0I5|- I DITI Month Day War Mom on war FROM . 4_ 1. nmetncan lnuiarI#d'5s7'ican Native at. Hispanic MT 3- 59375 and -It. Nursing home 5 2.AianIP ct Nat' 5, Mwnmamy 5. 7. Re ahliilafion ampitau B. om SEEKJEI Bl" HEDICARE b. Mdlcare (or corrparahia railroad insuranoo number912] 5] I sermon A. IDENTIFICATION AND BACKGROUND INFORMATION 6. FACILIW a. Slalef-10. Paownan SECTION R. 7. 3. Dlggi-t+AtfligE I. Code forrasidenfdisposition upon discharge Board and mareiaaslstad EMJCD 4. Another nursing facility 5. Acute care hospital 5. hospital. MRIDD tacitly 7. Rahaitilitalion hospital 3_ nsgsous codes do not apply to this form] FDR Asspigs. a. Primary! reason for assassrnant ME 6. Elischargosciwreium not anticlpataiti g_ 9933933.; 7. Discharged--reium antfcipatoct 5 other B. Utscnaryad prior to oompiating Initial assessment .. Slgnatums of arson: who complotart a Portion of tho Accompanying or Form D. Optional State Code I certify that the accompanying ammtety retlacts resident or tracking 4_ QISGHARGE para a! ggam information for this resident and that I collactad or coordinated collection of this Information on tho dale: spodiiod. To the boat of my itnawiodga. this information was collect in ac-oordancacuaptnbia Medicare and Medicaid raquirernanis. I ll'In'ar5land_ that this inionnation is user! as a basis for ansurinu mat ruiria-nts reoelva appropriate and qulily care, and as a basis for payrriant Month Day I Year from Iadarai fundu. I further understand that payment of such federal funds and continued partici- pation in tho notrornnant-fururied hearth care ptonnama is oondilionnd on tho aomrar.-y md truthful- naas of this inlonnation. and that I may he parsnnotiy to or may subjoct my organization to substantial criminal. civil. andtor ndrniniatraiiva ponallins tar submitting false inforrntinn. Iatlo carlify that Ian authorized to submit this hfonnation by this facility on its behalf. Signature and Tttia Sections Data 9 Key items for resident tracking :3 when box blank. must enter number or letter when letter in box. check Ifoondition appiles Paint Dare Febmaffu' 29. 2008 MDS 2.0 September. 2060 Numeric Identifier 5030 MINIMUM DATA SET (MDS) VERSION 2.0 I FOR NURSING HOME RESIDENT ASSESSMENT AND cane BASIC ASSESSMENT TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION 1_ E. Signatures nl Parsons urtto completed 5 Portion of the Accompanying Assessment at a eceom an i am nneecuraa re a res ausaeamen or a n9 tar this rasifiau aI'Ia that I cnltenlad or celteclinn at information an the 2. gauge 1 Ma}: 1 Fnmma 1 dates specified. To the best of my krtowtadue. thin was miles! In with applieiisbln Mexfilcare and Eadicald requirements. I that this 'used as that re dents a ta q.1al'ly care. a as a as arpe ment lurlher euct1iudernIjhI1dn'hand sin in a cnremmarll-un -a a earn ramsseun "menu" on eanunacya . 5.55%: this lrfitomelkn, and Inn! I may be subject to or may sutaieci my ta 4. RACEIEI 1. Antadcan lndlanmlasitan Mauve 4. substantial criminal. civil. andtar artministrallva penalties far submitting Ielse [also ETHNICITY 2. 5. white, not of 5 certify that tam authorized to by this Ieeility an its bahnll. 3. not origin 009'" 5_ SOCIAL ewmy Humbq Signature and This Sections Dale --L --I a uenIcAneb 25' . re OFODITIJB ta roe naurante nuM'e'utcAto 9. -pa "gs If I. rectptentj G3 El. cudas do not apply to we tonn] a. Primenr reason for assessment ugm 1. assessment {required by day 14) 2. Arms! assessment 3. Slgnifiuanl uhartgu In status assessmafll 4. Significant eurrectlun at prlarfull assessment 5. Quarterly review assessment 1D.stgn'rticent currectton at print' quarterly assessment 0. NONE OF ABOVE Is. codes for assessment: required tor Medicare PPS or the Stat 1. Medicare 5 0' assessment 2. Medicare 30 ay assessment 3. Medicare so day assessment 4. Medicare 90 day assessment 5. Medicare assessment 6. Others!-ate required assessment 7. I.-ledlcatltt 'f_4 day assessment 8. other Medrcare requtred assessment GENERIC I 3 Key Items for computerized Ieslrtenl tracking when be: blank, must enter number orletler Print Date February 29, 2008 when letter in box. check if applies Complete this Infannattun for submission with an fut: and quarterly assessments Annual. St nificanl Change, state or Mecrtr.-are mqutrnd assessments, an Guamu-ty Reviews, MUS 2.0 September. 2000 Ra5iI1EnlNarne GEORGE LARDCCA 5035' MINIMUM DATA SET (MDS) - VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING W. SUPPLEMENTAL MDS ITEMS I Enler [or all assessments and tracking forms; It available. er in Irlha ARD althlu assessment or 1:1: discharge data of mi: form I: hetween July 1 and Sopiamber 30. skip lo W3. 2. Influenza an. Old Ihe resident racelva Ihe Influenza vaccine Inthis Vaccine facility for year': Influenza season (camber 1 ilzrough March 31item Wzb) 1, Ya: Yes. 94: to Hem W3) 13. lnlluqnu vaccina nal rncalvad. data 1. No! In dumg this year's nu seasan 2. Received nuiside of this lacllily Not allalhla -II. Dfratad and declined 5. N01 offered 6. Io uhlaln Iraccina 3. F'naurna- a. In the ranidanvs PP\!s1alus up to dale? canal 0. No (If No, go to Itam wan) vaccine 1. Ya: (If Yes, aklp Hem W331) b, ll FFV not received. sxate reasan: 1. Nol eligible 2. Offered and damned 3. Not oflerad P-v'nt Date February 29. 2008 Nurniaiirz 5030 MINIMUM DATA SET IMDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING REENTRY TRACKING FORM I AA. IDENTIFICATION INFORMATION 1. LAROCCA mus-IE0 c.(La5t) 2. GEWJERG 2.FarnaIa I1 3. IFITHDATE3 I - - man an air Year 2: 3. aiacx. nut orniapanic origin ispan 0'19 5. SUCIALC9 a. Social Seaurlt Number Ia. M-adicara number (or oumparabla raltraad insurance numberIzls IA I IJ FACILITY n.Statu Nab.FadaralNoI3 [uniltafd raclptanll 8- REASONS [Note-Other coda: do not apply to this form} a.Pn'mary reason lorassessmant 9.Ftaanlry 0 9 9. Signatuma uf Panmna who a Portion of the Accompanying or Trucking Farm artity that this accompanying inturrnatian anizurataty reflects rasialant or tracking I. far this resident and that I cuttectad ur cuordlnaled callactlm of this an Inn dalas apadriad. To the best army Icncr-vtadga. this lntormatlan was collect In accurdanca with Madicara and Maclcaid Imdarstanct that this h'IIarrI1atIan is used as a basis for ensuring that residents racatva appruprtata and quality cara. and an a basis mugcraymant from tadaral funds. I further unamland that payment of such ladarat funds and aantlri partici- pation in tha government-funded haalth can prugrarna is aondltibnert on tha accuracy and I.ruIhluI-- ms: of this tntarmattnn, and that I may be parsonatiy subject to or may ai..Ib]acI my arganlzatiun to substantial criminal. civil, andtar administrative penalties tar aubrnitting false information. I also certify that I am aulI'Inn'zad to submit this hforrnelion by this facility on Its behalf. SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION 41. Dl t" REENTRY a of run rv |o [2 -|2|o|aI a] Day Year db. 1. Private uamerapi. wiTrTno home haalth services 2. Private I1nmaI'apL with home health services 3. award and nardassisted Itulngigrnup non-Ia 4.Nurahg Home 5. Auutacarahaepttal 6. haspital. MFUDD facility 7. Rehabilitation 8.Dthar 3' MEDICAL Isloisinl Signatura and min Sections Dale Key items tor computerized resident tracking when box blank, must anlar number or inner Print Date February 28, 2008 'when applies MUS 2.0 September. 2000 Pa (GEORGE LAROCCA Numeric ldenlifier SD30 NHNIMUM DATA SET (MIPS) - VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING W. SUPPLEMENTAL MDS ITEMS -5 . National Enter [or all aasaasmanls and tracking runtls. I_l available. Provider ID I If the ARD of ihls assessment hr the discharge dale 0! mi: discharge tracking form is balwaan Jury 1 and saplamheran, skip to W3. Influenza a. old the teslderrt receive In: Influenza vamlna In this Vacclna for ihla yuan': ln_lluanza aeasun (Dunbar 1 hrnugh March 31}? 0. No Nn.gnt-: Itamwzb) Yes {lfYas, gala Item h. It Influenza vaaclna nut received. male teasnn; 1. No! In during this yaar's nu 2. Received nuislde 3. N01 e!|gib1a 4. Dlfered and decllnad 5. Not offered 5. Inahiity in obtain vaccina Pneumm a, la the raaldanra PPV status up In date? cuccal 0. No (II No. no to item W35) Vacclne 1. Yes (If Yes. aklp Rem Willa) 13. ll' FPV not received. sia1a raasun: 1. N01 ullgihla 2. Dfferad aid 3. Not altered Dale February 28, 2003 Numeric identifier 5030 MINIMUM DATA SET (MDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT mo cone SCREENING DISCHARGE TRACKING FORM [do not use for temporary visits home] AA. IDENTIFICATION INFORMATION 1' GEORGE LAHOCCA E9 I. (First) I). IMICICIIE o. [Lad] (I. IJIISII 2' Lhiaia 2.FerrIaie Month Day Year 3- 5. AND I olo|1 in. Medicare nornborior oomporahie railroad insurance nurni:-an I I I. Stain SECTION AB. DEMOGRAPHIC INFORMATION [Got-I1pl_ele_ only for stays loss than 14 days] (AA8a=tii 1, or Dot: the stay began. NoIo--Does riot' include readmission ifrecord was ENTRY mood at tho iimo ariomporary discharge in hospital, etc. in such cases, use orioradrnission data Iols I1I6I- I 2| 0| 0| 7I Month Day Your 2. ADMITTED 1. Private homeropt. with no homo health senrioes FROM 1 Private homefopt. with home health services 3. Board and ooreiassisted Iivingigroup horn: 4. Nursing home 5. Acute care hospital 6.133 chiatrio hospital, liriRI'I'.iD facility 7. Rs abilitotion hospital B. other SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION Islolaloil RECORD NO. SECTION R. ASSESSMENTIDISCHARGE INFORMATION 7. MEDICAID I I I I e-Iatsi ii at I I I I lntedicald rociplontb 8. REASONS ASSESS- codes do not apply to this form] a. Prirnary reason for assessment 5. not anticipated Discharged-mtum antlcipatad ti. Discharged prior to completing initial oirooamoni '?Igmturo| of Person! who completed a Portion oi the Accompanying Asoossmol or 3. Dodo for rosident disposition upon discharge 5 1. Private homeiapi. with no home health services 2. Private homaiapt. with home health services 3. Board and oareiassistad living 4. Molnar nursing facility 5. Acute care hospital 5. hospital. MRIDD facility 1. Fiahabilitaiion hospital it, Dacaossci 9. Other b. Optionaistofo Code J. Tricking Form I certify that tits hfomtation aoomnloly resident omoanmarrt or tracking -infonnation for this rosiduni and that I oollooiari Oi' coordinated ooilaction of this iriiormdion on tho dates spoaifie-:i. To the bust oi my iotowiadgo. information was coiioct accordance with Bccaphiblfl Modicaro and Medicaid requirements. I uniiorstanci, that this I: used as a basis [or ensuing that residents receive approp:-iota and quality cars. and as a basis for poymarrt iron-I rodorai funds. I umziomiartvzi that payment or such federal funds and continued partiti- potion in tho govammoni-Ionoed health care programs is oorttziitionao on tho accuracy and truIhiui- halts oiihis inioI11tation,andIhai i may he personally Iobjact to or may aubjact my organization to subaianthai onrtrur administrativo penaitiaa [or auhrn false hionnatioh. I also certify that i am authomoci to submit thin irrformation by this iaoitily on its buhati. Sociiono Data Signaiura and 'fills 9 Key Items tor raicleni tracking When box blank. must enter number or letter Print Date February 28, 2008 4. Date ofdeath or disoharya I oI2| 8' olole I Month Day Year When letter in box. check if ounciition appiies MDS 2.0 September. 2000 Numeric Identifier BDSD MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND cnaa scneemne BASIC ASSESSMENT TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION 1- RESIDENT "mag GEORGE LAROCCA a.(Fir5I} b.(Mida1elnitIal) c.tLast1' 2' 1.MeIe 2.FemeIe I1 3- -- maize: Menth_ |1'tnt'_ Year 4. tucefi 1.Amencan tndtanr.-trasrcan N-atlve 5.WhihI.:total 5 3. Black. not at Hlspente origin Hispanic . SOCIAL .5 II5 Iflrfif sgfifirgpwe ace ecurty 1' "man shI--I22 I-- 9 2I 5I Numgy.-5% It. ttlee care number erua-u - 'a ma lnaunsnee number} @l9I1l2I2 are |TeETr:.Ate g. uittflatd IoIvla|3|5|4|s|RI I I II I. rectpfenua B. do thtatenn] 2. Annual assessment 3. stgnittcent change In status assessment It. Significant cnrrectlon at prtertull assessment 5. Cluerlerty revluw assessrnent curreetim of prior quarterly assessment It. NONE OF ABOVE b. Codes rerassessments for Medicare PPS urine Sm- 1. Medicare 5 ea assessment 2. Mecqcem 30 try assessment 3. Medgcem 60 day assessment 4. Medrcere 90 day assessment 5 Medtcare assessment 5. other state assessment Medicare 14 day assessment 8. Otnarudtcara raqutrtad assessment I3 Key Items for computerized [j wttan box blank. must enter nurnherur teller Pn'nt' Date February 23, 2008 B. slgnaun-es ef Portions who Completed :1 Punter. at the Assessment or Tracking Funn I certify that the interrnelion accurataty reflects resident aeaessrnanl CII'Il'flfl{Infl Inlerrnetian ter thin resident and that I cutlectad ur cnordtnelee of this Information on the dates specified. To the beat at my knowledge. this Information was salad in eaeordanca with applicable Medicare and reqttrements. I understand that Ihts is nod as a basis fur ensuring that residents temiva ppreprtata end qtaltty care. and as a basis fer payment trern federal funds. I understand that payment at sudt ladenal Funds and conlhuecl petlen In the health care program: 1: eendiltenad en the acctracy and naas el this Intennatlnn. and that I may be personally sut:-fact ta er may subIad my nruantzatlen to iuI:tsl.aIlIEflI for submitting false Intennattun. I atee that I am authorized to submit this InI't:rmatlcn by this renilityon its behalf. Signature and 11t'-e Sections Data Ce replete this lrztar-matron for submission with an' full and quaderty asses ements Admlutnn, Annuer, SJ change. state or Modterne mqu'Imd assessments, or uarferiy Reviews. N23 when Ietter in hex, check if eenclition applies MDS 2.0 September, ZIJUIJ Resident NBITIE Numeric Identifier MINIMUM DATA SET (MDS) - VERSION 2.0 FDR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING GEORGE LAROCCA 5030 SECTION W. SUPPLEMENTAL MOS 1. Nauenai ID Enler for oil asaessmanis and iracking icrms. I available. fl|3i3|5|5i2 |3i3i7fl lithe ARD oi this assessmonl orlhe discharge dale afihls diaciiarge mm is between July 1 and Sepiembaracl, skip to W3. 2i Influenza Vaccine a. Did the maiden! receive the Influenza vaccine in ihla b. It influenza vaccine not received. slate reoaon: iaciifly inr [his years Influenza season {October 1 through March 31)? - Cl. No (lib-Io,go to item W2b] 1. YES [If 'res. go in iiern 1. Not during ihie years flu season 2. Received outside of ihle laciliiy 3. Not eligible . 4. Offered and declined 5. Not offered 5. inability lo obtain vaccine Pneumo- Vaccine - a, Is the realdanfs PPV uialue up to date? D, PPV noi received. stale reasonilcrn W3b) 1. Yes [!fYes, aldp iiem wars) 1. Noteilalbia 2. Offered and dacflnact 3. No! offered _Pn'nt Date February 28, 2009 Numeric 5930 MINIMUM DATA SET (MUS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING REENTRY TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION RESIDENT GEORGE LRROCQA 'Ia. Dam of mamry - a. (First) b. (Middle Initial] to. (LastMala 2 Female I1 3 IBIRTHDATEEJ Mam Day Year 4b. Private homelapl. with no home health services 03!! Year FRAOTM 2. Engage hornefapl. w_I|th some health senrlcas rt. (5) 1. American lndlanmlaskn Naltva 4, Hgspanm, Nflfimgwofifaaslsta livIn9J9ruuP homo 2. Islander 5_ 5 5. Aouta care hospital 3. mack, mg; of gI'IgIn Hispanic origin 6. hospital. MRIDD Iacility 5_ a. sacral sewm Number . 7. Rehabilitation hospital I no EEI AL - -- MEDII: I IsIo|aIoI Ia. Medicare number for comparable railroad Insuranoc numberI2Is In I I I FACILITY Ia PROVIDER a 13 5IOI3I1I I I I I I I7 t:l.FederalNo Medicaid raorpianq 5- [Note-Cilhercodos do not apply to this form] a. Primary reason for 9. Fleantry 9 'Ignaturnn of Parsons who comptelod a Portion at the Accompanying or racking Form ruarfiy that the accompanying htorrnation accurately rallacls resident assessment or tracking infmmauun for this and that I collected or coordinated cotlection oi Ihts information on tho dalas oclliad. To the best of I-rly knowtadga, this Information was collect in sccordanca with appli Ia Medicare and Medicaid raqutramantsl I Lmoerstoncl that this information tsused as a basis for ensuring that rasidanls raceiva appropriate and quality cars, and aa a basis for payment from tociaral funds. Ifurthar understand that payment of such tedaral funds and oontinuad paliafl in the government-funded haallh care programs is conditioned on the accuracy and truthful- ness or this Information, and malt may be personally subiacl to or may subject my organization to substantial criminal, civil, arldfor penalties for submitting false Information. I also cerlily that I am auttlorizecl to submit this infonneliun by this lacilsty on Its behalf. Signature and Title Sections Date a. II. C. Kay Items for computerized resident tracking When box b?BI1|t, must enter number or letter Print Date June 27. 2007' when letter In box. check if condition applies was 2.0 September. 2000 Numeric: Identifier 5039 MINIMUM DATA SET IMDS) -- VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BASIC ASSESSMENT TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION 1. RESIDENT 5.I Signnturus who completed a Portion at tho Assessment er GEORGE LAROCCA Tracklne Form v- Irma Ir-ma>> the 1- GENDERE 1_ MM, 2, Fammg 1 dates specified. Ta the heat at my lI.ncIwledge.th|slrIInn11atinn was collect in eccurtferrce with 3 Mud:an'a1enI:I raqulrennents. I this ir:IennaIIeniisrI.Ised as . ass nreneur I atren ntereseive iate en ua I:are,|aI rlrom radars! II.ndge.lfu1heruI'IdersIand mm Day Year 4- RACEII3 1. American Indlarmlasiten Native 4. Hispanic substantial r:rin1ina|. civil. andror administrative penalties {or false inlonnslinn. Ialsn ETHNICITY 2. AsIanIPecIIlc Islander 5. Vrhite, not 9! 5 certify that I am eutnorfzad to submit this Iniormalinn by this on its behalf. 3. Black. nol oft-llsperllr: origin win 5' I . SOCIAL a. Snclal Security Number ma Dam I MEDICARE 9 1 5 NUMBERSQ b. -- -we number or um" -- Insurance number} EISIAI c. E. a. State Na. I II I I II b.I=ecIaraINoIOI1I I I I r. 7. MEDICAID g. - Irnora I I Medfcsid recIpI'enI'J G) 8. Rggsons do noIsppIytIflfiIBIDmI e. mam" 1. assessment (required bvday14) 2. Annual assessment 3. Significant change in status 4. Slgnificant correction or prler lull essessrnent 5. Quarterly review assessrnenl 1fl.SignilIc.anI correction 0! prior quarterly assessment 0.. NONE OF ABOVE Codes for assessments riqulrnd tor Iludfcarn PPS at the Star 1. Medicare 5 ds assessment 2. Medicare so sy essessmenr 3. Medicare 60 day assessment 4. Medicare 90 day assessment 5. Medicare assessment 6. other state Medtcere 14 ulred assessment assessment 6. Other Medicare .rI:-Iqufled assessment 9 Key Items for computerized resident tracking box blank, must enter number or letter Print Date June 200? E3 When letter in box. check it condition applies GENERAL INSTRUCTIONS Cempiete this lnrunnaglaq for submission with .11! Jul! and quarterly assessments Admission. Annual. 5 nlicant Change, stare or Medicare required assessments, or narlarfy Reviews, etc?" M05 September, 2000 GEORGE LAROCCA Resident 6030 NUITIBIIG MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR Irquasme HOME RESIDENT ASSESSMENT AND crane SCREENING BACKGROUND SHEET) INFORMATION AT ADMISSION SECTION AB. DEMOGRAPHIC INFORMATION SECTION AC. CUSTCWIARY ROUTINE 1. Dfilfl "15 - Does noiindude_ readmisslonlr record was 1. CUSTOMARY {Check all that apply if iasi has only.) ENTRY closed at time of temporary disohame la elo. In such cases, use nounne 539 yaarpdor CYCLE OF DAILY EVENTS I7I Stays up Iale al aflarapm) Month Day Year "1 W5 I b. Maps regularly during tiny to! least 1 hour} 2 AnMrr1'?n 1. homeiaol.wm1 no home health senrloes . oa an IV 9 g_ mummy name 'fiwgfifigfl Slays busy will: hooblos. reading, or fixed daily roullne .1 . A I ilal . a. piicfifi Maroo SPWS Ia': gfi1hB3rb5"3"?" h?5P"3' nnfl?ggjg Moves Independently Indoors (with appliances. ifused) 3 LIVED lobecco products BI Ieasl dolly g_ Tc 2' I lh er ABOVE h. 33:. as In on pre erences - all r! i' I 5, (Chock raflenr live-din during 5 years prior lo dale of I envy given in rlem .451 above) Eats belwean meals all or rnosl days - prior stay at name a_ Use oi alcoholic hover-agels) at ieasl weekly K- Slay in other nursing home NONE I Diher residential and re home. assisted ADL pm-I-gmqg Ill.-Ing, group home . setting In much or day in- umnn samng u_ Wakans Io toilet ali or most nights Mom; OF ABOVE Has Irregular bowel movernenl pattern showers {or 9' be two NONE OF ABOVE 2' lg . Egg 6_ Se calla, .. on INVOLVEMENT PATTERNS . no as . ome i. Dally conlacl with relallussialose friends 3. omp eta . . Grad . - 3. LANGUAGE (Code for correct response) Usually attends church, I-emple, synagogue Iei:.: a.Primary Language Finds slrenglh in lallh u_ 0. English 1. Spanish I 2. French 3. Dihar Dlly nimal . I nuolved in group eolivmes w_ if nlhor. specify netzrl HISTORY I1 Mn 1. Yea UNKNOWN-Resiclenlffamiiy unable lo provide Information "l_co TH conHl'IIons Ea? are relarad ta MWDIJ srslus J'hn_r were RELATEIIJJTCI manifested lleibre age 22, and are likely in continue rnderirllely} MRID STATUS Hal applicable--no MHIDIJ ID A A "mg Wm, Cami,-W or-' PERSONS COMPLETING FACE SHEET: DOWNS EYFUTUWB 5- a. Signlure oi RN Assessment Coordinator Dale Aulism lhebasloi in am ormalionwoscn in acwr enoawi Omar Oman": madman mama 10 Mam" 6' aa iu Modicaila and Medium; rgquirenls. Ihal lhis informalion is used as a PP M5159 with "0 wfidflififi '5 oasis lur that residents recehr appropnale and quality care. and as a basis {or paymenl from federal mods. I lunhe-r underslannl that paymenl oi such lederel lunds and continued partici- 11. I notion in the haallh care programs is conditioned on lhe accuracy and lrg.lih1'uI- eaouwo 1 -- 2 - 7 I ~33" Man"-. Day yea; [cam sulamil lhI: I-nforrnelion i:Iy lhis on iis behalf. 'ah Sionalura and 'nus 59" Elma b. o. ti. 9. 9. h. I:I=When hm blank, must anlar number or letler =Whan ialiar in box. check if cnndilion applies Print Dale June 27, 200? M95 3-0 299? Nurrtenc Identifier 6030 MINIMUM DATA SET (MDS) VERSION 2.0 I. FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING DISCHARGE TRACKING FORM [do not use for temporary visits home] SECTION AB. DEMOGRAPHIC INFORMATION SECTION AA. IDENTIFICATION INFORMATION from lederat Iurtds. tturther understand that payrnent at such Iederal tund-:I and continued particl- patian In the government-[united haallh care: programs Is cnndiltnnad an the and truthtuI- ness at this and that Imay be persurtatty subject In or may subject my or-narttzatlan In substanllat criminal, civil, penalties for submitting rates intormalion. I also certily that I am authorized to l'l.tbI'I'II't tntonnatton by IN: on its benall. Signature>> and Title Dale 9 Key items for computerized resident tracking When box blank. must enter numbar urtetter Print Date June 2007 o_nIy tor stays less than clays} I 1. - LAROCCA I ''as a II ernara Is 8 cases. 2' 1.Mare 2.FemI.=.Ie I 1 -- I 3. EIIRTHDATEGJ |_3rE_l_ 1 9 2 Day Year Ba 2. Prtuata htametapt. no hurne haalth sarvlces *3 '33' FROM 2. Private zromerapt. with han'I_a health set-mes 4, R5539 1.AmerIcanIndIartINa5t-cats Nattve at. Hrsfianit: 3. Board and 5' 5 5.95 cttIa_trtI: hospital 5. socam. Number Ina ebilnation I1nspIIaI SECUR B. Other AND I 2I2I--I I3I9I2I5I t:I. Medicare number {or cnmparabte raatroad Insurance num herSECTION A. IDENTIFICATION AND 6. MEDICAL -Ii. FACILITY snowmen SECTION R. ASSESSMENTIDISCHARGE INFORMATION 7. 3. DISCHARGE a. Code upon -- 5 .43.. STATUS 1. Private hnmelapt. with no home health services Private homatapt. with hornet health services 3. Board and living 4. Another facility It. ae?ggns [Nate-cftharcoctes clonal apply farm: 5- A0015 fire a. PrII-nary many 6 - OED 3 7' ::II.:Inpt1:l2I1ated 8' Dccamd 8. Discharged prtor to iniltal assessment . 9' Omar 9. of b. 0 fl ms! Tracking Fern: on 8 9 I the tntarmatlnn accuratety rtaflacts resident assessment or tracking 4_ 5 page rIIorrnatiI'.In tar resident and that I collected or can-utnalad at this an the DATE datesspecifIad._Tu the anceplabla MEUIDBIB and I understand, that Inturmatinn is used as a basis for ensurtng that rulctants receive appropriate and quality care, and as a basis for payrnant Month Day Year When letter in bar. check It applies MUS 2.9 September. 2000 Numeric Identifier 5030 MINIMUM DATA SET VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BASIC ASSESSMENT TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION 2. Annual aasessmanl 3. Slgniflcanl cl1ange_In sIaIus assassrnenl 4. correclion of prior ILII assessment E-.Quar1ady review Assussmenl or prior quarlarly assassment D. NONE OF ABOVE Codes for assessments required for Medicare PPS or the Start 1. Medicare 5 da assessment 2. Medicare 30 try assessment 3. Medicare 60 day assessment 4. Me dicare 90 day asjsessm em 5. Morflcara assessment 6. Omar sIaIe required assessment 1 Madicam day assessment Ii. other Medicare re-quIrad assessment Key items for computertad resident tracking when baa blank, anlar number or letter Print Date June 2007 1, E. Slgnalurun of Parsons who I: Purflun of ma Accompanying or Rfiflig GECIRGE LAROCCA Form - I canry Ihal the accompanying Infonrmian accurately railecis rasidanl mesr.manI I dung 3' (Fun h' (Middh Inman (Last) d' infannalfnn far this resident and IhaI I mlleclad nr cnllacliun ul Ihis inIa:I1arIIon on lha GENDEREI 1 Mme -.1 Female I 1 dalns To the heal was ?IIuI:Ifin applica a icaaraand Mad i raquiramanls. arsland Ihat '5 narrna an in usadas a basis {or ensuring mar ras'danIs reaaiva and quality care, and as a basis lur payma I13 [lav Ya; mass ni II1Is InIan'nalia_n! and Ihat I may be personany suI:' at In or may subject my urganlzallon In - RACEIE3 1. Ameflcan Indfaxlmlaskan Native 4. Hlspanlc sutzalanisal crirnlnal. r.-ml. ancllar adminislraliva panallias suhnillhg false information. ialso ETHNIGITY 2. A5Ian1'PacIfi[: mafia" 5, "mile, mg uf 5 carlify ma'! I am authnrizad lo subrnil this Imarmatiun by Ihis facility on as hahall. - 3. Black, not of Hilpanlc nrigin sad a. Soc-Ial Security Number "MEDICARE 9 1 2 2 5- Numggfigg b. er rare number or mmaarable ra Iron I15-urance numberII?nIcAzr_: g. .. an my. . ifnara I Medicaid figgsofls caries do no! apply to Ihla farm] a. Pnmary reason for assessment mfim' 1. Admisslon (required byday 14) GE ucrIon? Complete this Information IorsuIhmIsaI-on with alf full and quarterly assessments Apnual, Si change, stale nrmadtcara raqulred ass assmenrs. or uarlorly Renews, M33 ELTI when latter in box, check II condition applies MDS 2.0 September. 2000 GEORGE LARDCCA Resident 5030 Idonliior MINIMUM DATA SET (MDS) -- VERSION 2.0 roe NURSING HOME RESIDENT ASSESSMENT AND CARE BA CK GROUND (FA CE SHEET) INFORMA TION A ADMISSION SECTION AB. DEMOGRAPHIC INFORMATION SECTION AC. CUSTOMARY ROUTINE 1. DATE OF ENTRY Month Day IIEI llEI' Date the stay began, Note -- Does not lridir-do if record was closed' at time oftomporary discharge to hospital. at: in such cases, use onor admission date ADMIITED R0341 1. Private horneraotvrith no home health services 2. Pnvala homeloptmrih home health services 3. Board and home 4. Nursing home 5, Acute care hospital 6. hospital MRIDD facility 7. Rehabilitation hospital B. Other IIP DE OF sf?ton . RESIDE - LIVED ALONE ro PRIMARY RESIDENCE D. No 1. Yes 2. In other living. group rtorrte MHIp5yc|1ietric setting setting NONE OF ABOVE I Check on cutting: resident lived in during 5 years prior to file of entry gtlreri In item A31 abovoi Pt'lor stay at this nursing home Stay In other nursing home Other residential and care home, assisted LIFETIME on two occupations] cola" . osr: ootng 2.8th rode-lless 3. 9-1 grads High school . nice or 5. some colic ESE 7. Bachelor': ree B. Graduate day no . LANGUAGE (Code for correct response) a.F'rIn1ary Language 0, English 1. Spanish 2. French 13. Other b. if other. specify I I HEALTH HISTORY CON DITICN3 RELATED TO HIRIDD STATUS Does resident': RECORD Ind: mental illness. or dsveloomontel disebilittr nroblerri? Down's Autism Epilepsy organic condition related to MRIDD with no organic condition cats aflti hisiorv oi retardation. manifested before age 22, and are likely to continue indefiitfletyi Not pt;-licable--no [Strip to AB11) with organic condition 11. TI COMPLETED I2 it In Month Day Year It (Check all that apply. if all inionnadon UNKNOWN citeclr last bolt only.) ggrg; CYCLE OF DAILY EVENTS fivmg jays up after 9 pm) b. hngfifilffiflr Gaps more at': ur ng .33: {at least 1 hour) G. Efl SIDES Du 1 - ays a week - 'v mm mung ays busy with hobbies. reading. or fixed daily routine d_ adgrfiaatggtom Spends most of time alone or watching TV 9' 33:5 Moves independently indoors (with appliances, It used) Use of tobacco products at least daily NONE OF ABOVE EATING Pnrreatts Distinct iooct preferences 7 Eats between meets all or most days I- Use at alcoholic beveragets} at least weekly HOME OF ABOVE ADL PATTERNS In bodclolhes much of day Watson to toilet at! or most nights Has tmzgulor bowel movement pattern Showers tor bathing Bathing in PM 2" NONE OF ABOVE INVOLVEMENT PAITERNS Daily contact with relativeslctose friends Usuaily attends church. temple, synagogue ietc.) strength in tallh Dally animal companlontpresenoo Involved in group activities NONE OF ABOVE UNKNOWN-Reside-ntrlamlly unable to provide information [:I=Wnen box btorlit. must enter number or letter El =when teller in box, chectt it condition opplles SECTION AD. FACE SHEET SIGNATURES SIGNATURES OF PERSONS COMPLETING FACE SHEET: I .1. Signature of RN Assessment Coordinator Date {lite o'rma|rort accuratfily reIleEi3 re.-Tdr e"r'il assessment or ifaildiff I 615717'? 555 nicrmelion tor this resident and that I coitecied or coontinatad collection oi this on the dates specified. To the best of my knowledge, this iriotmolion was collect in accordance with opt:-iicable Medicare and Medicaid requirements. I Ltndarslend that this information is used as a paste tor ensuring that residents receive appropriate and qualittr care. and as a bsis tor peyrrteri roirt federal funds. Iturtl-ter mdarstartd that payment of such tederat Iunds and continued partici- rmtion in tho health care progtarlts is conditioned on the accuracy and In.lti'iful- 'less at this lt1lorrl1alion,and that i may be personally subloct to or may subiecl my organization to substantial civil, endlor administrative penalties lot' submitting false intonnatlon. I also certify that 1 am authorized to submit this infflimation by this facility on its behalf, Sionature and Title 5 ections D519 05:9 June MUS 2.0 Sdptornblar, 2000 Resident Name GEORGE LARDCCA Numeric Identifier 5030 MINIMUM DATA SET (MUS) - VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING w. SUPPLEMENTAL MDS ITEMS 1. biannual Pruvldarlb the ARD otthis essessrnertlorthe discharge date of this discharge tracking tom: is between July I end Septemtter skIP 10 W3. influenza 3. Did the resident receive the intluanza vaccine in this Vaccine facility inr this years influenza season {Oelclber 1 through March here wan) 1. Yes iinres, go to Item W3) is, it vaccine not received. state reason: 1. Not In facility during this years tlu season 2. Received outside ofthis 3. Not eligible -1. Dflereci and declined 5. Not offered 8. Inability to obtain tiacnhte Pneuat1o- a. is the resident's PPV status up to date? cocciitem Vaccine 1. Yes (II Yes. skip lam W3b) 0! b. If PPV rtc-I received, slate reason: 1. Not eligible 2. Offered and decfined 3. Nol offered tie June 27, 2007 0 I NUiT'lEl'[i: 5030 MINIMUM DATA SET (MDS) -- VERSION 2.0 I FOR NURSING HOME RESIDENT ASSESSMENT AND cane SCREENING DISCHARGE TRACKING FORM [do not use for temporary visits home] SECTION AB. DEMOGRAPHIC INFORMATION IDENTIFICATION {Complete only for stays loss than" days] . as on GEORGE LAROBCA 1_ 5515 or Dole the stay began. Nala~--Doas irracordtvas . . ENTRY at oi' temporary diroharps to hospital', etc. in such cases, use a. [Firm o. (Last) dale 2- i.Ma|e 2.Fomolo I -I -- ILBIRTHDATEQ ]9 H2 Month Day Year um 5: NI 4. 1. American lndlanffiilasitan Native ai. Hispanic 3. Board and caroiaaslsled ilvingigroup nonw 5' 5 a. I:i1l_a3rio hospital MHIDD facility 5. socult. G, u. Soclal sol-.unIy Number 7. Re I u|sl1l--l:I. Modlnaro number (or oompatohle railroad Insurance nurnbarSECTION A. IDENTIFICATION AND BACKGROUND INFORMATION B. MEDICAL 5- . Stat . RECORD N06 Fadara!NoSECTION R. ASSESSMENTIDISCHARGE INFORMATION 7 - 3. DISCHARGE a. Code forrasidonioiisposltion upon 5 No' STATUS 3. Private homolapt. with no home health services - it not a 2. Private itornaiapi. mill home health sunrises 3. Board and carolossisteci living lb 4. Another nursing facility 5. REA5ousTNolo--Oiho1' oodaa do not apply to this 5- FOR 5. hospital, MRIDU Afis?filgrs. a. Primary reason for assossmant I Rahabimaflm 6. Dl:charged--ratun1 not anllolpalad 7. anticipated gnaw" 8. prlorlo completing Initial assassmenl who c- mplolutl a Portion of tho Accompanying b' option" state Edda Ioanify that the lniarrnalinn accurately reflects Iesklant asaman-Ianl or tracking g_ g]5g1.mRg5 Dale of death ordisctlarga Information for "15 roatdanl and that I collected or coordinated nollactlon or this on the M75 data: opooified. To the bosl or my lcnowisdgo. this itlortnalion was mllool in accordance with acceptable Metllcara and Madlt.-nit? requirements. Iundatstantt. that this lnlotmalion is mad as a basis lor ihal rasldants raooivo appropriate anti ouailly oars. andas a basis ior payment from federal lI.lm:ll_ lfutlhar undarntand ihat payment oi such lode-ml funds and partici- pation in tho gouarnmanl-funded health care programs is conditioned on the accuracy md iruthluI- nass orthilr information. and that I may be personally subject lo or may aubjaat my organization to substantial criminal, civil. andfor administrative penalties for suixnitlirIg lala-a information. I also certify that I am aulhorizod to submit this information by this locilily on its bohalf. Signaluro and 'File Sections Data (9 Key items for computerized resident tracking when hot: blank. must enter number or letter Print' Date Marci: 'if, 2008 gfiiysl olalal Y: or wnen letter in boar. clladt if condition applies MD5 2.0 Sepiernber, 2000 SECTION AA. IDENTIFICATION INFORMATION Numeric identifier 5030 MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR rrunsme HOME RESIDENT ASSESSMENT AND CARE BASIC ASSESSMENT TRACKING FORM 1- RESIDENT "mag GEORGE LARDCCA Initial) c.(Last) 1.Mate' 2.Feme|e I 1 3. Jtlfitllh Year - Rnceicfi nar_ 1. American tnctienmlasksn Nature 2. .AsisnIPacii'Ic Islander 3. Black, net of Hispanic origin 4. Hispanic 5. While. not of Hispanic origin TI BOCIAI. SECURING AND MEDICARE HUMBERSGJ IC In 1ulm:ll nan mad.no.] e. Number I-- as 2I5 b. rtedtcara rer or compare "aitrcad Insurance number} FACILITY 7. MEDICAID NO. '1-"if if not a Medicaid reciptentja 3| a. Federal Ne|oIvIs|a|sI4|a|RI I IIJ 9. Signatures ef Peranns sxhe a Puritan cf the Assessment ar Tracking Farm I certify that the accompanying accurately resident assassin em or trading inicrmaticn tt1ts resident and that I collected er cnllactl-M at this trrfermelien en the dates specified. To the best at my Iu-use-ledge, this infennstien was collect in sesordarvcs with applicable Me-cicare and Medicaid requirements. I that this information is used as a basis tar ensuring that residents remive appropriate and quality care. and as a basis icrdpayrnant gnu-n iedarnt funds. I further understand that payment at' such federal funds and continue partici- etiun in the um-ernmertt-iunded health care programs Is cendiucned on he accuracy and truthm at this iniennatic-n. and that I may be personally subject to or may subject nw cruantzatim to substantial criminal. civil. nctfer administrative penalties for submitting false InInl11'laliarL I also certify that I am authorized to submit this information by this facility on its behalf. Signature and Title Sectinns Date REASONS FOR ASSESS- MENT a. Primary reason for assessment 2. Annual assessment 5. Quarterly review assessment I1. NONE CIFABDVE 1. Medicare 5 an assessment 2. Medicare 36 try assessment .1. Medicare so day assessment 4. Medicare 90 cf]! essessrnani 5. Diner stars required assessment 7. Medicare 14 day assessment codes do not apply to this term] 1. Admission assessment {required byday 14) 3. Significant change in status assessment 4. Significant ccrradtcn of prior tutt assessrnent ct' quarterly assessment ta. codes for assessment: required for I-ledicarc PPS or the Star I 5. Medicare readmission/rstum assess-rnent 8. other Medicare required assessment '3 Key items for cotrlputerised resident tracking when be: blank, must enter number crletter Print Date March 11, 2008 When letter in hex, check if condition applies I Complete this rnfermeflan for submission with all rurr and quarterly assessments Admission, Annual, 5! niflcanl Change, state or Medicare required assessments. or Reviews. ctr.-3 MDS 2.0 September. zone - . a Resiuanmame GEORGE LAROCCA Numeric Identifier 5030 MINIMUM DATA SET (MDS) - VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING SECTION W. SUPPLEMENTAL MUS ITEMS National Enter for all aasessmenls and ranking forms. if auallabre. uh ma ARI) of this ur the discharge date: of inls discharge tracking fawn ls betvmen Juty1_and September 30. iklp In W3. 2. Influenza a. Did the resldenl receive the Influenza vaccine in this Vaccine lauility for 11155 year's season (October 1 lhmugh Man:h 31ham wzu; 1. You (If YesInfluenza vaccine not racaruad. siala raason: 1. N01 in tacflliy during this years flu season 2. Ranuiuad omslda of incilfly 3. Nut nigible 4. Dfrared and declined 5. not altered 5. to obtain vacclne 3. Pnaumo- a. Is ihe resident': PPV stalus up to date'? cnccal D. No {IfNo.unI-aile.-n1 wan; vaccine 1. Yes [If Yes. skip ilam W3b} b. If FPV not received, state reason: 1. eligible 2. Offered and dadhad 3. Hal uflerad Print Date March 2003 Regeis Cars Csnfisr Admission Assessment (Comprehensive) (Medicare 14 -- day assessment) GEORGE LAROCCA I ARD Date: S01: Sec Current MGR Current MCD Current Med Rec Date of Birth: Current Room: Signature of RN Date Signed as complete Rugs Score: Print Date: 0512512007 091220925 09122092511 QV63548R 5030 1013011923 585A VENETIA uv RN. 0512312007 RHB Wednesdav. June 20. 2007 I I Itumeric Identifier an-tn MINIMUM DATA SET -- VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BASIC ASSESSMENT TRACKING FORM SECTION AA. IDENTIFICATION INFORMATION 1, RESHJENT 5. Signature: of Perseus who Comptoled a Portion of the Assessment or NAMEE, GEORGE LAROC CA Tracking Form 2 a. (First) b. |MIa'dIe Initial} c. {Last} {Jr!5r} . . I at'nn waseo aazn nee WI Mme 2' Famma I 1 I?M:tdics?e that Intormation is used as a 3 BIRTHDATEQ basis for Ensuring that residents racatva appropriate and quality care, and use basis tar payment tmmfedsret funds. Hurther understand that payments! sutth federal tunds and continued partici- pation in the gavamrnant-lunded health care programs is conditioned on the accuracy and _Mm1th nay ties: ness of this information. and that may be perscnally aublect In or may subject my organization to 4- HACEIE9 1. American lndlanmlaskan Naltve 4. Htspantc 'substantial airninsl. civil, administrative penalties for submitting fatse tntonrtatton. Ialso ETHNIGITV 2. AsIart:'Pat:ifIc Islander 5, vtmue_ not or 5 eorlify mat I am authorized lo submit this Information by this facility on its beharr. I rt In AND 2|5| a. ta. care num if nrcompara Insurance number) "rn1.nuonr oconnor dietitian fr mean . -- - - - we c, PEREIRA an osrzarzuor PROVIDER Noe 0 OEI1 PTIDT l1,c U5I2BI2DDT (219? pend ngcg] recipient} ,r\fl,Ff,U51( '5 I 9 j. 8. Reasons codes do not apply to Ifits form] a. Primary reason for assessment k' 3: significant change in status assessment 4. Significant conectt-on at' prtor full assessment 5. Quarterly review assessment correction or prior quarterty U. NONE OF ABOVE I1. Codes for assossmanla ruquirud Ibr Medicnru PPS or the Star 7' 1. Medicare 5 da an! 2. Medicare 30 or assessment 3. Aflgodfcma gg gay assessment . adtcarta a assessman 5. Medicare assessment 6. other-stats raquirsd asassment Medicare #4 day assessment 8. Other Medicare requtred CI when but: blank. must enter number or tetter Printflara June 14, 2007 ..ey items for computerized resident tracking When tester tn bax.d1et:k irconumon applies Admission Assessment (Comprehensive) GENERAL INSTRUCTIONS Cumptero this rnrormatfnn with all Mr' and quarterly assessments (Admission. Annual, Si Chang 9, stars or Medicare ruquirad assessments, or Quarterly Reviews, are? MUS 2.0 September. 2000 {Medicare 14 - day assessment) SECTION AB. DEMOGRAPHIC INFORMATION GEORGE LAROCCA Resistant l~tu-Inert: Identifier 503-U MINIMUM DATA SET (MDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BA CKGROUND (FA CE SHEET) INFORMA TI ON A ADMISSION SECTION AC. CUSTOMARY ROUTINE 1. Date the star begun. N-ate-- Does not Include we 1. cn tr I: I .lfalt.' tor lion UNKNOWN. nu ma I It! . DQJEREFF closed at otterr.-porary hospital, us: ROUTINE I "3 3 5 Git MW CYCLE or DAILY IEIDIIJITI Stasulataal Iht ft 9 Efijffiy "9 (5-9. 3 37 Fm] Monm Day Year to this Na ps I-egutarty durin day [at least 1 hour - 2. I. t1omalant.wIlh no Home neaI'I'n services I Ia'rl1?'l'6 health IIerr"vic:es mg, Goes out 1+ days a weak . 0 I 4. 'mg group ma Stars busy with hobbies. reading, ortintad daily routine d_ 5. Acute care hospital II My E. hospital. facility a Ratniatlrolrum spends most at time alone or watcl1lrIgTV e_ 7. Rehabilitation hospital 3. other homo] Moves Independently Indoors (with BIJPIIEFICBE. Ii user!) f_ LIVED 0. No 1_ W3 Use of tobacco pn:IdI.II:ts at least daily g_ i fl 2. In nlhertocllity NONE h_ ZIP CODE OF EATING PATTERNS RESIDENCE Distinct loud preferences 5. RE5IDEN- fi'7IucJI_stt settings resident Ituadin during 5 years date at entry nrven in item .481 above) Eats batwaanmaals all or must days I Prior stay at this home 3, Use at alcoholic bevorageis) at least weekly tr in other HUTSIIE heme - b' Qther residential and care home. assisted ADL PM-I-ERHS luring. group home . . setting a, in badclathes rrtuch at day ITI- selling a_ Wakene Io toilet all or most nights NONE DFABOVE Has irregular bowel movement patient 6. CIFEIIME . Bathing in PM .i een two ?cu patlons] NONE OF ABOVE r. 7. EDUCATION 1. No on onI INVOLVEMENT PATIERNS II-flghafit 2. th radelless 6. some college cml1.1t5li'gIcd) 3: E?igh gag? I Daily conlct with friends 3. It. (Code forcanect response] Usually attends church. temple. synagogue (eta) Language Finds strength in faith u- I 0. English 1. spanlsh 2. French 3- Other Daily animal b' whet' sperm Involved in group activilia 9. MENTAL Do IdanI' RECORD 'nrf I I rd ti . 1- HEALTH ma r6 on OF AEOVE HIBTORV D. No 1, Yes UNKNOWN-Rasldenvtamity unable to provide: intormailon 10. all conditions mar are ratatad to status that were manulesred before age 22, and are Jikety to continue indslinrtelyt STATUS Not MRIDD [Skin to SECTION FACE SHEET SIGNATURES mung O, 3 - SIGNATURES OF PERSONS COMPLETING FACE SHEET: 9 mo . I I Signature of sassrnant - I-<35 Ooaacanmmos Ziam cznma. Ooumnmzom man Omfizmfin -. . . mg" m. Emnma mm" 9 mega; umwucmoni mwfinfloam Ea 23% . wmzmioa 233 _umQzmofi Mama; 02:3. . - .- banana>> . mmowmm . .m,1mmn.. waanmma . . Omqm 23% I L, Emma ma 23:3. . . ls.) Regeis Care Center Quarterfiy Assessment (Medicare 60 - dav assessment) GEORGE LAROCCA ARD Date: Soc Sec Cufrent Medicare Current Medicaid Current Medical Record Date of Birth Current Room Signature of RN Date Signed as complete Rugs Score: Print Date: 0310612007 091220925 09122092513. QV6354BR 5030 1013011928 528B ARMINDA PEREIRA RI 08/101200? RHC Friday, September 7, 2007 0 Numeric Identifier 5030 0 MINIMUM DATA SET (MDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BASIC ASSESSMENT TRACKING FORM JTION AA. IDENTIFICATION INFORMATION 4. carractlun DI prlor full assessment. 5' Guirtariy revlew assa ssrnenl 1D.SignI'I'nt correction In! print quarterly assessment 0. NONE OF ABOVE b. Codes fur assessInen1s required for Medics>> PPS or the Slat - Medicare 5 assessment 2. Medicare SD ay assessment 3. Medicare 60 day use ssmenf 4. Medicare 90 day assessment 5. Medicare readmissiari/retum assessment 5. Duierstate required assessment F. Medicare day assessment 8. Other Me required assessment GENERAL INSTRUCTIONS Complete this Jnformarrnn Iarsuhmisston with air fur! and quarterly assessments Annuai, Change, state or Mudtcom required assessments, or uanerty Reviews. em. E1 Key Items tor computerized resident trad-ting when box blank. must enlet number or letter when letter in hex, check it conditlon applies MUS 2.0 September. 2000 Pn'nt Date August 1 7, 2007 (Quarterly Assessment (Medicare - day assessment} 1_ Tfignaturas or Pctsuns who a Portion oflho Accompanying Assessment or NAMEQ GEORGE LAROCCA Tracking Farm i- In-Ia>> mu I we 2. GENDE 1_ Male 2_ Fgma|g 1 app cane Ia icare dicaidraquiremanis. un erssn a nonna on was ass 3. urII'tat'dt bsift: I I 0| |3 Ifll Mm"! Dav Yam pstlun in the grwarnnient-furided progrelms i: on Iigeenaccureasy HACEIQ 1~ Amema" NBIIV5 4- I alse ETHNICITY 2.Aslar|IPacIflc|sIandar 5. While. not or 5 certify Inattam authorized Iusubmil Ihis iniumlnlicln by on its behalf. 3. Black. not or Hispanic origin HISPENC . 5. SOCIAL a. Social Security Number I a. IJ. raTIrI:5' Insurance number) I 019ocunnur dietitian OBIDW2007 . G. n_ We PTIDT . I b. - I Ramlre Mgg?quk N1ALN LCSW bi>> Ins E1 E2 in aaIa9I2oo7 CE4G1267H1 namgyzaov 7. MEDICAID qfs..-- reciprenrf' . J. B. fiegsous codes do not apply In this [am] a. Prin1a_ry reason tor assessment MENT 1. Admission assessment [required by day 14) 2. Annual assessment 3. mange In status assessment ltastcient GEORGE LARUCCA Numeric 5030 MINIMUM DATA SET (MDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BA CKGROUND (FACE SHEET) INFORMATION AT ADMISSION SECTION AC. CUSTUMARY ROUTINE I SECTION AB. DEMOGRAPHIC INFORMATION 1! one or ENTRY Doie lfio slay began, More -- Does not include FEDCIFIJISSIGN ramrd was closed at time orlemporery discharge to hospital. etc. In stroll cases. use poor adntission date 0 Month Day Year nominee ENTRY) 1. Private homsJr.Ioi.w1'Tn no home heaiih services 1 2. Private nomala pt.with home health services at. Eoarfiarfil home . urs onto 5. Acute care hospital 6. hospital, MRIDD facility 7. Reh b'l'tat' no 'tal H. Olhl: I I in 3. LIVED ALDNE TO CODE OF PRIOR PRIMARY RESIDENCE 0. No Yes 2. In other 9" RESIDEN- (Chocir all resident lived' in during 5 years prior to data of entry given In item A51 above) Pria slay at this nursing home 3' Stay in other nursing itome Other residential and care home. assisted Iiulng. group home Is. MHl_neychIa|rio setting MFUDD setting NONE OF ABOVE 1, LIFETIME UCGUPA - Eu: he can MD ntpetione] {Highest LovoI COITIEIB . a nice Gadgets deggce . os olng 2. radetlass grades -Ll-lrgh school LANGUAGE (Code for correct response) a.Primary Language 0. English 1. Spanish 2. French Other 9. MENTM Do-es re_sident's RECORD Indicate any history ofmental retardation. HEALTH menial Illness. or developmental disability problem? o. No I. Yes. 0 CONDITIONS [Check all conditions that are related to status ml were TO beiore age 22. and are likely to cortlinue indefriiteiyi 13 status Not MRIDD {5|ripioA31$) 5 3'1 MRIDD with organic condition Down': 1'1. Autism Epilepsy cl. Other organic condition relalncl to MRIDD e. MI'-tl'lJi2l with no organic condition 1 -- 7 11' TIDN Month Day Year COMPLETED I cul- . fchocir all that eppfl-.il' all information fast has only.) Tl rm Wanda! CYCLE OF DAILY EVENTS Stays up late at nlgI1l(e.g., alter 9 pm) Naps regularly during day [at leastl hour) Goes out 1+ days a week Stays busy with hobbies, reading. or fixed daily routine d_ admitted from anotirer Spends most of time alone or ours to home Move inriepertdentiy indoors (with appliances, It used) Use of tobacco products at least daily g_ NONE OF AEICIVE EATING PATTE Furs Distinct food preferences 1- Eata between meets all or roost claps I- Use oi alcoholic beverage-ts] at least weekly NONE OF ABOVE ADI. PATTERNS In bedclolhes much ofday Wekene to toilet all or most nights Has irregular bowel rrmrernent pattern Showers for bathing Bathing in PM NONE OF ABOVE MENT PATTERNS Daily contact. with reialivoslciose friends Usually attends church. temple. synagogue {etc.} Finds In faith Daily animal companlontpresonce Involved In group activities NONE OF ABOVE UNKNOWN-Rosidanuramlly unable to provide trriorrnotion SECTION AD. FACE SHEET SIGNATURES SIGNATURES OF PERSONS FACE SHEET: cer 3 accompanying In orm niormatlon for this resident and that I collected or dale: specified. To the best ti my this i Medicare and Meclicaid requi-ementa. I understand that this intormaiion is used as :1 deals lor ensuring that mm federal funds. I lurther understand ii1aI paymnt at such iodarel funds and oontinued particl- ootion in the government-funded lteailh care programs is conditioned on the accuracy and of this end that i may be personally sI.Ii:IIeol to or may sublect my organization to criminal, adrninisiralilra penalties :erlil'y that I am outta:-rizod lo subnii this intorrnata'on by this facility on its bohail. rest a Ing I led collection at this on the is lion was collect In accordance with residents raciue pproprlale and quality care. and as a basis for payment at ialaa InionnaLion_ laiso b. Signature and Title Ssdions Date :I=wIIan be: blank. must enter number or letter =wrIan letter in box. check if condition applies Print Date August 200? tiiuarterly.-lissessmeot M03 2.0 September, EDOD {Medicare 60 - day assessment) PPS ASSESSMENT FORM i'-itmerit: Identifier 5030 Print Date September 07, zoflfiluarteriy Assessment (VERSION JULY 2002] A53. - lived 5 years pno.-to date at entry) MAKING {Expressing infonnation contort! -- trot-raver able] a. Prior slay at this nursing home SELF uunen. 0. UNDERSTOOD 5 'Vegas b. stay In other nursing home 31009 1. UNDERSTOOD - titrficuily finding words or 1' ta 5 o. Other residential - board nti care home. assisted living, 2. SO UNDERSTOOD - ability is limited to matting concrete 3 d. MHI setting Undemianfil content HOIVEVEI able e. MRIDD setting C6. To ng UN DER- G. UNDERSTANDS e. NONE OF ABOVE STAND 1. USUALLYUNDERS TANDS-rrtoy miss some perliinlenl oi' IDESEEQE A1. GEO-RGE Lpaocca 2. SOMETIMES adequately to simple. NAME direct cumrnunttallon it. (First) In. {Middle initial) {Last} ii. 3. UNDERSTANDS A2. RDEFJT D1. fifilltiyto see in adequate light and with grasses it' used) W-=n FIZ tats I i - sees fine detail, including reguiar print in A3. AfiflSElil5TS- a. Last day oi MD5 observation period newspapemhooks REFERENCE 1. IMPAIRED 5335 large print, but not regular print in DATE 5 0 0 7 newspapers! books Monih Day Year 2. MODERATELY IMPAIRED - iitrtileti vision: not able to see newspaper headlines. but can identify objects I DATE OF Data of rsonlry lnom most recent discharge to a hospital in 3, HIGHLY IMPAIFIED - Object identification in question, but FIEENTHY last an days |or sinoo lost assosst-ont or an-risainn if loss than on days} eyes appear to gbjetts 4. SEVERLY INIPAIRED - no vision or seas only light. coiors. mi] of shapes: eyes do not appear to follow objects Month Cia Year INDICATORS (Coda tor indicators oiitservod in last so days. irrespective or the A5. MARITAL. 1. Never rnarrleti 3. W'idi2i'oli'Bl;| 5. 1 E1. 01: assumed causa} . STATUS 2. itrlarned 4. Separated DEPRES- 5101.]. ti. indicator not In last 30 days 1. indicator of this type exhibited up to 5 days a week I I I I i ll REESRD 2. indicator of this type exhibited daily or almost daily (6.7 days a week{For thoso mm; with supporting dncumontniion in the medical op 9.51-H555 lufiapotitlva health DIRECTIVES sllook all that apply] complaints-6.9.. . . 3- porsisienity seek: medical b. Do not resuscitate c. Do not itoapttaltza siafinrtenmi-3.. obsessive siatomo dtssemrbia consciousness} Mr B1. COMATDSE ha . i. ti. No 1. Yes (Skip to Section G) fa" 5" long: Let me die i. Repetitive anxious MEMORY 'Recah' of what was ioarneo' or itnownj (non- b. Rapaliiwa questtons-en. health related) a. Short-tonn memory to recall not 5 mhuias *toumr? .19 99; what do sagas attmtigg-.1 0- OK 1- METHDIV ac?" taassuranos regarding . schedules. meals, c. ,_1uming_ I-E|aflnI-Ishlp 133,5, in. L-ong-term memory Git-seat-rtsloppears to recoil long past out tor ht3Ip_ Merit-or 1. =tt.s.-n 41 =tt [I-gmthagp me--I SLEEP-CYCLE ISSUES B3. ljhal reside was untrue ya - - to mull during 1. Unpiaasa .1 mood in as tiys . morning 3 ti. Persistent with 5 it A ILIW a, Current Season d. Thai hat.-the is in a nursing home 8 Lhsomnialchango 'n usual 3 la 11 to. Location of own room E-"germNONE OFAEOVE are racatrea 9" SAD. APATHEHC. Amtrous man' flamafifacas anger at corn APPEARANCE Elli. COGNJTITFE (Made decisions regs ing tasks or' ti'at'iPTr7a) 58'' 1- 536. Pfiififid. 13653' SKILLS FOR am notlwingbffl1_iVS 1. duilicuiiy in new Si|l.|E|liDrI5 ieariulness (3 Am" 2. MJDERATELY i'MPAIFtED--dacisions poor. cuesisupervision 1. Expressions of what Repetitive physimi I PAIR I I appear lobe unrealistic movement-e.g.. pacing. - -- fears-o.o., roar ol being hand wrin?iiI'IEl. restlessness, 2 ..lDlGATORafC'ode for behavior in tire last days} (Noramccut-are litigating. plotting DF conversations with staff and family who have direct knowledge LOSS OF INTEREST DELIRIUM orrosidanrs hobs-vior over this time}. - pggtoptc I g. Recurrent statements that o.VtfithdrIwaI trorn activities of argon. D. Behavior not present something is about lntornsi--a.g.. no interest In 0 DERED 1' "01 . to happen-e_g_. haiiavas long standing activities about to die. lJali'1Q\\'iBliamih'flriend5 0 9 ng ha" 3 amid' p. Reduced social DISTHACTE difficulty paying attention; gets . . sidetracked) E2. Man it One or more indicators of depressed. and. or anxious wars PEi'-l5lS- not ttaslly oltsrod by attompts lo "I:t1oerup". console. or roassuro we so assent: behaves haisha is somewhere else; contusas and mood 1 'minim! pram" 2 mdjwors pmsem 1' lndicztlors easily altered I not easily altered QEPISDDES DF DISDRGANEZED speech is incoherent nonsensical, irralatranl, or rambling [tom subject to subjeI:i: loses train oi thought) Ftdgetlrtu or at skin, clothing, changes; rapalttwa physical movements or ng on tt. PERIODS OF alu-ggishnass. staring into space: tiiffiottll to amuse; little body rnottmeni) f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE DAY-ts.g., sometimes boiler. aotnoiimos worse; bahviors somoinnes present. somafrnos noii MOS 2.0 PPS Juiy 2002 (Medicare E0 - day assessment) Human! GEORGE LAROCCA Nummic ldmufiu 5030 (Co a or rial trnrig a in lie 3! tips 4. BEHAVIORAL froqum-icy in loo: 7 days G3, TEST FOR 1- aflnavlnr fled H1 Ias=d71cier? ,3 BALANCE I13. flah?algedbposlmanlas I . I It . oavioro its occurro again 5 as . ns a uo corp am so ou sicasu 2. Bahsv_ioi- oi this occurred 4 to 6 days. but less lligndaily {son training 2. Partial piyiyslcal suppuii during last: pp 3. Bi-havior of Inns type Dccuned daily siands does oi iollovfi oifaci ris ior last 3. ol able lo all lost thou ya cal ail: mplom in last 7 days . Bahovlor rloirpraiiani DR behavior was altered 1. Behavior was not oaaily altorai: a. Balanca while 0 ti. Balance while suiting-position, lninlt oorilrol [1 a. WANDERING {moved with no rational purpose, rraarriinghr oblivious to needs or solely} FUlv<:iiCli1AL (Code Mat 7 days that interfered i-irifi Early or IN ac-ad resident or rit-lr or ABUSIVE BEHAVIORAL (othors RANGE OF RANGE OF were threatened, soraamad at. curs-ad oi) OTIU "on MOVEMENT . El . it. PHYSICALLY ABUSNE BEHAVIORAL (oli-ions ware 1, Llmlatlan an one slde 1. Pgrfiasfioss hit, shovad. scratched, sexually abuiiadj (Hi a. ai: at 0 -[made disruptive soiirids. noisinass. b. Arm-Including shoulnar or elbow sell'-abusive acts, so: all tioha 'or or disrobhg in public, . srriearaclitriraw luu:ltl:ciis. huavriflr-ig. lummrigati through others' o. Hanrl-including wrist or ringers 0 belongings} ii. Lcg--inc|uclng hip or knee 9 9 a. RESISTS cARE{ros:s1odtolilng ia. Foot-lncluiilng anlilo or loos a 61' in} ADL PERFORMANCE oven ALL "r ms 5 0' during last I clays--No.l insiuoing saint?) G6 OF (Cri so}: if a pifed in last 7 days} LUCDMO11 1. help or provided only 1 or 2 times rm b. Wiiooled salt during '35! 7 flats GE NEODES OF Cliiaagm iialfl' at apptig Euririg last 7 do at a a or ri-ios mo Ifi 1. SUPER oncouragomoril or analog provided 3 or more times during TRANSFER last 7 days-OR--5uoarvisicn [3 or more ilri-res) plus physical assistance b- B95 73"" "595 he" provided only 1 or 2 limos duririg last 7 days mubiily or lranaiar 2. l.li|l.iiTED highly involved in activity; received physical halo in GT me or tiiamo Id v.ira'ra orouzan into subla 5 unntl 351 dad ribs cine 3 ii a ras anicou aorrn Tloiil 3. EXTENSI vs pisrfoniiad part at aoii-try. oiiar last 7-day H1- CAT 5'30" 55 3 (code ror PERFORMANCE ovzn ALL SHIFTS) 53" during liar? (Dill '95! 7 5315 D. use ofindwaliinp r.r.ri'nary catheter or oslorny TOTAL ataii perloniiance oi activity dunno onllre 7 days as not 5 W3 00" 1. USUALLYCONJTNENT-BLADDER, 'soda It 1 3. ACTIVITY pro NUT ocoun during oniirs 7 age aow?r., less than ii-aarriy mcamu"355 ial 2 or more times a wall bul rioi daily. . paiformance classification) 3. FREE UENYLV LADDER, lariciad to ho lni:ont'nenI daiy, but some help ii"-rm will rs.g., on day sriirr): BOWEL, 2-3- limos a mseir 2. One person physical assist a_ par action, riser; mg mg 4. i_:onirol BLADDER. rnullipla daily episodes; 3 Tv.n+ par-sons phy5ica| as?i5| Occur dun.-lg an"-9 7 day; BUWEL. all {or almost all} lli'i'i*E a Eclgifliifilfl Control of bowel inovgrnanl. with appliance or bowel coritiniinca - or am-, I a. Moslifiam How ranisni moves in and iron lyiig position, turns side In aisle. hlEm[:E Ow amp' ye ti BLADDER Coniml oi urinary bladaiar iuricliori dribblsa. voluiio insufficient to ti. TRANSFER How rssioanl balwaan surfaces-toliroin: bed. chair, 3 2 sioukilirougli underpants), with appliances loley) or conllnonoa 4 wheelchair. standing position (EXCLUDE ioilrom tiaihlloilat] BDWEL c. WALK IN . 2 H2 ELIMINATION c.Diarrhea ROOM Ham Lfigpgom \gal|_5? glggogan lolions II1 hi.-ether cl. Fecal Ir-npacilon d. WALK IN Howrasiderii walks In corridor on uriil 3 ct?l)lElgfiEc))R I "Ema nd H3. CE is. to: linp calfioiar o. - ourrasldaii movos between oca ions in 1 rronni a -- A 1 TION adjacent corridor on same floor. If in whaolahai, pnoenpu Baaiilaooar ralralriing program ofl onoo in chair . a" 1 In i ioslrirny present 110 How rosin-an_l movos_lo and raii.ir_ns from all unil locations For Section I: aback only those diseases that have a rclationslilp to current ADL status, cognitive UNIT mrfiisnsot aside l'o;3ming& aouihiliios, or ll' lty has I slalus, niedlooi lrsalnionls, nursing monitoring. or nsli of death. [Do not 5 9 HB ODT. I'fl'5l an ram ISIBI1 -0 he oor. Iiin wh icrialr sIl- iiliicle I a - d'IBif I1. DISEASES a. Diaholas maliilus v.HerniolepiaiHemipsresi.s DRESSING How rasloanl puts on, fastens, and lakes of! all iloms oi . An ad sclerosis ri|- --.-. I'||ll 1: . Efi Bruin 88 I I LASHD) I-Parapleaia EATING How rsaidanl oats and oriniss of skill iI1CiUdE.'l5 intake or nmqiahrnent by other means lube leading. lot.-.il parameral risan z.CIuadripIegia QIJEI IDD I.Por'ipi1r3raI vasciilar disesis e-afilepression l. TOILET USE How issidaril usoa the mint room [or oornmoda, hodpam urinal}; transfer or-Joli loilat. oacl. manages osiorny or m.Hip lflillanic oapressiva (bipolar adjusts ofolhos din-,3; mphasia PEREONAL hyglifna. including cnrrihirig hair, ca ml ingtao . ii win .a ma ai.i inp lace, 5. re pa sy hands, and pairinum baths raid showers) I-ih_Aothma A G2 ri i 2 tho NONE OF I1 I 5 all'. Coda for roar do - in "9 A I curios apparoaloor aihnlibiolic rosislonl 'rnleotior septicemia Meihlciilin resisloril lronsiriitlod disease 0. Independent-No help provided ii) 1. lialp only 4 dill) iTi.rberculosis 3 2. Physics: help limits to lransler only 3. Fli slcal help In part of batl-ii-lg aciivily '.Ur'nary lraroi iriieotion in lost it. To Ide once 35 day; 8. Aclivily aaifdid not occur during entire days d.HlV i itviral hapalitilua G. |Woiirid lnlaciian r. Respiratory lnlac-Jon n-im_i3riiF nit r:il=inirr= MUS 2 0 PPS July 2002 Print Date September 07, 200DuarferiyA9sossmel1i {Medicare 50 - do assessment) i Prir! .0335: - 1n" :3 OTHER J5 '(Fi5reach type ul' ulcer. crude forthn lilgiiasfslago in ilreiasr 7 days . CURRENT 298 9 ULCER using ace in riem is none ages 1 i DIAGNOSES 3- a. Prassizfi ulcar--any Ieslnn caused by pressure rasulling in damage of underlying iissue 0 h. Slasls lasion caused by poor in the lower cred: all problems praaerll in rear 7 days Lnlass other iirne lrarna is inciieemi) NDJTIONS -IISTURYUF NUICATOHS or FLUID omen -- M3. Resident had an ulcer lhal was rasolved urmred in LAST so DAYS TATU5 ULCER5 I:l.No 1. Yes aflalusmne M4 JTHEWSKI A . a. lwasaons, rulses 9-Efl?mfi PROBLEMS a.We|ahl gain or less or 3 or an Lesions: 01' third defifflfii 3 74"' :.Dpan lasims other ihan ulcers. rashes. curs cancer lesions] [Check n" d.Rasi1es--a.g., eczema. drug rash. heat rash, herpes zbsler l:.InatJiliiy in lieu rial clue to |'.lnte mal bleeding Ifllaf appry e.Sliin desensitized to pain air pressure ha 1: . 5 rinass oi ramh Mm - 7 [Slum tears orculs (olher lhan surgery) c. Deb;-draied; aurpur in 1&5' 9? gfiumlcal wounds axaeads inpul Lshurinnss of breath I NONE OF ABOVE I. fluid: did NOT rzunslaadv gait M5. SKIN a.Pressura relieving deviaalsl ehalr consume alilalmosl all TREAT- . Iiquidn provided during la" I-.-.Fressure relieving davlcai.-ll for bad 3 flay; [Jl'Dfll'Bl'l'l 8" or hydralicn intervention in manage skin problems . that apply 5 PAIN Code the highasl it-val cumin present in me last 1' days res: 7 :1 OMS 1.5 'cal cl car u. nzrsoueucv which iv. INTENSITY of pain 1: 9, I . mime" "mph" 9, . of dressings (win-i or wihoul Inpical medications) qlhar shows auiclanua oi pain pain [skip In J4) 2' Modmam Fain impp callnn ans lolharlhan in last) I i.0lha." or pwleclwe skin care lnlhar Ihan in rear) 1' Pm" '"55 3. Times when pain is horrible wows OFABCIVE -L 2. Pain daily nr . oas, pain 5 ura AND CARE uiih-3 oaliulitis, J4 ACCIDENTB {Ch an um a I c.0pen lesions an ll-re real . pp in 15? during last 3' dflailsiliuses lrimmed during last all clays .Fell in past 30 days :l.0lher fractures in last 1110 days) . . . dayn loot cam la.g., used Epsnlal l:l.FeIIin past 31 - urn days it or-' naovs I J54 STASFW msidanr' cognitive. Am. "mm or of dressings lwrih tuplcai medications] patterns precarious, or clelerlorallng] or-* Aaovs .: . b.Rsiclent aarparienci-lg an acuie episode or Iara-up of a racwranl ii Br llrabhm N1. THEE (Ch ecir appropriarn time periods avnr inst 7 days) disease, IE or iewar to live AWAKE Resident awake all or most or rllna {l naps no more than unu hour mar ilmn>> rm-inrli in or= ABOVE aMam1ng ORAL a.ChawIng problem PROBLEMS b.fi-rfternoran OF ABOVE prubiam N1 MAE KL HEIGHT eoord Ia.) height in inches and lb.) weight in pounds. Basra wBi_;hi on most TIME - AND recent measure in last no days; measure weigh! consislanlly in accord wiih LVED slandarcl faciliiy praclica-9.9.. in am. allar voiding, beiore meal. with shoes 3- mill [01. NUMBER [Record um umber enler if none used} K3. as or more in last days; or or more in last. mE|3|cA. CHANGE clays finus D. Na 1 . 'res 03 NJECTIONS [Record tin: numimr of DAYS of any iypa rocmverr during . ma! I "O'l'f in. Weight galri-5% or more in last 30 days: or 10% or more In Insi as an' an ar mm Used) 130 04. [Rn curd mu number or DAYS during last 1 if no! . - En' _fiU1,fiL_. E: at app 1' days] I THE used 1 acting rneds us less a weeklyHypnotic .*PRoAci-l- a.ParunleraillV man a planned walghl chang EDICATIDH b. An! 0 e. Diuretic hfavading lube 1] 6 TERAL {Ski Ia Soclicm {In i aria nor - - as P1. CARE-- Enact lraarmenrs received during DR ENTEHAL n. ads the prnporlion al total salorlas Ills rsairianl received lhrough TREAT- the fur id day: INTAKE parenteral or lube readings in lha Iasl. 7 days TR EATMENT5 PROGRAMS 0. Hana 3. 5 1% lo 75%. Du 1 g. $3553 233%" 4. '?656 In 100% AND b' I - Ggifis umalysis lrealmenl . Code Ihe average fluid inlakn per day I36 IV or lube in last 7 days Pmfiram 0. None 3. 10 I c.lV madlcallnn I. 1 In 500 cclday 4. 1501 10 2000 cc-Jday 2. i:l.lntalreluu1pui special care unll M1, ULCERS [Record the numbers! ulcers 31 each ulcer acula cause. lfnann prnsanr at cl stage. mmni cc-ciaall llial apply medical condition u.Ho5plr:a care [Dun In any during first 7 days. Code 9 9 [Rnquirn {uiihudy exam] cagsul l.Ds1l:my care p.PecllaIrrc ll. Slaga 1. araa oi skin redness a break in ma skin] Ihfli does not disappear when pressure is relieved. UTETBPY Siege 2. A partial loss of skin layers that present: r.Training in skills required in clinically as an abrasion. blister, or shallnw ualar. I sudiunmu {stills IE-9-. . ouse c. Slaps 3. skin isalosl, eiposirqfi the rlfinculamaus ]Tracha? mm? ssues - prasen as an era er wl nrw: nu . 5 care ii ci I . 3 me OFABDVE cl. Slaqu 4. A lull ihudrnass nl slim and subcutaneous lissua is lost. emnebg muscle op bane. LVBI'llIIaiclr' Dr rasplralur MOE 2.0 PPS July 2002 Resident GEORGE LARUCCA Numeric idantrtior PE. PHYSICIAN In the LAST 14 DAYS [or since admission ll less than 14 clays in ORDERS facility) how many clays has lire physicdan (or euthorlzed assistant or - practitioner) changed the residents orders? Do not intrude order renewals without change. iEnier tr if runner a. Resident expressosrunctioatea preiareracs to return to the community - - POTENTIAL D. No 1. '(as c. Slay projected lo he or a shall -duration-discharge proleclecl within - -- 90 days {do not include expected discharge duo in denim O. No 2. Wrlhin 31-50 days 1. Within 34] days 3. Discharge status uncertain OVERALL Resident's overall level of so! surficiency has changed sigflcontly as at CHANGE IN oempered to status ol9U days ago lorsinoe last assessment it less CARE NEEDS titan 90 days} 0. No change 1. lower 2 Deteriaratedracaivas supports. needs less more support restrictive level ol core 0 R2. SIGNATURE or sensor: OODRDINAT THE ARMINDA PEREIRA RN 11. Signature of FIN Assessment Coordinator (Sign on above line} RN Assessment Coordirtalori 043' I1 I 0' 'rear practitioner] ertantinecl IPIE resident? {Enter none) P1. b. THERAPIES - Record the nufier or days andtolalmrnuras each of the TREAT. loflotving therapies was {for of least 15 minutes a day] in the last 7 calendar days (Enter 0 if none nrless man 15 rnin. daily} pRgcE_ [Nn1n--?ount only post admission therapies] AND A if of days administered lor or more tel {Bl OGHAMS total mlnules pmvicbd in 7 days a. Speech - language pathology and audiology services 0 tr. Occupational therapy 6 1 8 0 Physical lherapy 6 1 0 d. Respkatnry therapy 0 0 0 In o. therapy (by any licensed mental I 0| at P3. NURSING Record the NUMBER OF 0.4! each or the rurlon-r'ng rensbililailon or fi.EHAa|LrrA. techniques or act.-cos wasprovldod to Ur residents for TlElNr more than or equal to 1 minutes perdoyln the Iris: 7 days WE ARE {Enter 0 if none or less than 15 daily] a. Range of motion [passive] 9 5. Walking (3 I1. Range or mollcn {active} 0 9. Dressing or grooming c. Splint or brace 9 h. Eating or swallowing TRAINING AND SKILL I. can [3 PRACTICE IN: cl. Bed J. 0. Transtar k. Diner (Use F53 codes for est 3' days.) P-I. DEVICES AND 0. Not used 1. used less than daily 2. Used daily Bed rails a. bed rails on all open sides ol bee h. types of side rails used (eg, hall real, one side} Trunk restraint cl. Lh'rIb restraint is chair prevents rising 0 i ISICIAN In the LAST 14 (or since admission if less Ihan 14 clays In VISITS Iacilitr] how many days has the physician {or eulnoriced assistant or 0 signed as complete Month Day 5151;: mains: HHS rs a Monitors 5 day or Medicare readmission! T1 SPECIRL return assessment TREAT- MENTS AND FROG E. physician ordered any of the DURES lolowing therapies to begin in FIRST 14 days ol stay-physical therapy. occupational therapy, or speech pathology service? 0. Na 1. '(as :.Tl-trough day 15. provide an estimate of in number nl clays when el1r3esl1 lhorapy service can be expected to have been delivered d.Thro-ugh day 15. provide and estimate of Ihe number or lrretapy minutes (across the therapies} that can be expected to be delivered. CASE MIX Medicare Slate GRDUF Print Date September 07. 2007 Quarterly Assessment runs 2.oT=T=s July zoo: (Medicare 60 - day assessment} MOS 2.0 September. 2000 ResideniNom I ARDCCA Humoficiflentfliaf SECTION 3. SUPPLEMENT-MUS 2.0 (NEW YORK) 1' Enter currentnumber. Foliow lnsimction in the manual. 0 5 2. PRESSURE Record the appropriate response. Stage 3 out pressure ulcer 4 ULCEHS sites present upon admission or readmission. i. All currently reported sites were present on admission or readmission 2. some of the currently reported sites were present on admission or readmission 3. None of the currently re ported sites were present on admission or readmission 4. No stage 3 or 4 sites currentiy reported 3. SUBSTANCE Substance abuse hlsiory. Has the resident with HIV engaged ABUSE In substance abuse behaviors more than one month ago which continue to influence care curreniiy given to the resident? Record the appropriate response. 0. No 1. Yes 2. Resident does noihave HIV 4. DISEASE Record only those disease diagnoses that have a relationship - DIAGNOSE to document ADL stems. cognitive status, mood and behavior isiatus, medical ireaimBnIs_ nursing monitoring. or risir oi death during the last 30 days. (Do not fisi diagnosis}. {Check air that appiy) HIV dementia HIV wasting disorder following organic brain damage organic brain damge Spinal cord injury Hemlplegie Hemlpareses Hunihglorre disease Dementia Registry Reporting 1. County (FIPS) code oi prior residence 2. Physician license number 1. NONE OF THE ABOVE inflate September 07, 20tIJuan'ariy Assessment {Medicare 63- day assessment) Reeident Name MINIMUM DATA SET (MDS) - VERSION 2.9 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING GEORGE LAROCCA Numeric identifier 5030 W. SUPPLEMENTAL MUS ITEMS 1. National Provider ID Enter [or all assessments and tracking terms. it available. It the ARD or this assessment or the distztiarge data discharge tracking town is between July 1 and September 30, skip to W3. influenza Vaccine a, Did the resident receive the Influenza vaccine in this tor mis years influenza seesun [October 1 through March 31item W213) 1. go to Item W3) D. Influenza uacche not received. slate reason: 1. Not in laatiity during this yeafe tiu season 2. Received outside at this facility 3. Not eiigibta 4. Ciflered and declned 5. Net offered 6. Inability In obtain vaccine Pneumo- cnccal Vaccine a. is the resident's FPV status upta crate? D. No item Wain) 1. Yes si-tip item WSIJ) D. It PPV not renewed. stale reason: 1. Nat eilble 2. uttered and declined 3. Nut ofierecl at Date September 07, Assessment {Medicare 60 - day assessment) MUS 2.0 May, 1005 Rega?s Care Samar Quarierfly fissessmeni GEORGE LAROCCA ARI) Date: Soc Sec Current Medicare Current Medicaid Current Medical R?cord Date of Birth Cu Room Signature of RN Date Signed as Rugs Score: Print Date: 091220925 091 220925A QV635-48R 5030 528B VENETIA UY RN. /1 110912007 PD1 Wednesday, November 14,2 MINIMUM DATA SET (MUS) VERSION 2.0 FDR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING Numenc Identifier 5030 BASIC ASSESSMENT TRACKING FORM AA. IDENTIFICATION INFORMATION 1. Medicare 5 da assessment . Medicare SD ay assessment . Medicare 60 day assessment . Medacare 90 day assessment . Mecficara assessment . Other stare reqmrad assessment . Medicare 14 day ssassmant . other Ivlsdicara required assessment 9 Kay items for computerized resident tracking I: when box blank. must enter number or letter IEIE when I-aner in box. check It condition applies Print Date November 14. 2G07EJuan'srIy Assessment RESIDENT 9. Signatures t:IPursunswI1u Cornplaittd a Purtlun at the Accompanying Ansossmunt or GEORGE LARDCCA -- I rt'! It: I Inf mat' Isl refi ct 'ct la sesame a' 'Hm: ?'I"a51) 1 It Mae 3 Female I 1 dates apeciliad. To best-nl my knowledge. this IHIEIFITIEIIDI1 was cnliaclatl in accordance with applicable Medicare and Mudicaid tequiramenls I understand that this infatmstiun is used as a mwes rorI1 paymen u_su anuo garner HE-Panic andfor admirtisirative penallies for submitting larss information. I ran ETHNICITY 2. Asiantpacuic Islander 5, mule. I101 5 cafiify Ih-3| Iam atrthorized Ia submit this ittlurrnaiion by faclfily on its behalf, 3. Black. not of Hispanic Origin 0 . 5383;?' nl social Sammy Number Sxgnature and Title Sections Dle II--I 1-: I II MEDICARE ":91 22 09 2 5_ NUMBEREEI rare number or comparame tauroa numberucanrtor dietlttan /r k1-ks 1110312007 c. a_5,a1ENu_ PEREIRA BM . N0Motazpme 111031200? I I KMcNab SW waazzoor 1| 1. MEDICAID PTIOT . :3 Ia. woarzoov Shin Scull N1-2 per; 119. . I. recipient I. Rggsous mdes do not apply In Ihis form] a. PrImsry_reasan {or assessment k' 1. Admission assassrnent [required by day 14} I 2. Annual assessment 3. change In slalus assessment 4. Signllicanl of print fuil assessment 5. Quartany review assessment 1D.S'tgnIfIcanl correction or prior qflfinerly essessmenl D. NONE OF ABOVE b. codes for mqutrud for PPS or that Stat GENERAL INSTRUCTIONS Comptam this In furmatfon for submission wilh -HIP um' and quarlarly assessments (Admission, Annual, 5! Cltangu, stain or Madfcara mqulrad or Quarterly Ftovlaws. arc. MDS 2.0 Seplember, 2000 I - 'Rem-_ GEORGE-LARUCCA ldorrtliior 5030 MINIMUM DATA SET (WIDE) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND ones SCREENING BACKGROUND (FA CE SHEET) INFORMA TION A ADMISSION AB. DEMOGRAPHIC INFORMATION SECTION AC. ROUTINE Dare the stay begflil Nata Does not include readmission if record was - closed at time of temporary discrrarge to hospital. etc. In such cases, use prior adnrission date 0 5-I1I - Month Day Year 2 ADMITTED 1. Private homeieol.-.vith no home health services 1 I FROM 2. Private home health services 3. Board and Iivingigroup home 4. Nursing home or Acute care hospital ti. hospital. MRIDD facility 7. Rehabilitation lioapitai B. Other LIVED 0, ND ALONE 1_ yes 0 - 2. In other Iacllity ZIP CUDE OF . PRIOR PRIMARY RESIDENCE - {Clirrcir all settings resident lived in during 5 years .on'or.I'o date or entry given in item A51 above) SYEARS Prior stay at this nursing home PRIOR To Stay in other nursing home ENTRY (_JIhar residential and care home. assisted living. group home settinig MRIDD setting NONE OF ABOVE 5" 6. LIFETIME OCGUPA - TIDNISI in he ween two occupations] No schooling {Highest 2.8lh radeilass 3. 9-1 grades 4. B. LANGUAGE {Code rbrcarracl response) Language 0. English 1. Spanish la. It other. specify I 5. Tee nice or 6. some oolle agree 8. Graduate degree 2. French 3. Other ll Does resident's RECORD history at mental retardation, HEALTH menial or developmental disability problem? o. No - i. Yes {Choc} at? conditions lira! are rolaiedio status that were RELATED To manifested before age 22. and are rikeiy in wnirnue inderaniietyi 9. MENTAL MFUDD STATUS Not MFUDD (Skip to N311) MRIDD with organic condition O0-'m'5 tiiuliam 1 Epilepsy other organic condition related to MRIDD e. MFUEID with no organic wndilion 11 $35 GROUND INFORMA- TION Month Day Year COMPLETED C:I=Whon box blank, must enter number or letter =When letter in our, checii II condition applies Print Date November 14. 200?Quariarl'y Assessment' 1. (Ch:-cl: oil that apply if all r'n!on'i'iati'cn test box only. I yumpfiw CYCLE OF DAILY EVENTS to Stays up late at night alter 9 pm) 3- Naps regularly during day {at least 1 hour] 5- Goes out 1+ days a weak Stays busy with hobbies. reading, or fixed daily routine d_ admitted from another Spends most at time alone or watd1ingTV nursin home Moves independently Indoors {with appliances, if used) Use of tobacco products at least daily 9_ NONE OF ABOVE h_ EATING PATTERNS Distinct food preferences I- Eats between meals all or most days I- Use or aicohoric bouerageisi at least weekly Ii- NONE OF ABOVE ADL PATTERNS In bedclothes much of day Wal-rens to toilet all or most nights Has Irregular bowel movement pattern Sttowerri tor bathing Bathing In PM NONE OF ABOVE r. INVOLVEMENT PATTERNS Daily conict with relativesiclose Iriends 5- Lisuaily attends murdi, larnple, synagogue {eta} Finds strength in faith U. Dally animal oompanionlpresenee Involved in group actiutlis w_ NONE OF ABOVE UNKNOWN-Reeidenufamiiy unable to provide infonnalion SECTION AD. FACE SHEET SIGNATURES SIGNATURES OF PERSONS COMPLETING FACE SHEET: 3, Signature of RN Assessm n) oordl tor <> rm new -w~sr> the 3- GENDEREI M535 2_ I33,-nag, I 1 dates specified. To the best DI my Icnuwledge. this Irtforrnatlon was tzallaclad in ar;carrJet'tctr with Meqtcafiehaaind I und:rstarIIiWII1uI this rescue a etesn us: ::are.nn ass as or ament ERTHDATEE 1' DI .. I 3 l1|9 I2 [8 Imrr'tIsder:lf'fn s. I funds cnnIInue:FIlpyarIIcI- mt. my mat 4' RACEE 1- 4- HIEP-9935 substantial criminal dttit edninistrativs penalties submitting lalsa Inforn-taliert talsu 2. AsI:tntFacIIlt: Islander 5. white, not 91 certify that 1 am to submtl Ihls Inft.-rmalirttn by this facility on its behalf. 3. Black. not afl-lispanlc origin Htspantc or-sin 5 SI EM and Seams 0 la 5. SOCIAL a. Social Number 3. II II MEDICARE Ruuagngg b. are number nrt:t:trn Iara Ie rallrua Insurance rtum er] I rt: Inm1:dbottIuconnc-r dietitian omsrzaur . no. 3. slale ND. -- IEZI PROVIDER f1PTIOT b. tJ?tu9t20u7 ARMINIJA PEREIRA RN f. . MEDICAID . - tiga? BuffImfi'{/rybrur Medicaid I. i recipient!' - J. 3. codes do not apply to this farm] AsE5%?s_ a. assessment 515917 1. assessment trequtrect by day 14) 2. Annual assessment 3. change In status assessment 4. cunsclion at prior full assessment 5. Quarterty review I of prior quarterly assessment D. NONE OF ABOVE b. Codes for assessments required furfiadtcam PPS or the Stat 1. assessment 2. .30 ay assessment 3. Medicare 50 day assessment 4. Me diners 90 day assessment 5. Medicare assessment 5. cm: er state requtred assessment 7. Medicare 1-t day assessment B. Other Medicare required assessment GENERAL INSTRUCTIONS E1 Key items for computerized resident tracking when box blank. must enter number or letter Quarterly Assessment Date Juty 12, 2007 E1 When letter In box, check if condition applles Complete this !or submission with at! tuft and assessments gldmissinn, Annual, St nrficunt change, state or rrtqulma' assessments, or uarterly Reviews. etc? MD5 2.0 September. (Medicare 30 - day assessment) GEORGE LAROCCA Numeric Identifier 5030 MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR HOME RESIDENT ASSESSMENT AND CARE SCREENING BACKGROUND (FACE SHEET) INFORMATION AT ADMISSION SECTION AC. CUSTOMARY ROUTINE SECTION AB. DEMOGRAPHIC INFORMATION 1. Ifif? the stay began. Nara -- Dons out raadmisaon vffioord was 1. CUETDMARY {Chock air that oppiy.iraii:nrommrsan UNKNOWN.clie'c'lrlest box only.) ENTRY closed at time ortamporanr to hospital. etc. in such cases, use nourmg data CYCLE or DAILY EVENTS fin yearprior [2 3- D97 Ye" Naps regularly during day (at least 1 hour} h. 2. 1. Private no home services 1 hafggiffagr mu>> our car as: ivirig youp nine - . 4_ Nu[aing hum, stay: busy with hobbies. reading. or [tied daily routine d_ 5. Acute care hospital .dmmod {mm 6. hospital, ii.-iRiDD facility another Spends most of time alone or waIcttingTV 7, Rehabilitation hospital nursln I a, other home Moves independently (with appliances. If usedrtoeacco pl'ei:IJcta or least NONE ABOVE ., EATING PATTERNS PRIMARY RESHJENCE Distinct food preterences 5. {Cbeclr_oIIa_ert_1nya resident llvodin during 5 years priorto dale or i entry given at item A31 above} Eats between rrlaais all or most clays - SYEARS Prior stay at this nursing home n_ Use of alcoholic beuer'age(s} at least weekly l|'I other NONE OF ABOVE . I. other residenllai lacili1y--I:ieard and care home, assisted AOL living, group home 6 setting In beclclothes much of day I11- MRIDD setting e_ Wellens Io toilet all or most night: It- NONE OF ABOVE 1, Has irregular bowel niovemant DBIIEITI 0- . . Showers for bathing eainin9lnPM be can two ccupatlons] NONE OF ABOVE r. erg:-Itlcihtlrilfi 2. mg 6. Sam: ccgugr?ra 5 INVOLVEMENT FATTEFINS . es . . E: B. UINBUAGE iCoo'a tor cenect response) Usuatiy attends church. temple. synagogue (eta) a.Primaw Language Find: strength In faith u_ 9- 1- 2' 3' Omar Daily animal companionipresence D. It' other, specify I I I i Involved In group activities UNKNOWN-Rasidenvlamliy unable to provide inlunnatl-an limiters SECTION AD. race SHEET SIGNATURES STATUS Not uiaree [Skip to AB11) . SIGNATURES OF PERSONS COMPLETING FACE SHEET: MRIDD with eruaniccondsilon pawn-5 h_ a. Signature of RN Assessment Coorflirieior Autism y' El nymgi DIITIIEI iflfl &.'.l1iffl re 6 5 I or re ITIQ 'l1i'DtTI'iflIiOl'I for this resident thakt1I cneroineted collectieerinot this the . . I . 1. . Ulhfif 07991753 ?0fldi150f'| T319193 '0 MWDD 5- in;-Iffiefd es am - - as': or en tiring that reside is eceive re 'ale and qua ity care. an as sis or peyme MWDD "0 organ: Emma" iron: lederalslundc. i lurthar at such federal tennis and continued partici- 11 liteailhbcara prugrtilnie its - as ormat on. an me rsona GROUND -- -- Eoogiomiai criminal. civil. rindior odmirllalrlfiiaun uisoinimrnarion Ialee certify that I am authorirl to submit this information by this facility on its behalf. 1| Month Day Year sionaiuro and T-no Date boil blank. must enter number or letter =Wi1on letter in coal, checir fl condition opplloc Printoate August 02, 2007 Quarteriy Assessment M03 2.0 Saptambor. 2000 (Medicare 30 - day assessment) A MDS PPS ASSESSMENT FORM Print Darn 02, 2007 Quarieriy Assessment . . 5030 (VERSION JULY 2002) @593 5? $99355 maiden! iwedm 5 years Door to am oienfry} MAKING inronnairon caniani- howevar able) 2. Prior stay atihis nursing horns SELF UNDER. 0. UNDERSTDOD D. Stay In other nursing homo 51009 1. UNDER-STCIOD - finding words or finisiing Oihcr residential iaclliiy - board and care home. iafislsted living. 2. UNDERSTOOD - abfliiy is Iimiied to making ooncrola oasis group home woven cl. MHJ MWDD "mug CB ABIUTY To [Understanding vorbaiinionnaflon content however abis} uupan. o. e. NONE DP A80 VE STAND 1. USUALLY miss some paniunlanl oi OTHERS rn-ossagfl A1. GEDRGE LARDCCA 2. ooaqualaly io simpia, NAME diroct conunurucaiuon a. (First) b. {Middle Initial) o. (Last) d. (Jri'5r) 3. RAREL UNDERS TANDS A2. noon o1. 723% see in adequ.-BE fight and mm grasses rt usoflf Fl"i5l*| I 0. ADEQUATE - seas fine detail. including regular print in A3. o. Loo! day oi MUS observation period . nawapaperybooks . IMPNRED - sees large print. but not regular print in -- nowspaporsi books - Month Day Your 2. MODERATELY IMPAIRED - limiter: vision; not able to see newspaper hoadiines. but can ideniify objecls Ma. DATE OF Data of rnonlry [mm mm: noon: Ismpory to a hospital In 3. HIGHLY IMPMRED - object ldentiiloallon In question, but REENTRY inoiBD day.-riot since last or och-fission If loss than an days] 93.95 appear") fuflgw objects 4. SEVERLY IMPAIRED - no vision or sees only Iighi. colors. or shpes; eyes do not appear to follow objects Monih Do Year 5' {Coda far observed in last 30 days, irrospscuvs or rho A5. MARITAL 1. Never married 3. Wiclowod 5. Dhiorood 2 IE1. assumed cause) STATUS 2. Manioci 4. Saparaiad DEPRE5- N, 0. indloalor no! exhibited in last 30 days AG MEDICAL 5 0 3 5.2.13 Maub . 1. Indicator ofthis typo exhibited up in 5 days aweeir. RESSRD Indicator oithls type daily or almost daily days a weekADVANCED |For those items vvilifs supponing documunlaiion in tho record. as I1. Repelilive heoilh DIRECTIVES chooi: all lhalapply} an idem made negaf complaints-s.gslalernanis-e,g,, "Nc|lh.ing vegerafiva assign ?scemroie "3 concerns with body 31. COMATDSE . . - No . Yes [Skip to Section Rfigwls "mm? 3? ionu; La: ma die" I. anxious IEMORY Honor: of who! was learned or known) {non- . ape we was ions-6.9. has ralais a.EURhr1rl-lam memory OK-aaemslappaars lo racaii silor 5 rnlnuias "where am go; What on 1 persistently seeks ai:|eru|nru 0 . emory DK 1. Memory problem ragsrdung - o. verboiizailon.-.-- b. Long-term memory Oi<-saamuappsars to rocali long past mung our for help_ at-lam M, SLEEP-CYCLE ISSUES B3. lino! msrdani was normally owe to renal! dunng J. Unpleasant mood in 35 BIS mun-'ling BELI clCurrent Season d. Thai haishe is in a nunshg homo 55 Dr insomniaticigings in usual (1 b. Location of own room anmya awNONE OF ABOVE aro sno, Anxious c_ nameufacaa angfir B: 33 received an. cooN|11v'E (Mada decisions rr.-gaming tasks or daii_i-We) a. sell depreciation-a.o.. Sad. pained. wonied racial SKILLS FOR am noining: Em no use D.nll.Y o. oonaistantiraasonabla In brows Drficagighjj?q. 1. In new snuauons m.CnrIno. 0 A -2. poor, cuasisupenrision f. Expressions ofwhat n.Ropotiivo physical required appear Io be unioolisiio muvemoni-o.g., pacing, 0 7 - foars--o.ui. roar oi being hand wringing. restlessness. I. for bahauiorin me last 7 days.) (Nora: accurate assessment fidgafinu pidmg - I OF nzquireo with sioiinnd family who have dinner irn-owieoige LOSS OF INTEREST humid" cm" um Recurrent Iniomemls thal Withdrawal from sou' . 0. V1 BED oi reconi onset in Emu"ea" social iriiaracilon difficulty paying attention: you -. HOOD Duo or more of claprmisad, sad, or anxious mood wore PER5IS- not easily nllored by attempts to "cheer up". console, or reassure we mam present believes heishe is somewhere else: coniusas nigh! and fly) O. No mood 1. lrndioolors present, 2. prasanl. indlooiors easily aiioroo not easily oitored OF DISDRGAHIZED speech II or rambling irom subiaci in d.Pki?lHa DS or pici?iflg I: hS,flC: BUB mnuon1ganisPc|:$ caling out? aw" rap 0 vs OF sluguismass, staring into space; diificuit io arousn; I-illia body mm.-amoni) MENTAL FUNCTION VARIE5 OVER THE COURSE OF somaiimis boiler. sometimes worse; baho-irioru sometimes present. sometimes non MDS 2.0 PPS Juiy 2002 30 - day ossossrneni) GEORGE LAFIUCCA .. . "mm soar: Resident (Code forahiifiy do.-any test in the last I days) 4. BEHAVICIRAI rreouenggin lost days 63. TEST FDR svmamus . ahavior not ash' ya BALANCE U. Maintained position as required in test 1. Behavior of this Iypo occurred 1 to 3 days I1 Ieitl 7 days 1. Unelead but able to rebalencs physical support 2. Behavior of this type occuned 4 to less lhah daily (see training 2. Partial in 3:31:31 support during test 3- BEIIEVIDT D7 W5 M39 U!-Ill' manual] Islands site but does not follow ill ions for test 3. ol ab-lot alt mpltestw cal help Behavioral In last days 3 I Behavior not present OR behavior was easily altered 1. Behavior was not easily altered (Bl a. Balance while standing . ti. Balance while trunk conlrol 1' (moved wi'l'I1 no rational purpose. seemingly 0 ohm-Imgg in mad; or Mary) G4. FUNCTIONAL or a onnp est a in I any or or LIMWATIDN seed resident at n'clr ABUSNE BEHAVIORAL [others 0 RANGE OF A) RANGE OF MCITID were threatened, ssraemesl al, our-sad st) . . IHI 0. lie linuletton 0. No loss AEIUSIVE BEHAVIORAL were [3 0 1. Jmltallon on one elite 1. bee hit, shoved. scratol1d. sexually abused) 5 2 Fuluoss BEHAVIORAL (made disruptive sounds. noisinena. nnreern ing. sa ll'-abusive acts, sexual behavior or dienrbing in public. srneoroditrraw loodrieces. hoarding. rummagad through others' o. shoulder or elbow c. Hand-including wrist or fingers #155366? d. Leg-Including hip or knee 6. FIESISTS IJARE {resisted Ialting rnei:licatianalinjei:lione.ADL G. ankle or toes 51' {Al ADL for resident'; ranronunnca ovannu. Owe' ms SHIFTS during first 1 cim--ivai fndurfing setup} <35 spp'lfa'a' as: days] help or provided only 1 or 2 times QH b. Wheeled sail I duo-iglasl7 days G6 at: a re aPPl' rig est a MODES OF e. Bedlaal all or most of lime i 1. encouragement or cueing providedfl orrnore limes during TRANSFER laal {3 or more times} plus physical assistance 5- 73"' "555 TOT 555' provklad only 1 or 2 times dufing Iasl days rnobllilli "amt." 2_ Lhw]-Ea 'd in' ad ad' retained aim] in (57 Some or all DI activities were broken Inll:I 5 ring as: guided rnmeuvering or 3 50 fefildanl "Wm help provided only 1 or 2 times duriig last 7 days 3. resident parlennad pan of activity. over loel 7-day H1. CDNTINENC SELF-CONTROL CATEGORIES period. help oi' lollowing lypeis) provided 3 or more times: 4 Mp" (Carlo for resident 3 oven ALL --Full PBITOTWEFIOE CIWIDQ Dali (DUI D01 7 days 0. CONTiNEl'ilT-complete control findudes use ofindrvaling urine.-y catheter or osromy device lira! does not lost: none or small 4. TOTAL stall parlormanoe of activity during entire 7 days i. USUALLY EONTTNENT-BLADDER, incontinent episodes once a weal: or less: B, AIJTIVJTY DID NOT OCCUR during entire 7 days BDWEL, than weekly SUPPORT 19' 2, DCGASIONALLY JNCONTINENT-BLADDER, 2 or more times a week but not daily. OVERALL SHIFTS during last 1' hegandiass or resident': salf- 3owE1__ ancg 5 week peifannance classification} 3. FREOUENTIY INCONTJNENT-BLADDER, tended Io be nconlinent daily, but some .-- or help stall oanimi present on day shill]; sonar. 2-: times a wear: I on . .. One person physical assist B. ADI. ilsall did not 4. inadequate I_:onIrol BLADDER, mulliple daily episodes; 3, Twia+ persons physical arteisl may gm-|ng min 7 gay; BOWEL all [or almost' all) of the time . a a HOWE canlrol of bowel movement. with appliance CI bowel continence CDl'lTl~ programs. ll employed How resident moves to and lrorn lying position. tum: side to side, 2 2 fl_E_m:E "gm! I II I. BLADDER Control of urinary bladder lunolion [if dribbles. volume 'la in. TRANSFER How resident moves between eurlaoas--lollrortl.' bad. chair. 2 2 COM - soak through underpants}. with appliances inlay) or mnlinence 4 wheelchair. slanclino position lollronr bolhnoilalt BDWEL n|w=H c. WALK IN 2 2 H2 ELIMINATION c.oianhaa Egg" flew resident walks hstgeen looallorls lg room PATIERN I d. Fecal impaction . WALK IN How resident walks I1 on lrnil I cafifilnpfit 3. a.Any scheduled toilating d.Inclweliing ca't'heler e. flow resixientmoves between loeeifina ll'l hiei'her room one it -- AND Elan on adjacent oorndor on same floor. ll wheelchair. self-suifiniency PROG Bladder retraining program on uni-r once in chair . . Lonlurny present catheter . . . l. TIDN How resident moves to and from all unit locations ie.g.. - For Saclion I: check on! these diseases that have a relationship to current NJL status, cognitive . UNIT areas set aside for dining activities. or treatments}. If not lly has status. moon and behav oratalus, l'l'lEdtl'.'B| treatments. nursing monitoring. or rial: of clalh. {Do not i floor, how I eirlml moves lo and from distant areas on or -in at --lic|ani: uni air 7 DISEASES rnellilue vtiemiplegiall-lemiparesis g. "afifisslills l-bw resident puts on, fastens, and takes all all Items of wililtfliiplo iidarosifi 9 I I l'll I ll -Iil'- Im I I 4 I-3 d-Aflfiliagclfirmic . I1. I disease MSHD) EATING I-low raeldant aisle and drinks [rogmllass oi skill). includes imalra of by other means tube feeding, total parenteral (Congestive he an leilure l,Perinherel vascular disease aeflaprasalon 1. TOILET USE How resident uses the toilet room [or oonnmode. bedpan. urinal); lranfilar enroll loital, cleanses. ehangaspad, manages oslorriy or . m.l-lip lraciura ll.Menrr: depressive fbrpolar adjusts dailies Aph disease} f. 85:! 1, I-tow resident maintains personal hygiene. Including conibvng heir, gg.5r:hlzophranie hrusmng Iaeih. mavmg?tagfhim makeup, lace, acambrai palsy hands, and perineum UDE baths and showers} . tcerabrovasoular G2 BATHING Howrestnienl takes alull body betlv'sl1ower. sponge bath and . . iwcidfinl trenslers Inroul of Iublshower wasting of backand hair.) - I2. IN (none apply, CHECK Ike NONE DFJluEGlr'Ebox) oafo osrdee do 1 vi I -. . BATH 5 plea in - . - ggfigg appfiar now resistant lnlecllor tag, Melhicillin resistant h.5axualIy lrarlernillad disease 0. Independent-No help video atinzohl A 1. so pervlie-on-Overs help only I I1. Iosindium to. cklf} i.Tut:en:ulosis i' 2. Physical help Ihnlt to transfer only . 5. 3. Ph sioel help In part oi bathing aclivlly .t.lrlnery tract inlezzlianin last . -4. To all do eriI;len?B . . 30 days 3. Activity I sell did not occur during entire 1' days til-ilv nlecllon 1 l..'Jiral e.Pnaurm:inia I Wound Inleisii-on f.Fie3plr?ttory inlecuen W: MD5 2.0 PPS July 2002 Prinroaie August 02. 2007 Quarler1yA.ssessmenl (Medicare 30 - day assessment) Au rd 9t'Tn7 {lam-ma--m-tall lrfifinfisrfl will '3 On; "(For ofuicer, code faraho in tlterast 7 days - cunngfir 298 9 M2. tr:-Jnu scare in from stages 1. 2 3, tr) DIAGNDSES a. Pressure lesion cauecl by pressure resulting in A213 I damage or llssue . 0 Stairs ult:er--open lesion caused by poor crculsliorl the lower .11 ct-tacit all problems present in last? trays unless other time frame indicated} omottsl ttsrottFo'F' 1 NIJICATORS OF FLUID OTHER M3. nE5m_VEp Resident had an was resolved or cued ln LAST so DAYS STATUS 9 Damian! ULCERS CLNCI 1. [1 M3. "fims ens, ttfidema PHOBLENIS a SE5 . -- e.Wa|ghl or loss of 3 or 3R Lasiofls txliurns [second or 3 PRESENT c.l.'.Ipen lesions ctlher than ulcers. rashes, cuts cancer lesions) [chunk 8" d.Ftashes--9.9.. eczerne. drug rash. heal rash, herpes h.Il'libfl11V to lie llel due to tlruemal bleeding drstoppry a.Sl-tin desensitized to path or pressure Shanna" 0, breath lung aspirations 31$: 7 1957' noehydmad; in last so day; wounds exceeds Input I. Shortness of breath OF ABOVE fluin'. did NOT n.Unsleedy nil M5, TfiiE(gt|T a.Prest=.tra relieving choir consortia all - . . |::q:td5 dudng Int lfrasxrt: for bad C. Ul'l'I |]l'DQl''BflI Chock all d.Nl.l1I'l1bt'l or hydration lnlaruenthn to manage problems turn: apply a 'ultra roads the highest lava: nfpnin present in ma tasr 7 days dufing 7 - 9' rroms tr. which b. EHTENSITY or pain "mm we rastdam mmpga,-,1, or of (wtlh ortt.-tlhot.tl lopl-eel other shows evidence or pain 3- Mild Pain an a. an No pain lamp to 2. Madam pain at (other than to rust} 1 pain was "Ian l.0lher preventative or protective sitln care [other than to teatTimes when path is hornlale OF 2- or ertcrutiating ME. fiosfint has one or-more loot corntl. cattuses tfiiga?fiaas bunruns. toes, 9 less. pain. lruclural problems b.Irtlet:llon ol the purulent dralnaga rtethat rmmal in [lit da '3 "rm an ll' 30 610:1 frag . I 180 3' 7 clurttg lest days 9 Pa" 2' "'55 as or protective foot care used special In past 31 - ten days CJF ABOVE 5 a.Cnt1dltlorlsl'dlsease5 malts resident's oognlliva, mono or up behettlor pittems preosrlous, or deterlorelhg) DF Afiovz CONDWON5 an acute episode or flare-up at a remnant i. 5" '5 PW N1. T1 (Check appropriate time cstind-stage disease, 6 or lower months to live Fiesidertl awaits all or most of time naps no moral]-ten one hour d~o~E OF ABOVE Irm- .M .E K1, ORAL a.C.hawing problem l:Ifl1I"lQ t: van ng PROBLEMS OFABOVE b.5wa|Iuwins problem tr ut N2. AVERAGE HT eoord height In Inches and lb?) weight In pounds. Basel weight on toast (When awake and not mcsluing treatments rs) AND econ! measure in last 30 days; measure weight consistently in accord with INVOLVED WEIGHT standard In em. alter troidlng, belora meal. shoes AGTMNES 0. Mast--rnare than 2:3 or time 2. than 1:3 or time oil01. NUMBER (Record! a number or used to the rast' 7 days; . 3 I as enter 0 lfnone ussdl CHANGE 18-0 days _'tlnH,5_ D. No NJECTION 5' {Record the number of DAYS irrfecrrons of any type received during b. Weight gain-EM or more in last 30 days: or 1 mt. or more In last 3' me km 1 my!' ads' -0 'mom used] 180 II we 1 'ms [14, {Record are number of DAYS during last days; enter if no! ed. No! .7 [Check all' that apply tn last 7 days] THE "5 amen!" Mi med: used Hypnotic e.F'arenleralIIv a planned weight change I ES pmgrarn b.At1uanxtely (I u. Diuretic c. Antidepressant (1 K6 ARE (Skip to Section rt' net'utt:r5a is checked} P1. PE EPEEIEC 5ARE-- choclr treatments or progrernsreceived during an ENTERAL rt. Code the proportion of total calories the resident received Ittougrt - the last 1'4 days parenteral ortul:-e leetlings in lho Inst 7 days blg?lgg, ENTS PROGRAMS 0. Hon 3. 51% I rstt. figs' 1.1'ltIEo25'ts mrirtln a.Chemotl-terapy 2. 26% to 50% PRO- BEAMS treatment b. Code the average fluicl per day or tub-etn1ut'! days one 3. 1031 lo 1500 ccrday medhafion 1 1 In 500 4. 1501 to 2110!] t:t:'daY 1 or I - .- d.lntl-teroutput special care urtll M1 ULCERS (Rooardtne at each ulcer stag:-reg .55 or a.Monllon'ng acute cause. 1! none present at a stage. record Code at' the! apply 3 5 medical cond Ilian o.Hosplt:.a care [Due to any during last 7 days. Code 9 an 9 or more.) {Roqmrn rurt body .. cause} -g -- csre p.PecIlelrlc unlt s. Siege 1. A area of skirt redness {wtlhoul break In the skin: that does not disappear when pressure is relieved. ll-555F313 C3-T9 . la. Stage 2. A partlal thickness loss ol layers that presents :11 mils required to as an abrasion. or crslar. '9 I5-9-. taking medications, hotrse c. Siege 3. A full of stun Is lost. axposlng the want. llssues - presents as a snap or j.Trat:heostomy care gnu} I ll . Mn a jam OFAEOVE d. Stage 4. A full thickness or and subcutaneous tissue ls lost, estposhg muscla Wenlilelor or respirator A-j_ MD3 2.0 PPS July 2002 Rasidanl LARDCCA 5. WEE-335135 - P33713159 numfioroi Rays and late! rnirwias each of ma following lherapies was (for at least 15 minulas a day} in the last 1' calendar days {Enter 0 {mono orloss than 1'5 min. daily] only post admission therapies] 5030 PB. PHYSICIAN In the LAST 141 DAYS lot since admission illess Enan 14 days in -. omens racmly) how many days has me physician (or aulhurizad assistant or praclauonor) chongaci the resident': orders'? Do nor include Ordar renewals wilizout change. iEnlar0 if none} ETDISGHARGE a. Resident prolaronca lo ralurn lo lhe comrnunily .. POTENTIAL D. No 1. Yus o. Slay projaclad in be rare short duraliun--discl1arga proleclad within 90 days (do not include azpoclod discharge dua lo daalh) 0. No 2. Vlfilhln 31-90 days 1. Wllhin 30 days 3. Discharge slalus uncertain OVERALL Rolsidanfa overall laval ol sail suincianoy has channad slgrirrcanuy as (12. CHANGE IN compared in sialus nr Bu days ago ljorslnoa last assasamanl if less CARE NEEDS lhan SD days) ii. No change 1. Improvad-raoalvos lower 2. Datarioralad-receives supporls. needs lass more suppori loval ol cars 0 r) examined the resident? lErrlar0 llnone} R2. SIGNATURE PERSON COORDINATIN ARMINDA PEREIRA RN 0, a. 5|-gnalura ol Boorrfinalur {Sign on alioi-e ma Coordinator 0 7 Ag ll of days for 16 minutes or more total of minutus provided in Iasl 7 days Speech - languagp pathology and audlology sarvicos 0 la. Occupational Ihorapy 6 3 Physical lhurapy 0 0 d. Raspiralory therapy 0 0 0 a. thorapy [lay any licensed menial P3. NURSING Record the NUMBER OF DAYS each oiihe lollowirrg or raslo.-olive techniques or proclfces was provided lo the rasldanls Jar T10}-u morn than or aqua! to 15 minutes per day in the last?' days 1 (Enlar CI if none or lass loan 15 min. daflyl I. Flange of motion [paaswa] 0 i. Walking 0 Range 9. Drassing or grooming 0 c. Splint or braoa asaislanoa 0 IL. Ealing or swallowing [1 TRAINING AND SKILL I. oar: (J PRACTICE IN: Bed nlohllily 0 I. Conmunicalim 0 a. Transfer a II. Diner 0 Use lira follow.-rr codes for east? Ha 5.1 P4. DEVICES 9 AND O. Nol used RE5'rfiA_m'r3 1. Undies: lhan daily 2. Uaad daily Bitd rails a. --Ful bed rails on all open side: ofbocl lo. --Dll1eriyp-as oi side rails used half rail, one side) 0 . 0 raairalnl cl. Limb rasliairll 9 Chair pravanla rising 0 SICIAN In Ira LAST 14 DAYS (or since admission rr lass man 1-1 :1 5 in radlry how many days has lha physician {or aulhorizad ans slant or 1 signed as complain Monlh Day Year Skip unless IN: is a Medium 5 day or Medicare roadmlasianl T1. return MENT3 AND physician -ordered any oi Ina DURES following lnarapiaa to begin In 14 days or therapy. oocupaiional therapy, or Ipaaoh oalhoiooy sarvloa? 0. No 1. 'res r:.Thn:ugh day 15_ provide an of ma nurn oar oi clays whon al 1 lhurapy service can on expecsad to have been delivered d.Tl1rough day 15. provide and oslimala of U13 number of therapy minulas (across Iho Iharapiaa} Ihal can be axpeclad lo be dalivared. 1'3 CASE MIX Marlioaro - Stain onoua lililfi Print Date Auflhsi 02, 2007 Quarterly Assessment (Medicare 30 - day assessment) MEI-S PP5 Juiy 2002 M03 2.D 5aplan1l:ar.20lJD IARHPCA Numgfigidgflufigr SECTION 8. SUPPLEMENT-MDS 2.0 (NEW YORK) 1' N?jagg?fi Enter current number. Follow Instruction inthe manual. 0 PRESSURE Record the appropriate response. Stage aorat pressure ulcer 4 ULCERS sites present upon admission or readmission. 1. All currently reported sites were present on admission or readmission 2. some of the ounentiy reported sites were present on admission or readmission 3. None of the currently reported sites were present on admission or readmission at. No stage 3 or 4 sites amenity reported 3. SUBSTANCE Substance abuse history. Has the resident with HIV engaged ABUSE in substance abuse behvtors more than one month ago which continue to iniiuenoe care currently given to the resident? Renard tits appropriate response. 0. No 1. Yes 2. Resident does not have HIV 4. DISEASE Record only those disease diagnoses that have a relationship DIAGNDSE to document AOL status. cognitive status, mood and behavior status. medical treatments. nursing rrtorilloring, or 21st: at death durhg trio last 3D days. (Do not list inaotitro diagnosis]. (Check out that apply} I-IN dementia HIV wasting disorder foliowhg organic brain damage disorder totlowtrig organic brain dornsge Spinal cord iniury Herrlipareses disease Dementia Registry Reporting 1. County code oi prior residence 2- Physicirt iioense number i. NONE OF THE ABOVE . 'Dara August 02, 2007 Ouarteriy Assessment' ffirifidicaffl 30 - 0'83! 653655-Wen!) GEORGE LAROCCA Humane Identifier 5030 iiesicient Name MINIMUM DATA SET (MDS) - VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING . _c-non w. SUPPLEMENTAL MDS nems 1. National Enter for all assessments and tracking forms. if available. II the AFID of this assessment or the discharge date at |i'IiB dlsahanga tracking form is between July 1 and September 30. skip to W3. 2, influenza 3, Did the resident receive the influenza vaccine In this Vaccine fa-cility tor this year': Influenza season (Ocleher 1 through March 31)? O. No (If Na, to item W2t:) 1, Yes gaieltem It Influenza vaccine not received, state reason: 1. Not in facility this years 1111 season 2. Received outside cl' this facility 3. Not eligible 4. Offered and declined 5. Not offered 6, Inability to obtain vaccine Pneumo- a. Is the PPV status up to dale? cows! 0. No (II No. 91310 Item may Vaccine 1. Yes (It Yes. etch item With) 9' b. If PPV not received. state reason: 1. Nat eligible 2. Uilcred and declined 3. Nut oliereu .r page August (32_ 2007 Quarterly Assessment {Medicare 30 - day assessment) MDS 2.0 May, 2no5 Regeis Care Center Quarterly Assessment (Medicare 14 - dav assessment) GEORGE LAROCCA AHRD Date: Soc Sec Current Medicare Current Medicaid Current Medical Record Date of Birth Current Room Signature of RN Date Signed as complete Rugs Score: l'rint Date: 091220925 091220925A QV635-43R 5030 10I30i1928 585A VENETIA UY RN. 0612812007 RUB Thursday, July 19, 2007 Numeric Identifier MINIMUM DATA SET (IVIDS) VERSION 2.0 FUR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BASIC ASSESSMENT TRACKING FORM QECTION AA. IDENTIFICATION INFORMATION Cnmpintn this for submission with an wit and quarterly assessments Annual, 51 Chang>>, state or Medicare requfrndassessmonts, or Ouartenty Ravinws, etc. 3 Key items for computerized resident tracking 1| Men box blank. must enter number or letter IEI when letter In box, check it contiltion applies MDS 2.0 September, 2000 Date June 27, 2007' Quarterly Assessment (Medicare 14 day assessment) 1. 9. Signet {Parson wt ocam Iota-d Portion I As n-I GEORGE LAROCCA I I: an scompany ng sesame or Ii-"r . . a_ b_ I.-wag] c_ 'Lash d_ (J,-Igr} I that the accompanying resident assessment or intormelion Ior this resident and that I collected or co-ord' I collection of lifts 'nf ii the 2. 1_ Man; 2. Female 1 flags sglaacatagi To the crap'); Ir: ep Ice aucarean I re rernen. un arssn at srnonna :1 us a basls for ensuring that residents repeat': appropriate and quality care. and as a basis for from federal funds. lturthar understand that payment otsud-I federal turrets and sontinued parII'oI- Ma Yam petiun the health care programs is gzondiliorted on the ecurecy and lru1htoI- 4_ 1. Name 4' [5 [6 mass or this and that I msy_ba sub to or_mey subject myo anlzatlon to sutaslanltatcrunmat amt andrur ensures ors talse tntermala I Isa 'I?Iander 5. 5 certify the! lam aurimriz?d lo stfomit this Infonngtion by IaLI:iIity ongits behatf. a . as ,n 5. socw. a. Santa! Sesunty NpflI::I"flgm MEDICARE ,Nuu3|5Rs@Ib- - --HFIUITI Jer ornompare re re: roe Insurance numberARIIHNDA PEFIEIRA RN H?fflgi?gfj 9512512007 .. Sta oconnor Ittucte? - p_rroT - (33.6-1 u, b.Fadera|No.I3I3I SI r. 5; QILH 1. MEDICAJ . - 5351 pen no. I If I II "staid I ll .. recipient . l. Rfirtsofis [NoIe--0Ihor codes do not appiy to this lorm] a. Primary reason for assessment k' I. msgigfiasnqrenl (required by day 14) I 3: Significant change in status assessment 4. cerractlan of prior full assessment 5. Quarterly rovtew assessment 1D.SignifIcanl correction at prior quanerty assessment CL NONE OF ABCJ I1. Codes for assessments required for Medicare FPS stars 7 1. Medicare 5 da assessment 32. day assessmenI' . care assessmerr 4. Medicare 90 than 5. Medicare assessment 6. other state required assessment 7. Medicare 14 day assessment 8. Other Medicare required assessment GENERAL. INSTRUCTIONS Resirlenl GEORGE LARDCCA Nurnori: Idanlirior 5030 MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING BA CKGROUND (FA CE SHEET) INFORMA TION A ADMISSION SECTION AC. CUSTOMARY ROUTINE SECTION AB. DEMOGRAPHIC INFORMATION |:I=Wien bolt blarlit. must enter number or =when lane: in boat, chedi if condiliun applies Print' Date July 19. 200.7 Quatieriy Assessment Does no! 1. 51' Ch it lfili KNO ll 'okla lb . 1 DSJEREF closed era. in sl.il:h cases, use I as a '1 am", In [mam Wm': 5 0' mm CYCLE OF DAILY EVENTS 5 5 -- I2 ID ID Slay: uploie alnigi1l{a.g..aller9 pm} I. '35? Naps regularly durln-g day (at least I hour) h. 2. ,Imu||'rrEn 1. Private homaJanLwI'ii'I no home health services 1 mm, Hg", grl-static hegllh sehrvicss 13;, Goes out 1+ days a week . 0 an car seats I: I no roup am: 4. flufgmg mm, stays busy with hobbies, reading. or titted daily mullne d_ 5. Acute care hospital mm 6. PsyI::hlatI-It: hospital. MHIDD facility another spends most of lime alone or WalChl.l'IgTV 7. Rehabilitation hospllai rlmsin 3, mm; from: Moves Independently indoors (wilt: appliances. Ii used} 3. LIVED O. No 1. use 0! products at Ieasi daily 9, NTR 2. In other facility NONE OF ABOVE EATING PATIERMS h' PRIMARY RESIDENCE Distinct food preierences 5 ESIDEP-L [Chuck all sailings resident lived in during 5 years priorlo dale of'_ I HIgITfi6i.hY tiniry given in Item A191 above} Eals helwean I-naals all or l'l'lOiil days - P5F;i;Efl'iaRT9b Prior stay at nursiig home 3_ Use in! alcoholic baveranelsl at ieasl weekly 3- in ulnar HUGH HOME b. OF IL Dihsr residential and care home, assisted AOL living, group home -Ml-Iipsyohlalric selling IE In bedcioihes much of day "14 MFEIDD salthg e_ Wakens to ioilizl all or most nighls I1- NONE or ABOVE t_ 1-: Has Inegular bowel movement paliam 0- 5- Showers P- . ill- EalhInu|nPM icI:i.Ip:lit:IrI:] NONE OF ABOVE r. 7. EDUCATION 1. Na 5. TachnTE?i or trade school WVGI-VEHEHT FATTERN5 Ealgsgefiss ggroe Dally I:-onlacl relatluesiclose irioncls 3- 4: High school 5: Graduate degree 8. LANGUAGE {Code for correct response} Usually allends church. temple. synagoguo (oio.] 1_ Finds In faith D. English 1. Spanish 2. French 5. Oiher new animal Involved in group activities w_ ~o~so~eove 0. No 1, Yea UNKNOWN-Residenillamlly unable to provide lnron-nation 10. Bl: a re 5 mm SECTION AD. FACE SHEET SIGNATURES STATUS Mm amliuflafiu MWDD {Skip I0 Am" SIGNATURES OF PERSONS FACE SHEET- MFUDD tivith onglanic condition I a. Slgi-laluns of RN =w ment cordin- . Autism I I . 7 I -. agaun I 0' Elillaiisil nlorrnillofl iI:iih_ii_s our I .. deal this iitiorrnalignnfifi the .. Ii ail' . be! I kn I1 .thisinonnollonwoscoe iriacoordanoaw 0'93"" '"3'3'9d "3 itiIedioacIo and ihtil used as a 11 DATE. nation in the govarnrriartl-luntled health care in an lhe acnuraw and 1rU1hlU|+ BACK- -- nose oi lrlis irilonrlalion, and met I may be personally subject to or may subject my orpanizallonto GROUND subsianlial crirnlnai. civil. ancllor admlnislrallvo ponallies for suumilling ialse hIoitmoIlon_ I also FOR MA- senlly lltiil i am to ihis iniormalion by lhia facilily on its boliail. TIOR il.lant.h Year COMPLETED Siclrlaiure and 11l|s sections Dale b. cw ci. e. 9. ii. Mos 2.0 September, 200-D (Medicare 1'4 day assessmenl) PPS ASSESSMENT roenr . agfl Pn'ni Date Jury 19, 2007 Quarterly Assessment . . . SD30 (VERSION JULY 2002} . rcheui ail sell: _resrdar_11 lwodin 5 years prior to dare oi'onLry,l C4. MAKING (Expressing inronneiion conierr! - howe ver able) TIAL a. Prior alloy at 5 nursing home SELF D. UNDERSTOOD Tr ll rnd_ d' 5 YEARS 13. Slay in oiher nursing home 51-99:. 1. UNDEHSTOOD - resldenlialieollity -board oiidcara hornefassisiod living. 2 sowibrmes u~DERsr-can -anmtv Is Iimitedromamng cuncraea VER uruoensro veirbaiTri'i'"orrnaiion conieni however abie) 3' MRDD "mg ca' UNDERSTANDS .3, Name OF 1: ggiai?glal?i' miss some perliinioni or NT GEORGE LARQCCA 2. SOMETIMES adequately in simpie, NAME direci communication a. {First} In. Inuiar) c. (Last) cl. (Ji'iSr] 3. RARELYWEVEH A2. Room 1. Fl" I5 I 0. ADEQUATE - sees fine deiail. Including regular print In A3. a. Lesiday of M05 observation period newspapemrhooks REFERENCE 1. IMPAIRECI - sees large print, hui not regular print in DATE 6 0 7 newspapers! books Monih Day Year 2. MOD ERATELY INIPAI RED - limited uisio n; nol able to see newspaper headlines, but can identify objcle DATE OF Date of reentry from most recon! tornpory in a hospital in 3. HIGHLY object idantificallon In question. DLII lasted days[or elnee lost naeoazrront or adrisslon If less man 90 days) eyes appear to fo||ov.rabjec15 4. SEVERLY IMPAIRED - no vision orsoee only light, colors. or shapes; ayes do noi appear to follow objects Day Year (Code tor rndicaiors one an-odin tax! 30 days Irrespeoifira oi' the . I As, Rlfleilileig?nerrled l?wadowei?ld 5. Divorced 3 lei. DEIQRES assumed cause] pm 0. lndioelornol exhibited in last 30 days 559 "gab 1. lndicoior of this type up In 5 days a week 8. A "gm 5 3 lizll 1 fih'? Ii) RECORD 2. oaoro asypee ayora ay . aysawea mo or one terns suppo rig ocmneniol on a on moor . hflallh DI I1 is all that I . Wm M: I. RESIUETII ITIBUB pemmanny seeks memtal in. Do not raauscilale c. Do nol hospitailze Il;i1oihli3r;g aumnom absesslm Bf Persistent veg-eiairve sreiefna dfscemible consciousness] E?graimam W: with b?d" 31' COMMOSE reis hevin i'vedso o. No 'l.Yee rsiirp to Section or mg: we age: am"; "5 ecaiionvhai was foamed or ii.-row.-ii .3 Re [if t_ [non- . pa we 1: ions-e.o. re memory reoeli after 5 minutes 'Where do I on: Wire! do I . mi:-ry . arnory pru am now reassurance reg Oil'. or eereioracalliong past igzguglfilguagngfipuiasg?s 3 .on-onnrner-larn . r--E,-ad SLEEP-CYCLE ISSUES B3, rctracir all ma! maiden! was normally able to recall' during 1- mm" H1 RECALL days] Parsisienl anger will-i sell or manna ABMTY o. Currenl Season d. Tl1o1 holaho In In I: nursing homo olhore-e.g.. easily 7' Ir. in usual 9 . sleep poi rn Lama" e. NONE or= naove are receliod sno. APATHETIC. I o. Staff nnmesrracea APPEARANCE E4. corsunivfi {Made dad.-dorrs regarding laslrs oi' daily We} in I. Sud. worried facial 0 SKILLS FOR em nothing; I am no use iurwwed El. eonzrueniireosonehle 7 I5 broiivs warm nEc|5li?ig. 1. fi>>Ir?JoiFrEo uirncuiiy in new silufltiurle m-Cry ne. ness 0 2. MJDERA TELY IMPNRED-dareeiona poor, oueefeup-ervialon Expressions of whai n.Repeiliivo physical required appear in he unroelislic mnuerneni-e.g.. peeing. 0 EVERELVI a evrlrere rndo decisions rear being hand wfinging. rasllassness. . . abandoned, leii Bone, fidgaling. picking . W9 Loss or INTEREST DELIRIUM behavior ovorihis time}. I ml 1 [mm amviras GI. PERIODIC g, emrren amen a . I p|5oa_ Behavior not present something lerrible re aboui lniaresl-13.9.. "0 Iflieflifi '11 Cl genes 3- Bfihui-'EU! natal! recagrgi onsai cm Ida t_ I to happon--e.g.. believes long eianoing or 3' War 831 air! 5' hoorsri-eis aboulla die, AVMRENE55 "9 have a heart allack pufioduoad aociol inrararziion . ., ill' I ti ilfl 9 mm"? pay an FL 93 5 HOOD Dno or more indicators oi depressed. and, or anxious mood worn PEFHODS OF ALTERED FERCEFHDN DR AWARENESS OF not easily aileron by attempts to "cheer console. orroossuro 'sunRouNo:NGrHe.g., moves lips or teens in soineone mi 7 ggefient believes hoishe is oolnewhere else; coniusee and 0. Ho mom 1' Indicators Weigh'. 2' Fraser". 0 indicator: coolly olcrod not coolly allorod OF speech is lncoheranl. nonsensical. krelavani, or ranihlrig from subjecl lo sohjasizi: loses train of thought) OF . _fidoet' picking a1 slih. oloihing, napkins, air: physical rnovemanie or calling oul) OF aluggishness. storing inio space; diilicult lo amuse; body movernonl) I. MENTAL FUNCTION VARIE5 OVER THE COURSE OF THE someiimos boiler. someiirnee worse; behaviors sometimes ifiiflfianl. sometimes nail M95 2.0 FPS July 2002 {Medicare 14 - day essessmeni} . Resident GEORG LAROCCA I Numeric 5030 {Code for abrfiy dunrig last in the last 7 days) 4. EIEHAVIORAI Bclinviioroi synfilom frequency In lost' 7 days G3. TEST FOR - BENEVEDV in i851 7 GBVS BALANCE 0. iliiairilined posiiun as required in last_ 1. Behaii-iar of this 1t'P9 1 to 3 days in 7 dais 1. Unsiaad but able to rebalancs without physical support 2. Behavior of this type ornirrad it to 6 days, but loss. than daily [sou 2. Partial it yslcal support during test: 3- BENBVW 01' ml! WP-E Ow-Ified daiir manual) or but does not fol clii-safaris fol-teal 3. Not able! aliarnpl last wit aut ysiisa 5 {Bill Behavioral rnpiom in last 7 days . Behavior no present OR behavior was easily altered 1. Behavior was not easily altered (B) a. Balance while standing 1 1 b. Balance while siiling--posllion. lmnl: conroi 1 (mailed with no rslionaii purposa, nearningly oblivious to needs or seietyl ?'C'oH57or Eiunng Be! 7 Bay: ifiai' interfered dady functions or LIMITATION IN ac,-gym fig"; ABUSIVE BEHAVIORAL (hlhaiss OF OF were threatened. at. cursed all VOLUNTARY MOVEMENT O. No limitation (J. No loss D. PHYSICALLY AEUSNE BEI-UWIDRAL lolhars were 1. Limitation on one side 1. Partial loss nil, shoved. ahuaadSOGJALLY BEHAVIORAL 9 0 disruptive sounds. noisinesa. screaming, ii. .Arm--|nLilud|rig shoulder or elbow 0 self-abusive acts. sexual liahairior or dilroblnn in public, foodflaeaa, hoarding' rummagacl ihrnugh others' wflsi or fingers d. Leg-including hip or knee 9 0 o. RESISTS CARE {resisted talilrig a. Fool-Including ankle arloar. a 3 31' [Al ADI. for resident': PERFDRIIANCE ER ALI. r' '3 0 Still-73 during last 7 days--Nat induding sari.-pl Rffieci 3? appflofi in fast' 7 aaysl i. hflip or provided only 1 or 2 times nu - b. Wheeled self dwififl 'ail 7 5833 GE 2552:'; sf? fiat' apply during last' 7 days] MODES OF H. Badfaal all or most nilirne 1. anooixagarriani or cueing ovided 3 or more times during TRANSFER last [3 or more times} plus aloe! assistance 3 9341 U535 535 provided only I or 2 times during last 7 days mnlxilily or lranslar 2. LIMITED ASSiS'i'ANCE--l1aaidariI highly lmioluad in activity: reoalvad physical help 6? some or all were broken into subiaeks dul1flQ|35t 7 guidad maiauvering at limbs or other nuriwalghl bearing assistance 3 or more days! so that resident couh perform them iiaip provided only 1 or 2 times diinnp last 1 days 7'0" -ti 2. resident pad ail' adivily_ Enter last 7-day H1- 5 I off it 'dad 3 . "mi {coda rurrusidoni ALL SHIFTS) (bl-'i mi I391 7 0. control [includes use of indwelling urinary carhererorosiomy TOTAL stall' patiormanoa oi acii-.-iiy during arilira 7 days as 'flak E. NUT OCCUR dum mum 7 da 5 1. episodes once a week or less'. (6) ML 5 for MOSTSUPPORT - OVER ALL SHIFTB last 7' dayayririda ae!i'- 2 of "mm man a weak hm ml dam!' 7 perforrnance classification} . in) at a. FREQUENTLY tenclacl to be inouniinani daily. but some i "0 'mm coniroiprasenr (2.9. on day shift)' EIOWEL 2-3 times a week . Setup help only a. 1. One parent'! phyaical anaiat 5. Am acmny gm," um no' 4. hadaquaia _oorilroI BLADDER, muillplo daily episodes; 3. Two+ persons aeelsl occur izluriig entire 7 days 5: BDWEL 8" forafmcfif -BilBDWEL Control of buwal rriovemanl, with appliance or bowel continence I programs, it employed a. How raeiciant moves to and from tying turns aide to side. 2 2 HENIIE .B 33 BLADDER Central oi urinary bladder iunciion [if dribtitas, irtiiunie insuifcient to b. TRANSFER How resident moves between surfaces-iolirom; bad. chair. 2 2 CONTL seal-t through unitrpanis), with appiiancaa inlay) or oanllrianca .4 whealclieir, standing position DE inrirarn <>-Including shoulder or elbow Hand-Including wrist or fingers 0 d. Lao-including hip or knee 9 9 e. Fool-Including ankle or toes 0 I. other limitation or loss G5 5? {Check if applied In last 7 days} LOCOMOTI- rm sale It 63 ffieci eat fiat a i Hunt! last at MODES OF a. Bedlast all or 9 fl TRANSFER in. Bad rails used tor lied or Lronsler I - some or all at AOL activities were broken into sublasks durii1glasti' SEGMENTN days so that resident could perform them TIDN 0 H1. CUNTIAENCIE fit]-L (Code fnrrasfdenfs FERFOHMANEE OVER ALL SHIFTS 0. control finely-dos use urinary oathelaror oslomy device that doesnotlealr urine orsloor] 1. incontinent episodes once a week or less', BOWEL. less than weekly 2. OCCASIONALLV JNCONTINENFB LADDER, 2 or more times a wait: but not daily. BOWEL. once a track 3. FREDUENRY tended to be hsonlinenldaily. but some control present 9., on day shim: EICIWEL. 2-3 times a iveelr rt. tnoda ole control BLADDER, multiple daily episodes; BOWEL, alt {or almost all] the time a EDWEL ontrol or bowel movement, with appliance or bowel continence COt~.lTi- programs. employed Nauru: -- I1 BLADDER Control ol urinary bladder function tifdribblas, volume insufficient to soak through underpants}, with appliances or conttnanoa 4 EIOWEL H2 ELIMINATION o.Dlarrhea PATTERN cl. Focal impaction 3. AFFLIANCE. scheduled catheter AND PROGRAIJS Egnledder retraining program i.Datomy present c. External {conr.lom) catheter For Section I: check only those dlsases that have a relationship to eurrenl_.ADi. status. cognitive status, mood and behavior status. medical treatments. nursing monrtonnp. or l'I5|l. oi' death. {Do not list inset iva diagnoses) I1. DISEASES a.lJt.-motes meiillus ipsreiriis w_Mutt'pIe sclerosis ttfirleriosolarotio heart disease Lconoesllva heart failure Lnueclriplagis i Peripheral vascular disease aoflaprasslon m.Hip lracture ft.Msnlo depressive {bipolar disease} r.Aphssia s.Cerebrol palsy l. a-ocide I stroke I2. s.AnIil:iiotlt: resistant irilactior EL.Baptioamia Methicllitn resistant Sexually transmitted disease I to lift) iTul:sroulosts ',Urinarv tract initiation in loot :liJ days d.HlV Inleclion t..Viral hepatltilus e.PriauinonIe I Wound Iriectlon [Respiratory irifeoliort Anmfl: MD5 10 July 2002 (Medicare readmission urns-tum assess. JD:-I71-fnslifi Qua _a I . . Dink-E I OTHER - TYPE 0 r. co 0 Of UM Jirghesl slagn i.T1ha fast 7' days cuRREm- 9 U1-CERF using scaieinriam Mt--ie.. D=noria.' stages 1, 2, at) 3' 3. Pressure uioer-any Iasion caused by pressure rasullartg in CODES h_ . amage DI underlying Iissua (I II. Slaaia ulo&r--open iesiori caused by poor in the lower J1. - Check all problems Pl'afl5|'1HI1lI5t7 days uniess other time irema is indicated; 0 -Dmofis NDICATDRS ui= FLUID omen "sum I 3. REQQLVED Rasidenl had an ulnar ihal was resolved or cured in LAST an DAY3 STATUS . e.Deiusii:ins ULGE-R5 0 Nu 1 0 -- "Edema M3. afihrasions. bruises flan gig or JR LESIONS b.BI.ims {second or ihitrd degree) more ou 2 pmotf 8 lesions other than ulcers, mmas. cuts canoer iesionsi Chuck N, inieririgun. eczema. drug rash. heel rash. herpes zosier 3'5' '9 Needing iirai appiy e.5kin desensitized to pain or pressure shortness ofi:iraail1 gum; gas; 7 it.Recurrsni lung aspiratian: day,' Di C1-IIS 01311 enehyctatad: ouipui last 50 days earned inpui Lshorlness oi tirealh OF AB did NOT nail Ms. KIN rrpraanrra raliefinvgdeviceisj for chair consume allinint-usi all I TREAT. fiqudfi provided during Ia" MENTS IEUBVIHD dewceis) ior bad 3 i program d. h'uIn'iion or hydrelion inlirvartiinn Io manage skin problems ?:ll_l3Ms Coda the highest lover of pain presenirn the first 3' days 7 a. FREQUENCY with which b. mrensmr ai pin - resident or flifimipllcailan oi dressings (win or wuhuut lnpim] medications) gum; sham evicianoe oi pain T- Mid pain 3" I0 T591 0' ND min [amp In 2_ Madame Pam h.AppIii:aiiun ui ioli-ier than to feel] . Lulher prevanlatiira or prnteditre skin can; rothar than in fuel, 1. Pain loss than daily 1 Fa_" daily Ii. rf;M is horrible OF M6. Foot an id ntr-3 I bi . . ll PROBLEM3 AND CARE ii lrileeticn oi Ilia 9 puniieni drainage {ciumir arr - J4. ACCIDENTS rciwcir arr um appiyj tum appty 1" during Jul 7 cl. Nuiisioalluaoa lrirnmad duririg last so tiny: in past 30 days ci.Uiher fractures in is: 180 days; . any; efifleoewad or ilioiaciiva iucii care (9.9, used speciai h.FeIi In past :1 - 'ten days OF ABOVE gr STABIUW ma" Am. "mod {Application ordrassingii (with orwiihpui Iopical medications) oi: behavior paiiems or deleriorailriyi QLNONE OF ABO i-'E EUNDWIDN5 h.Resiria_nl as riancing an acule episode or a ilare-up a recurrent Pm N1. TIME (Check appropriara time periods over last 1 days} 5 0' *0 AWAKE Fiairiizierii ei-rake all or most oi lime naps rip more than me hour ABOVE nnriimn in im- .Mom inn )4 K1, GRAL a.cne>>r biem ha pm b.Afierrio>-J HIV dementia HIV wasting rtiaorderiollowhg organic brain damage disorder iollowlng organic omin damage Spinal cord injury Hemiplagie Hemiparaaee Huntington's disease Dernenlia Registry Reporting 1. County code of prior residence 2. Physician license number NONE OF THE ABOVE . Date Jury 19, 2007 Quarterly Assessment (Medicare readmission or return essessn Rasft-[ant Nme GEORGE LAHOCCA MINIMUM DATA SET (MDS) - VERSION 2.9 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING W. SUPPLEMENTAL MDS ITEMS Numeric Identifier 5030 I-latlnnal ID i Enter tor all assessments and it avaliable. It the of this assessment or the discharge data at this dlachame tracking term Is between July 1 and September 30. skip to W3. 2. Influenza D. title! the resldent receive the Inltuenza vaccine In facility tor this years Influenza seas-an (October 1 through Mulflt 31item Mb) 1. Yes (It Yes. gt: In Item ll' Influenza vaccine not received, state reason: I. Met in tacllity dunng Ihla years flu season 2. Received outside of thin facility 3. Nut 4. Offered and declined 5. Nut altered B, Inability to obtain tranche 3. Pneumo- Vaccine la the rusldenfc PPV status up to date'? D. No gel to Item With) 1. 'fee [Ir'1'es, skip Item W3b) ll' PPU not received. state reason: 1, Not eligible 2. Offered and declined 3. Not offered 1' Date July 1'9, 2007 Quartenty Assessment (Medicare readmission or return .935: Mus an May. 2005 Regeifs Care Center Significant Change in Status Assessment (Comprehensive) GEORGE LAROCCA ARD Date: Soc Sec Current MCR Current MCD Current Med Rec Date of Birth: Current Room: Signature of RN Date Signed as comulete Rugs Score: Print Date: 01I30l2008 091220925 091220925}! QV63-548R 5030 1013011 928 5233 Venetia 0210512008 CC 1 Wednesday. February 6, 200 Numeric Identifier SD10 MINIMUM DATA SET (MDSI VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE scneenrne BASIC ASSESSMENT TRACKING FORM I IECTION AA. IDENTIFICATION INFORMATION 1. eeonee LARDCCA a. (First) II. (Middle Initial} {Last} d. 2- 1. Male 1 |1l9!2!3] 4- RACEIG Native 2. Aaiarwactfieielander 5. White. natal 3. Black, nut uftlispanlc origin Hispanic origin 5. "jig EEZIEI Numaggsg ta. ereare rsim arinr camparebe railroad insurance nurnber) an B. FACILITY a.St:I1eNn. PROVIDER Noe I77 b.FederaiNp.L3| 3] 5] ol 1] do |o[1I 7. MEDIQAID rfnata Medicaid ractptenqa 3. Reasons codes as not apply to this torm] As5Ess_ a. Primary reason tor assessment "guy 1. Admission assessment {required fly day 14] 2. assessment 3. change In status assessment 4. Significant durreetton at prior full assessment 5. Quarterly review assessment 1|1.5ignitic.ant at prior quarterly assessment 0. NONE OF ABOVE b. Codes for assessment: required for Medicare PFS or am state I. Medtaara 5 da assessment 2. Medicare 30 ay asses-srnent 3. Medicare 60 any assessment 4. Medicare 90 day assessrnerrt ti Medicare readniissionrirelum assessment 5. requtrad assessment 7. Medrcare 14 day assessment 8. other Medicare required assassrnenl I Key items tor computerized resident tracking when hot: blank. must enter number or letter page February 05, 2003 Significant' Change in Status Assessment I 5 Signature: of Persons who a Purtiun of the Accompanying Assessment or Tracking Funn I the accompanying intarmatiun accurately reflects resident assessment nr -Intarmation for this resident and that I collected or coordinated cullaizlinn at this tniurmalinn an the dates 5 cilind. to the best at lmnwiadge, this InIcIn11al-inn was collect In aecul-dance with applies a Medirzere and Medicare requirements I understand that this infn-tmfitlon Ia used as a basis for ensuring that residents receive appropriate and quality we. and as a basis for payment from federal funds. I iurther understand that payment at such reds.-rat tuna; and mnunuad pa]-fig]. nation in the Qvvernrneni-fI.Inded health care programs is eanditioned an the ar:r:uraI:y and truthful ness ea' this and that may he personally subject in or may subject my organization to substantial criminal, civil, penalties tar submitting talse talsn certify that I an eulharized tn submit this by this an its behalf. Signature and Tltta Sections Date B. In. PEREIRA RN 'r tt1t:i1t200B Denise Ramirez MM -. error u2_rn4r2ons r. uconnor dietitian '7:--Erztciatgg ozrusrzooa 9. sw osroerzooa I1. GENERAL INSTRUCTIONS Ca.-rrptete urts lnlormauarr for submission with air fut! and quarterly assessments Admission. Annual. 3 rrmr: arr! change, state or Madlesm mquimd ls, or rrarterly Ra views. are. when letter in box. clued: if condition applies MDS 2.0 September. 2000 GEORGE LAROCCA "Wm identifier 5039 MINIMUM DATA SET (MDS) -- VERSION 2.0 FOR NURSING HOME ASSESSMENT AND CARE BA CKGROUND (FACE SHEET) TIDN ATADMISSION ECTION AB. DEMOGRAPHIC INFORMATION SECTION AC. CUSTOMARY ROUTINE Resident 1. one or: We the stay began. Note --_Doas not made; rasumrs.-mm ifremrd was 1. cusroronnv an that app . rr oil' I aiion Check fast box only; ENTRV ;?;gfgd 3ge?mmq discharge to hospital', etc. in such cases. use ROUTINE . In arm an CYCLE OF DAILY EVENTS '2 Iolu OF 3- Month Day Year to this Na 5 re . gutarlr dunn day (at least 1 hour Ap|u||n'En 1. Private itome.iant.w]Ii1 no home health 1 9 Private i1ome.lapi.wlth home health senrtces mg, Go-as out 1+ days a week 6- (AT ENTRY) 3. Board and careiassisted tluingigroup home 4. Nursing home Stairs busy with hobbies. feeding. or fixed daily routine d_ 5. Acute care hospital . at dry 5. hospital. Mrtron facility spends most or time alone or 7 Rehabilitation hospital nursing B: Other home) Moves independently indoors (with appliances. it used) f_ 3. LIVED D. No ALONE 0 at' tubal: dI.I:i 1 I St I tacit'! . 3' NONE ABOVE EATING l=A1'renr4s ""55 Disll at ad I 5. settings resr'o'em' itved in during 5 your: poor to date of We arena entry QiVE'i"i in item A51 above} Eats between meals all or most days . SVEARS Prior stay at this nursing home List: of aloohoilr: bearer:-mats] at Ieastweekiy Ir PRIOR To SI in other nursin home ENTRY 9 5, NONE of ABOVE I. yr Il)tVItno.r and care home, assisted ADL PAHERN3 sailing u_ in bedclolhas mudt of day In. MFUDD setting Watson: to loiiot all or most nights ll. NDNE OF ABOVE g_ Has irregular bowel movornant pattern E. . OCCUPA - shower: for bathing TIONIS I . I I Bathing in PM he on two orzcupatlunsj NONE OF ABOVE . 5 mg 5. ifififiifil orirae - on INVOLVENENT {H|ghaat 2. 6. Some coiie cmi|fiI|t3\IgI9d} $31 Egg? . Dally contact with raletitre-sicaiose trlends 3-- H. LANGUAGE {Code for correct response) Usually attends temple, synagogue (eic,} t. 3vP"'"a'Y Finds strength in faith II- O. 1- Sflafllfih 2. Ffanch 3. u_ b. it' other, opacity ~o~eomovs 0. No 1. Yes UNKNOWN-iiesldentifamily unable to provide inionnetion 'id. CONDiTi0NSItCiro_cir all conditions that are related to MRIDD status that were TO manifested before age 22, and are Iiiteiy to continue indeiinrieiyi Notappiicable--rto IUHFDD {5|cip1l:lAB11J SECTION AD. FACE SHEET SIGNATURES with organic condition SIGNATURES OF PERSONS COMPLETING FACE SHEET: it a. Signature at RN Assessment Coordinat Autism Epflepsy I I orma ifli'I CLIFE. . ntorrnallon for this resident and that I collected or coo collection of this information on the I Other organic condition related to MRJDU a. me: 9 aciried. To the best of my knowledge. this infor 'on was collect irtaccorcianrza with . applies to Medicare and Medicaid requirements. I understand that this irriurrnalion is used as a MFUDD "9 condition oasis for ensuring that rosidonts receive appropriate and quality care. and as a basin tor paymanl am-E lrom Iederat iunde. i iurthar understand that payment of such tettarai iI..rIda and continued partici- 11 BACK- potion in the govornment-tundad health care programs is on the accuracy GROUND -1255 oi this informotioh. and that may be personafly subject to or may suhjoct my organization to subtilanlial criminal. cruii. andior administrative penaities for submitting false iniorntett' on. i also 110" Mantra gay certify that I am authortaod to submit this inforrnation by this facility on its behalf. COMPLETED Siunaturo and Title Sections page box blank, must enter number or inner letter '91 bait. check it condition applies MUS 2.0 September. 2000 Print Date February 06, 2008 Significant Change in Status Assossrneni LAROCCA Numeric Idantl fier 5030 MINIMUM DATA SET (MDS) VERSION 2.0 FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING FULL ASSESSMENT FORM (Status in last 3' days. unless other time frame indicated} 3_ (Check all the.' resident was able to recall during RESIDENT . RECALL est 2 days) um: GEORGE LARDCCA ABIUTY a_ Th I I. (First) Ii. (Middle Initial) c. (Last) :1 (Just) Lucelion 3' 5 2. ROOM statf nemeelleces c. NONE OF ABOVE are receltod 4. {Made decisions regarding tasks ofdaiiy life) 3- Last day Df observation peffpd D. decisions 'l iubiu 1. MODIFIED INDEPENDENCE -- It Ii REFERENCE MAKING only some I it In new uo one DATE 2 print" cnteslsupervision Day Yfiflf Iain"-ed b. Original (Blot correrited copy of form {enter nuntaer eroorrection} 0 WFNRED mad" 5. INDICATORS (code tier behevicrin the test 7 days) assessment 43. DAT: OF Date of reentry from most recent temporary discharge to a hospital in OF requires convoi-seuons wiui staff and remlly who have direct REENTRY test 50 days lerelnco lost assessment or If less than an days} knowledge over this time]. IJ.EIel-mvicir not prfitleni -- -- I THINKING 1. Behavior present, not or recent onset 2. Behavior pro%, over last 7 days appears dtlfaronl Item roeldenrs usual Mom Day Year 5" 555 tunctlonlng 03.9.. new onset or worsening} 5, MARITAL 1, Never married 3_ Ufidawad 5, Divorced EEASILY paying attention: STATUS 2. Married 4. separated 2 e. .. moves I or let: to someone no RECORD present; b-elives helslse is some-fitiera else; conluses night and 7. CURRENT [Baiting Dliice to indicate; check all Itrol oppiy in lost' days] PAYMENT . . - c. EPISODES OF DISDRGANIEED speech is MEGICBIG diam VA Ital' diem Incoherent. nonsensical. Irreletrent. or rambling from - I: act; trial I I1 STAY Medicare per dlem Seller family pay: for full per rtiem 3" led to I 'uses 0 mung '1 ILPERIGDS or fidgetinp er picie-.g el stein. Medicare anelilary Medicaid resident liability er clothing, napkins. etc.: frequent position changes; repetitive physical part A p. Medicare wpoymant I1, movements or Iziling out) Igam par diam "Handing I, 3- PERIODS OF staring into space; dillicult to arouse; little body movanient] CHAMPUS per diem Other per diem . r. MENTAL Funcnon venues oven THE COURSE or THE 8. REASONS Ia. Prim ry reason [or assessment DAY sometimes better. sometimes worse: behaviors FOR I. Admission assessment lrequlre-:I by day 1-4} 0 sornelitrtea nresent. sometimes non i g:1m:?I I I CHANGE IN Residents cognitive status, stills, or abilities have dlenged as man me 5 a asses"! COGNITIVE compared to status of no days ago [or since last aseassmarfl Iflase '[Ne?e srxrus the an days) rec . or restart? 6. Discharged -return not anticipated NO Change 1' 7. anticipeIed subset or 3- SECTION C. CO MMU ICATIOHIHEARING PATTERNS "05 9' Rem"? (with ties plien if used) need be 1lJ.SIgI1IlIcent correction cl prior quartetty aseessmartl 1- HEARING completed] 0' "amp mp ABQVE D. HEARS talk. TV. phone 1. LIINIHAL net in quiet setting b. Cudel fomsaessrnerils required for ltfadlcere PPS orlho stem 2_ HEARS SPECML 5mm-"BN5 has in aqua gotta tenet quality and speak 3; mdgcam 33 3. ofuselul hearing . Medicare - 5. "adhere assesmm 2. (Check at! rear appry eumig last i' days; 5. Other stale required essessmenr . DEVICES, 335. End J: NEE Hearing aid, present and not used regularly other receptive cumm. techniques used tog. lip reading) 5. {Gites}: all tirelappiyl Durable power d_ NONE OF A5555 Legal Guamlm Family "umber respomima 3. ODES OF {Check all used by resident to make needs lain-w.-r} - 3- 9- EXPRESSION 5| 5; . 5; d, GUARDIAN Otherlegel oversight Speech 9" 9" we - b. Patient responsible for sell f_ a. com Durebl none I wr't'ng rnesse I bflfifd Ir. NONE OF W5A50V-E . erqairless or clrily neaeds 0 . I . . lher I 10. ADVANCED I-wtii sup rting documentation in the Amman 3| gn language . DIRECTIVES chock an' mar wagging or Braille . NONE OF AB DUE f- 11, MAKING (Expressing Inform aticn content-hon.rem-er elite; 90 ml Medication restrictions 9 . - . on Do not hoapilaiize -3. mm' "emmam 51559 1. finding words or 2. somerrnres is limited to making concrete Autopsy request 9 NONE OF THE ABOVE 1, requests to 3. RAREI. uneven :3 5_ SPEEFH (Code Iorspeech in the test 7 days) - TV Intelligibie words - SECTION B. COGNITIVE PATTERNS 5pEEcH__5,Lmd_ mummed mm 30!; 1. CDMATOS {Persistent vegetative stelerno discernible consciousness} 2.N0 SPEECH-absence of spoken words o. No 1. Yes Ill Ins. skip to auction Gt 0 6. AeII..t1'v 1'0 (Underst'arrct'rIg treroelinlarmalfan nanreneriatieverarnie) . 1, MEMORY mam? DI Mm was teamed or Maw miss some tent at? 5 a. Srtorl-Ierrn menury ox msieppeers to recall al'lEIl' 5 minutes OTHE RS - mmga 5 U. Mernery OK 1. Memory Problem 2. IMES IJNIEERSTANDS -responds adequately to simple. II, Lorre-teen memery UK-seernsleppeereto recall Iongpest "m In UK Mummy 1_ pmblem . 1 3. UNDERSTANDS 7. CHANG IN Residents ability to express, understand, or changed as cempared to status 90 days ego {or since last CATIONI assessment if less than 90 days) HEARING 0. No (Ergo 1. Improved Zflelerloreled :I=Whan box blank. must enter number or letter nwhen letter in box, check It concliliun applies Print Date February 05, 2003 MD5 2.0 September, 2000' . Flegldont |'TERhis 1, (Ability to see in adequate light and with glasses if used) line tietali, including regular print in rtevvspaperiboolts 1. large print, but not regular print in newspapers} 2. vt'elon:nol able to see newspaper headlines, but can Identity objects 3. HIGHLY identification in question, but eyes appear to follow oblecls 4. SEVERELY vision or seen only light, colors. or shapesuayas do not appear to lollow objects 2. Side viipion loLoI.. tggeos?lood "3 I I I Va jams Experiences any holes or rings around finches oi "curlair'ts' over eyes NONE or THE ABOVE 3' Glesses;contecl lenses: magnifying glass ID. No 1. Yes 0 SECTION E. AND BEHAVIOR PATTERNS 1. INDICATORS OF (Code for fltdicetors oosertred in test 30 days, inespacliue or the assumed cause} 0. indicator not exhibited in last 30 days 1. indicator or this type exhibited up to five days a west: 2. indicator of this type exllbitecl daily or eintost daily l6.? dye at week) UERBAL EXPRESSION h. health OF EHSTRESS seeks medical 11- Resident made negative attention, obsessive nlelemenlsu-9.9. "Noihmt:r with body functions matters: Would rather be dead: Vlhafe the one: regrets having lived an I. long: Let' me :59" contpielnlsiooncerns {non- health rolatedl a.g. persistently seeks attention! b. Repetitive questions--e.g., -M'era do I Wm [5555-IJfanCe do?" schedules, meals, l:eunt;lry_ clothing, relationship issues SLEEP-CYCLE ISSUES 1. Unpleasant mood in morning c. Repetitive v-erbetiutlons-- calling out for help. ("God iteip mo') ct. anger with soil or oIhers--e.g.. easily annoyed. anger at iacemenl in nursing a anger at care received no. Salfrleprecalion--e.g.. "i nothmg; i am ofno us to anyone It. Insomnlaichenga In usual sloop pettem silo, APATHETIG. AI'-ittlous APPEARANCE I. Sad, pained, worried recital turrowed .c I 1- fiuln r. "1 "5 appear to be unrealistic - leare--o.g., fear of being n' I35 hand wringing. resdessness, being with others gdg5gng_ pp,-M-,9 g. Recurrent statements that . - I-D55 OF WTERT sorndi-tln terrible to about - - tohavva-3-B-or-brtiaves long standing activities or 3 5' being with lemiiyifrlende I p. Reduced social interaction One or more Indicators of depressed, sador anxious mood were not easily atlerao by attempts to 'cheer up". console, or reassure the resident over last 7 days 0. No mood 1. indicators present. 2. Indicators present, indicators easily altered not easily altered Flesidents mood status has changed as compared to status at' to days ago -{or since last assessment it less than 90 days) til. No change 1. improved 2. Delerloreted trtjaehaviorai frequency in last 7 days Cl. Behavior not exhibited in last 7 days 1. Behavior 01 this type occurred 1 to 3 days in last 7 days 2. Behavior oi this type occurred 4 to is days. but less than daily 3. behavior or this type occurred daily Behavioral aftorobiliiy in last' 7' days 0, Behavior not present OR behavior was aasliy altered 1. Behavior was not easily altered rt. WANDERING [moved with no rational purpose, seemingly oblivious to needs or satiety] It. VEREALLY ABUSIVE BEHAVIORAL [others were threeteneti, screamed at, cursed at] G. PHYSICALLY AELISIUE BEHAVIORAL (others were hit. shoved, scratched. cexuaily abused} ct. SOCIALLY INAPFHOPRIATEJDISFIUPTIVE, BEHAVIORAL (made disruptive sounds. nolslneac. screaming. coll-abusive eels. sexual behavior or dlerobing in public. loodilecas, hoarding, runmeged hrough others' belongings) e. RESISTS CARE {resisted letting medicetlonaiinjeclions, ADL asslsiartce. or eating) Numeric idontiltar 5030- IN OI SYMP TOMS BEHAVIORAL Residents behavior status has changed as compared to status or en on days one {or since last assessment if less than 99 days} 0- N0 Ehfiltlifi 1. Improved 2. Daterlorated SECTION F. 1. SENSE OF A1 ease interacting with others it N. ease doing planned or activities IHENT At ease doing self-initiated activities c_ Establishes own goals Pursues involvement in tile or 1ectlt'ly te.g., tneitosliteeps friends; involved in group responds positlvety to new activities: 9 assists at religious services) Accepts invitations into most group activities NONE OF ABOVE g, 2_ Covertiopen conflict with or repeated I staff Unhappy with roommate h. SHIPS Unhappy with residents other than roommate c_ openly expresses with iamiiyitticnds Absence of personal contact with l'amily.'ft'lertt.'i's E, Filectt nt loss of close family memberlirlend Does not adjust easily to change in routines g. NONE OF ABOVE h_ .3. PAST ROLES Strong identification with past roles and its status a Expresses sadnesslartgertemply feeling over lost rolelslalus bi Hosident perceives that daily routine [customary routine, activities) is is very different from prior pattern In the community c. NONE OF ABOVE d. SECTION G. PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMS 1. IPJADL SHF-FERFORMAN Code for res'tdani"s PERFORMANCE OVER ALL SHIFIS during last' 7 doys--i'liot setup) it. help or oversight--OR--Helpiovorsighl provided onty or 2 times during last 7 days 1. SUPER encouragement or cueing provided 3 orinore lit-rte: during last 7 [3 or more times) plus physical assistance provided only 1 or 2 times last 7 days 2. Resident highly involved in activity: trtoeivncl phycirti help In guided maneuvering ol limbs or other nonweight bearing assistance 3 or more times- 0R--More help provided only 1 or 2 times during last 7 days 3. resident perlomtod port of activity, over last 7-day period, help of foiiovirlt-lg typets) provitbd 3 or more times: --Weight-boating support stall perlorrnance during part (but not oil} test 7 days -1. TOTAL DEPENDENCE-F ull staff perfornuiitcs of activity during entire? days ti ACTIVITY DID NOTDCCUR during entire days {at AOL SUPPORT rm-mosr OVER ALL SHIFTS during lost 7 days; code regardless ofresfdertittr sell'- dassiliceiion} 0. No setup or pi1ysli:aIhetprrom stall 1. Setup help only 2. One person physical assist 3. 'i'wo+ persons physical assist 4-: 'il- as tt. ADL activity itself did not occur during entire 7 SUPPORT e. BED How resident moves to and front lying position, turns side to side, 3 2 MOEIIJTY and positions body while in bad b. TRANSFER How resident moves between bed, chair wheelchair, standing position toifront bathiloitell 4 5' How resident welits between intentions in hlsiher to-om d' How resident walite in corridor on unit 3 3 -2. How resident moves between locations in hiafher room and TION adjacent corridor on same lloor. It In wheelchair. lJl-il'l' onceinchelr 4 .. f. l.0C(lPilD~ How resident moves to and retums from oil unit locetlons TION areas set aside for dining. activities. or treatments]. Illecl try has OFF UNIT only one floor. how resident moves to and from distant areas on 2 the floor. it in wheelchair, sell-sullicienoy once in chair 9- DRESSING How resident puts on. lastens, and takes oil' all items ct street clothing. lnciuding donningrrernoving prosthesis 11- EATING How resident oats and drinks [regardless or skill}. Includes intake or by other means lube teeding, total parenteral nutrition} i. TOILET USE How resident uses the toilet room (or commode, oedpan, urinal): transfer enroll toilet, cleanses, changes pad. manages pater-rty or calheter, ecfiu sis clothes I- Hour resident maintains personal hygiene. including combing hair, brushing leelh. shavlng,e ly'n makeup, betltsantziwshowars) 2 Print Date February 06, 2008 Significant Change in Status Assessment MDS 2.0 September, 2000 Rama"! GEORGE LAROCCA "mm menu", 503!) 2. TITFITNG resldanllolles a full body sponge bath and i 3- APPLIANCES Any smedmeu |ofle||ng plan a_ Did not usetoilet room! I: renslersl inl'-our ol tub shower washing or back and heiln} - AND cornrnodeturinal code fnrmasl dependent in self-perfom:-ance and support. PROGRAMS Bladder falfaining program b_ Pdamn-BIB "sad g_ BATHING SELF-PERFORMANCE codes appear below "am 1 En Ear 0. Independent-No help provided 1. help only Inctwelling catheter Oeiomlr present 2. Physical help limited to iransier only lnionniilenl catheter NONE OF ABOVE 3- 3" 9" 4_ CHANGE IN Resident's urinary continence has changed as to status oi' Ii. Total dependence URINARY 80 day: ago {or since last assessment if less thanslo days) CDNTINENCE B. Activity itself did not occur during enlire 7 days 0. No change 1. 2. Daterloratelzl (Bathing support codes are as defined in Item 1, coal; 3 above 3. 1'53? Fog {Code during reslln me last Tdeys} DISEASE DMGNOSES HALFNCE D. Maintained position as requied in test check ant: those discloses that Irv a relationship to current ADL slat!-I5. cognittiva status, 1. Unsteady, butaul at; |f "ham . . ,t mood and el-levlor status, medical treatments, nursing monitoring. or risk of death. [Do not list 2. Partial physical as M90 or stands lsilsibut does ml follow directions for test 3. Not auto to attempt lost without physical help 1. Balance whla standing te. Balance whlia sillirn-position. trunk control 3 Mumpla Salem" 4. [Code for r_meal'am; 7 days last lhlorfered wan daily functions or Fararalenla x. 'had "mfg": 5' Parkinson': disease RANGE OF RANGE or M0 nrolv lei VOLUNTARY MOVEMENT MDTIUN 0. Etc Ilfillflailm I No loss Hypothyroidism Ouednptegla . on on one 5 . 8 also |m|taI|on on both slides 2. Fuliillanss (B) Secure disorder 5 a. Neck in '?59353 attack rm) an is. Arm-including shoulder or elbow - c. wrist or fingers 0 Cardiac E. mi" an. d. Leg-Including hip or knee Beams," ham Him, 3' ankle at 0 Deep vein thrombosis '1l50fdB|' dd. l. Other limitations or lose 1 DE . 5_ MODES or (Check all rharopply duninglast Tdeys} HYIJDIBTISIOT1 disease, it Ganemalhariuutoh a. wheelchair mode of Peripheral vascular disease 99 5' Other cardiovascular disease PULMONARY Omar 9573"" C. NONE DFABOVE B. Asihrna hm 6, {Check all that apply during test 7 days} n_ ur Hedfasl at or most oi' time 3. Lifted mechanically d, I Eh I and rails used for bed ald mg" suds mam ss :19 um amputolior n_ a street: - mobility ortrensler b. lrapem cane' wa.kB,_ hm") a. flsleupamgis 0 Diabetic relrnopelhy uh mm-ma||y c_ NONE OF f. PE1hD|D9iCilbDl'|9 Giauwnm TASK Eons or all at AIJL activities were broken into sublaetls during last 7 Rm-9 5'9" mm, SEGMENTA- turn so that resident could porforrn them Alzheimer': disease it o-men 7'9" 0. No 1. Yes 0 Away, any ms 8. An; Resident believes heishe is capable or increased independence in 9 law. at less: some a. Gfirebrai Pals! 5. an. Direct care stair believe resident is capable of increased Cerebrovaowlsr accident Cancer POIENTI AL independence in at least some mu other man Renal failure Resident able to perform but is very slow 3 disease 1.1. NONE BF A30 l/E Diiforonca in ADI. Sell'-Performance or AOL Support. oomparirlg 2. INFECTIGNS NONE OF ABOVE 501'} mornings to evenings Sap"-mmia I - NONEOFABDVE a_ Sexually disease .. 9-. CHANGE IN Roall:lem's ADI. status has changed as compared Ciostricliurn lc. dill.) h_ I to si.ItI.l.I oft) days ago (or since last assessment if less than 90 . . Unnanr tract infection In last FUNCTION clays ago) no days J, D. No Change 1, 2. Deterloraiod 2 d. Viral hepatitis k' Pneumonia 3 .35 SECTION I-l. GUNTINENCE IN LAST 14 DAYS Respiratory lnraclion "Si: oreegue CCINTINENGE SELF-CONTROL CATEGORIES 3 THE - 2 9 9 'Code for resident': psesomrsuce oven Au. SHIFFSJ CURRENT OR MORE 33. 0. CONT if-'EN T-Complete control {includes use urinary catheter or oslamy oemmsp device that does not leak urine crslool} DMGNOSES - 1. USUALLY incontinent episodes once a week or less; 9 less than weelofy BDWEL. once a weak BDWEL. all' for elrr.-as: all} of the time INCONTWENT-BIADDER. 2 or more limes a weak but not daily. 3. FREQUENTLYINGONITNENT-BLADDER. tended to be incontinent daily, but some control present on day shill}; BDWEL, 2-3 times a weak 4. lrtanlequela control HLADDER, rnultiple daily Episodes a. BOWEL Control in! bcmal rnovemenl, with appliance or bowel oontinarlce programs, it' employed D. BLADDER Control of urinary bladder function (it dribbios, volume insuliiclent to costs through underpants}. with appliances Foley} or NENCE continence programs it employed 3owEr__ Bowel elimination paliem mama, feeder-Bl least one pa-"ER" movement every three days Fecal d_ Constipation b_ NONE OF ABOVE 9_ M05 El} Seoternber, 2000 Print Date February 06, 2008 Significant Change in Status Assessment DISEASES (If none apply, CHECK the NONE OF ABOVE flax) euoocnluem-lErAeoLlol - SECTION J. HEALTH CONDITIONS 1' FR.-JELEM {Check pros not in last 7 days unless other time frame is CONDITIONS mama") IN OF FLUID s'rArue - Emma . . 9. Weight oaln l:lr toes ol 3 or Few, will-lln a 7 day Dario Hallucinations r. shortness oi breath Fawn" lung Dehydrated; clulpul eaceeds '35' 9? input Shortness oi breath I. lnsufliclonl fluid; did NOT Evncepe iiainiinnl m. mnwme ellialmoet ell liquids Unsteady gait ,3 pmvidad cluring last: days .3 011-ran "9 paluaims NONE OF ABOVE Pr GEORGE LAROCGA Numeric Idonlillor_5C'30 Resldenl 1. ULCERS ffieroordlho numoerar ulcers el each ulcer sl'age--reEaro'la1-s of -5 3 3-FREQUENCY . D. INTENSITY ofpaln are eta e. record' ode aifihfepply 5 resident oomplalnsor A . [flue to any donng tau! 7 ays. Code 9 ormore_l ffloqotms full body exam] an show evidnca of pain 1- 533'" cause} 2 '5 0' "1 Zmodaretepeln 1. Pain less than daily 3. Times when pain is in. Stage 2. A pgarllal thloluteso loss or skin layers that presents . an ly -- r: cayasanorason. usenorsooworator 2 dal humus lint II I bl' I It FAJI-.1 SITE Flresent, check orisitoslhal apply irrtasr 7 days) 5- 35983 3- gttigsgneg giggle am 53;" E. Pain I. auzljsoent IISSLIE. Bone Pal" I3. naln {other than hipl g_ at Stage 4. A run l_hir:ilness or skin and subcutaneous tissue is lost. Chest pain while doing usual I"-Eta 3355"'. muscle bum' fl- 2. -n-pg op [For each type of ulcer. cod forth: highest slept: in me tool.' it Hgafiggha d_ Stomach pain I ULGER Hang sceletn item ll-if-i.e., flunono; stages 1, 2, 3, 4) Hip pain 5' Other 3- gresiure caused by pressure resulting in damage 4. [Chock art rhatappiyj 5 mg' 53" Felt Input 30 days g_ Hip 'mama 5" 335313" -2. 11313535 lesion causal by poor clncolatlon in the lower Fall l.n past 31.13:: days Is, Other flzdore in laot1n0 day: d_ mom; or: Agovg u_ 3. En?' Residaru had an ulcer that was resolved or alred in LAST 90 DAYS 5. Ccndilionorrlisoasoe metre resident' ii . NJL. cl ULCE STASLLIW behavior patterns a. 0- 1- V35 CONDITION Resident experiencing an lcute episode or a llaro-up at a recurrent 4' {check It ma.' afipfy during 'mm 7 day') - pr flupnlc H. OR LESIONS Abraslons. bruises 3' End-siege disease. 6 or rower months to live it. PRESENT ("and mitd dear") b- d. Uillen lesions other than ulcers, raaho. outs cancer lesions) c' Rashes-o.g.. inlenrigo, eczema. drug rash, heat rash. hrpas zostor 3' desensitized to pain or pressure 'iEc"E:Al:' STATUS Skin tears or oats [other than surgery] f_ . hewin rah! PROBLEMS Surgical wounds SKIN ounn last 7 do It NONE OFASDVE I Pressure rellovl Er ch ya) I 2, HEIGHT Record re.) height in inches and weight In pounds. Ease weight' on F. .ng a' wgiflclilfl l'l'.l gs! 30 days; measlfim mad res-sure rollevlng deviate} for bed wt l-ca-e. ., - - - . shoes DH. and 9 a m. mm"? heme Mae' program c. Nutrition or hydration Intervention to manage skin [ems o. 7 I1 I 6 8 U,m.we pm 3. nu 5-5% - CHANGE ln days or more in the last 30 days, or 10% or more surgical mum we ND 1_ YES to elgcialbn ot dressing [with or without topical rndic-aliens) other than g_ b- or man in Ihe last 30 days: or 10% or more at {other then to feel) II a ?3 7' 1 other preventative or protective skin are (other than to test) NONE OF ABOVE me "i 25" 6 l'Chocir during last 7 days} PROBLEMS n. uneaton oi moat meals . . Resident has one or more foot problems-e.g.. corns mlluses, NONE OF ABOVE bunlons, hammer toes. overlapping toes. pain. etructuml problems 5- rennet off our in last 7 days} Emnlw EM ceuulm pen as one am not a. bat'-Vfl'BI1 Naifycanuses during days 6' Ffifldiflli lube ta, mm tab'; ,5 1_ Rflcelwd preventative or protective foot care used special shoes Mechanically altered dial menigfic.' 5 Me H1 up inserts. pads. loo separators) 9. Application of dressings [with or without topical medications) Stmnua lnrat feed-not d. On a planned weight cnanga NONE OF ABOVE Therapeutic diet o_ pmwam NONE OF ABOVE G. PARENTERAL 10 Scflou Lia nor E1: is attacked} Acfwn-y pufisurf OR ENTERAL 9. codeine roportlon of total oolorlotl the raatdenl received through I mums pmmerafw tuba in M, 7 am (cu act: time periods amrasr 7 days) 1 None 3_ 51% to 1,5 Resident eweke e_|I or_most oi the lime naps no more than one hour per time pallad) In the: 2. 25% to so 'it: Morning :1 Evening a yr b. code the average fluid intake per day by or tu'ba inlast 7 days b' 3( Home oi: ABOVE 5 3- 1991 i0 1559 9053! ltli rosldont in comatose, skip to Section :ooDcDt::u:gmay 2, Avfififlp?g awake and not or AOL carol INVOLVED U. "1311 2,3 Di limo 2. Litfla-3383 in D7 ACHVITIES 1 Sorno-lrom V3 to 25 or time 3 None EC . Full 0 5 STATUS 3. PREFERRED at-'settings in which 1. ORAL fault, easily movable 5ub5lanl:es} present in mouth prior to ACTIVITY mm "mm pfigvglarmju Has dentures or removable bridge Sorrloiall natural teeth loot-does not have or does not use dentures made "Hm" mm NONE OF A5 DUE {Dr partial plates) 4. GENERAL (CHECK EH PREFERENCES or nu! agjiyily J5 cunenuy available to resident] . Broken' hose' or 'gem 'cl PHEFER- Cardslolher gmee a inflamed gums swollen or bleeding gum; oral abscesses; 534353 cransjans Walklnalwheotlng outdoors "me" {adapted to . b' Watching TV 212?? cleanlnti oi loothroentures or daily mouth care-by resident or roslclonlgs c' Gardening or plants as c: . NONE OF ABOVE 9. Emma} Lat?" "9 Print Date February 05. 2003 l. NONE OF 2.0 September ZDDO Significant Change in Status Assessment Roiildorrt GEORGE LAROCCA riamaria idanditer 50 30 5, pgepgns Code torresiderit preferences in daily routines -1. news 55 [Use the following codes for test 7 days.) IN 0. No change 1. Slight change 2. Major change gfilfid Extent of resident imroiverneni In activities Fag fang .., a. --FutI bed nails on all open side: of bad 37'0" 0- MEDICATION5 ti. types oi side rails used heri rell, one side] 9 1_ NUMBER OF (Record the number of different medications usadin the test 7 c. I-est,-aim to am TIONS BRIEF 110119 used} Limb restraint IL 2. New receiving oredications that were initiated during the o. chair prevents rising MEDICA. in: so days] HOSPITAL Record number of times resident was admitted to hospital with an 0 0- 0- ovrrtighi stay in last an clay: [or since test assessment lies: than 90 3. INJECTIONS gfiacord the numbern on Y5 injections or any type received durirre days}. (Eniaro if no hospital ?Ill'fl'ii'$5'i'0I'i5) 7 'days'. en" -0-J-"ma "saw EMERGENCY Record number of times resident visitcl ER without an overnight stay In lost 90 days (or since last assessment it Iess than 90 days) {Entero if no Iristts) 9' 4. DAYS {Record the number of DA Y5 during test 7 days.' enter if not used. Nota--er:ter for tonpuectirtg med': less than tveeiriy] . 7_ In the LAST 14 DAYS [or strum admission it less than 1-1 days in 7 VISITS taeitityj how many days has the physician {or authorized assiaiard or 1 b. P-ntianxlelir Diuretic practitioner) examiried the resident? (Enter it i'.'nmeJ 1' titntioepresaanl 9 8. PHYSICIAN In the LABT 14 DAYS [or since admission if less than 14 clays in 055535 lacililyi how many days has the physician [or eulhoitzed assistant or . P. SPECIAL TREATMENTS AND PRDCEDURES Practitioner] changed Ihe resident'! orders? 00 0-flier renewas without change. [Enter 0 itnariei ii. ABNORMAL Has the resident had any abnormal tab values during the lost as day: mg"-rs. LAB VALUES [Of since TREATMENTS Ventilator or respirator 0. No 1. Yes PROGRAMS cherriotharapy 9- PROGRAMS 3- Arlgohranvriglma SECTION DISCHARGE POTENTIAL AND OVERALL STATUS medication 9 m- 1. DISCHARGE it. Resident ezpre-aseefindioales preterenoeto return to the community d_ gllfitaesriniiareidameniia special PGTENTWL 0 ND 1 Hosp," b. Resident has a support person who is positive toward discharge Osmm, cam Pediatric unit 0_ ND 1_ Respite care - - own" that-any Stay protected t<> 1. Within so days Discharge elalus uooerIa_in pping,t:ansportdior1 NONE OF ABOVE "55THERAPIES - Record the number otciays andtoiai trtiriutes oi_iha . therapies was [for at least 15 tnintri-es day) in raslricfiva mom supp the int 1 cntendar days (Enter 0 ifnoi-is or tees then 15 min. da iiy) {Nata--count only post admission therapies} of days administered tor 15 minutes. or more A33E33MENT [B]=totat it of minutes provided in test 7 days [El 1 3 Residetcaa AT?gg??_ D. FamilyFamiiy b. Dccu|:In|itrnal therapy 0 0 0 0 [3 MENT c. Signilioani other: 0. No 1. 'tea 2. None ,1 0 OF PERSON COORDEN THE ASEESSM EMT: ii 0 0 Venena UYRN . Paymuhgiml "flaw (by any "Emma menial 0 8. Signature of RN Assessinont Coordinator (Sign on line) health professional] 0 0 b. Data RN Assessment Coordinator {Check on Interventions or strategies used in tho last 7 35 new matter where reoeiveit] Month Day yea, Special behavior evaluation program 3 Eveiuetlon by a licensed mental health speciaiisi In last 90 days I-035 Group merepy 9 Resident -specific deliberate changes in the environment to address moodthehavior paltarns--a.g.. providing bureau in which lo rummage F- ouelng NONE OF ABOVE i. 3. uu fis|r~Ja Rocorditio NUMBER OF DA Y8 each of the !'oi'!owi'ng rottaoititaiion or restorative techniques orpractices wesprovfoed to the resident for more than or equal to 15 minute: per day in the last 7 days t'EnterO irriana arteaa than 15 min. daily) in. Range oi motion {passive} 0 f. 9- I 9 Significant Change In Status Assessment on Splint or brace assistance it h_ Ea]-mg or swaflqwing I. cam Pith: DHIB February 2008 d, 53.5 1. cornn1i.init:ation 2' [1 k' Omar MUS 2.0 September, 2DDfl I SECTION 5. SUPPLEMENT-MDS 2.0 (NEW 1. um? NLMEER Enieri:uI'i'enl number. Follow lneimciionin the manual. 0 5 2. PRESSURE Record in: appropnale response. Siege 3 or 4 pressure ulcer ULCERS aliea prassni upon admission or readmission. roporled silos were preseni onadrnission or readmission 2. Some of the currently reported sites were present on admission or readmission 3. None of the ourrenlly reported sires were prasenl on admission or readmission 4. Ho stage 3 or 4 alias currently' reported 3. SUBSTANCE Subsianoe ables history. He: the resident with HIV engaged JIBUSE in sutislance abuse behaviors more than one monih ago which noniinuo to influence care curreniiy given in the resident? Record ihe appropriate response. Li. No 1. Yes 2. Hesiden! does not have d. DISEASE Reoord only those disease diagnoses thai have a reiorionsriip DIAGNOSE 1o docurneni ADL aleius. cognitive status, mood and behavior .9-iaius, msdleai ireaimenis. nursing monitoring. or risk of doom during the last 30 days. (Do not Ila! irieotive diagnosis). (check all that apply) HIV dementia HIV waaling Non--psyci1oiIo disorder ioii-owing organic Inaln damage dlaorderfoiiowing organic brain damage Spinal cord injury Hernipiagla Hemlparases Huntington's disease Dementia Registry Reporting 1. County code of prior residence 2. Physician iioense number 1. NONE OF THE ABOVE Pn'ni Dara February 06, 2008 Change in States Assassmeni NuneI'ic idantitler_fi_Qfl_fl nn&dmr LAROCCA T. THERAPY SUPPLEMENT FOR MEDICARE PPS 1. SPECIAL number at' days and total at' TREAT. recreancrn therapy ad.'1'ir'nlStai'acr' (for at last' minutes a day} in the MENTS AND test 7 days {Enter 0 if none} (A) II efdnye eciministered iclr 15 minutes or more lfii (B) 8 total #01' minutes provided In last 7 days 0' 0| Strip unless this is a Medicare 5 day or fitecticere return alsessment 0 b. DRIJERED physician ordered any at tolnrwing therapies to begin in FIRST 14 days at Slaypiryeical therapy. occupational lherapr. or speech pathology service? D. No 1 . Yes liner ordered. skip to item 2 u.Through day 15. pruvide an esfimata at the number of deg: gt-ren at least 1 therapy service can be expected id have nan ellvered d.Thrcugh day 15, provide an estimate at the number art therapy minutes {across the the:-mics) that can be expected to be delivered? WALKING Complete item 2 IFADL sen'-perfonnenca score for TRANSFER WHEIEDST is 0,1,2, are AND at least one or the are present: SUFFICIENT 0 Resident received physical therapy involving gall: training I Physical therapy emu entered for resident Involving gait training fi'.1bJ Resident received mrsing rehabiilaliun ll:-r waiirintt Physical therapy Involving walking has been discontinued within the past 150 days Sfrip to item .3 did not watk in rest tie]-er (FOR THE FOLLDIMNG FIVE ITEMS. BASE CODING ON THE WHEN THE RESTOENT WALKED THE FARTHEST WITHOUT DOWN. INCLUDE WALKING DURING REHAHUTANON 8. Furthest distance walked without eitti:-:9 clown during this episode cl. 150+ feel 3. 10-25 feet 1. St-149 feel 4. less lhan1l.'i feet 2. 23-50 teal b. 't1rI1e vraiirdci withdut sitting down during this episede. 0. 1-2 minutes 3. 11-16 mhulr.-5 1. 3-4 minutes 4- 16-30 mhuies 2. 5-10 minutes 5. 31+ fl'liW~l1B5 C. Self-Porfc-rrnence In walking during this episode. 0. help or oversight 1. enccumgernent pr cuaing provided 2. t.l!.tlTED highiy involved in walking: received physical help in guided maneuvering of limb: or other nonweighl heart:-g assistance 3. EXTENSIVE received weight bearing asslatame while walking El. Walking support pruvlcloct associated with this episode [cede regardless of resident's setfapertmnam:-e ciessilicatiarr) 0. Na setup nr physical help train staff 4- Setup help only 2. One person physical assist persons physical assist 9. Parallel bare used by resident in association with this episode 0. No Yes 3, CASBMIK GROUP Medicare 0 State Print Date February 06, 2003 Significant Che nge in Status Assessment M03 2.0 September, 2000 V. RESIDENT ASSESSMENT PROTOCOL SUMMAR Numteldfinlilmi Ftesidents's Name: GEORGE LARDCCA Medica; Record No; 5330 Check if RAP is triggered 2. For each triggered RAP, use the RAP guidelines to identify areas needing further assessment. Document relevant assessment information regarding the resident's status. Describe: -- Nature of the condition (may include presence or lack of objective data and subjective complaints). --Comp|ications and risk factors that affect your decision to proceed to care planning. --Factors that must be considered in developing individualized care plan interventions. --Need for referraisifurther evaluation by appropriate health professionals. 0 Documentation should support your decisio n-ma king regarding whether to proceed with a care plan for a triggered RAP and the type(s) of care pian interventions that are appropriate for a particular resident. 0 Documentation may appear anywhere in the clinical record progress notes, consults, fiowsheets, etc,). 3. Indicate under the Location of RAP Assessment Documentation coiumn where information related to the RAP assessment can be found. 4, For each triggered indicate whether a new care plan. care plan revision. or continuation of the current care plan is necessary to address 3 prcbiem(s}iden1ified in your assessment. The Care Planning Decision column must be completed within 7 days of completing the RAI ..rios and RAPs). (ti) Care Planning Decision-check ta) Check if Location and Date of if addressed in A. RAP PROBLEM AREA tfiggfifed RAP Assessment Documentation care plan 1. DELLRIUM 2_ Loss SEE RAP NOTE 01-31-2008 3_ FUNQTIQN SEE RAP NHOTE OF 1-31-2008 4. COMMUNICATION sac RAP NOPTE OF 1=31=2nua 3 .1. REHABILITATION POTENTIAL SEE RAP NOTE OF 141-3003 6. URINARY INCONTINENCE AND INDWELLING CATHETER SEE RAP NOTE OF 1-31-2008 7. WELL-BEING 3. MOOD STATE 9. BEHAVIORAL ACTIVITIES 1.FALLS UTRITIONAL STATUS SEE RAP NOTE 01-31-2008 13. FEEDING TUBES 14. DEHYDRATIONIFLUID MAINTENANCE SEE RAP NOTE OF 1-31-2003 15. DENTAL CARE SEE RAP NOTE OF 1>>31-2003 17. DRUG USE SEE RAP NOTE OF I-31-2003 13. PHYSICAL RESTRAINTS e. i 1_ Signature of RN Coordinator for RAP A essment?rdcess ARMINDA PEREIRA RN 3. Signature of Person Corn leting Care Planning Decision paint 03,9 Penman; 2905 Change in Status Assessment .: C1 03 ziu 'Nit-vA-- VENETIAUYRN. Iom--IoisI-- 2_ Month DA 4. Month :5 Day Your MUS 2.0 September 2000 Resident LAROCCA Numeric idenfifief 5030 MINIMUM DATA (MUS) - VERSION 2.0 FDR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING SECTION W. SUPPLEMENTAL MDS ITEMS Hallonal Enier for all assassmenls and Iraciclng forms, if available. [51714] ii' the ARD 01' this assessment or the discharge deie cri this discharge tracking Is belween Jay 1 and Seplember 30. skip to W3. 2. influenza a. Did the resldeni receive the Influenza vaccine In this Vaccine laclity for ihls year's Influenza season (October 1 Iflrnugn March 31item W2b) 1. Yes (If Yes. 90 to llem W3) 13. ll influenza vaccine not received. slate reason: 1. Not In faciliy chring this years flu season 2. Received ouiside of this facilily 3. Nu! eligible 4. Oifered and declined 5. N01 offered 5. Inebllily lo obtain vaccine Fnaurnm a. is the reside-nl's PPV slalua up to dale'? causal O. No [If Na. 90 to item Wan) Vaccine 1, Yes {if Yes. skip item b. if PPV not received. elele reason: 1. Nut eligible 2. Ofiared and declined 3. Not offered Print Date Febmanr D6. 2008 Significant Change in Status Assessment manna Woman. Oman 02:2. E.monn> . QHOWGM _fl.m.8moJ.. Hnmwuma O55 Eu: rowm a 32.5% OH - mmoamxmuunwa 3 ..mom: mme. mm" a. rcum?mns 3oEoJ_. OE - mamamxmvumma 3 <. ROUTE cimenosas nsommns EACH MEDICATIQN SW11 Po CuffTREATMENTS: WCLUDE Ali wouma CARE, . pxve-an-I, A. TREATMENTS vvwi NEEDED . FREQLJENCY Mung .. . B. DESCRIBE SPECIAL DI Ma 1 34 CIRCLE THE RACE on ETHNIC eaoup. *513d=H==i>aIIic 2 sp-anlc 3 Pacific lslaflderfl-llspanIc 9 Omar - .. . ABNORMAL. LAB . 3-7: IIOH-591 (9:93) II ew York State Department of Health RU-G II Group CC 8 RHCF Level of Cara: CI HRF NF HOSPITAL AND COMMUNITY PATIENT REVIEW 1 OPERATING CERTIFICATE NUMBER 2 SOCIAL SECURITY NUMBER OLE OI BIH I2I2I I0I9I2I5I 3 OFFICIAL NAME OF HOSPITAL OR OTHER AGENCYIIFACILITY COMPLETING THIS REVIEW Montefiore Medical Center -- Weiler/Einstein Division Hospital 41}. PATIENT NAME (AND COMMUNITY ADDRESS IF 11A DATE OF HOSPITAL ADMISSION OR INITIAL REVIEWED IN COMMUNITY) AGENCY |0l5Il"l2l |2|0l0l7l 2| 0] 0| 7| VISIT 48 COUNTY OF RESIDENCE #9551 . I DATE or' 5 I I 113 DATE OF ALTERNATE LEVEL OF CARE STATUS D. DAY YFJIR 6 MEDICAL RECORD NUMBERICASE NUMBER we-ml, Ill I .l0I0I0l2l3l7I7l2l8| IN HOSPITAL I APPLICABLE) No. YEA (7-54) 12 MEDICAID NUMBER 7 HOSFITALIEEZIOM NUMBER ISWSIIO I OI DI QIVI 6I3 I 5 I 4 I 8 g30-A 13 MEDICARE NUMBER ee|ol9I1l2l2l0l9l2l5 A 3 NAME OF HOSPITAL LJNITIDIVISIONIBUILDING Monteflore Medical Center - Moses Division Hospital 9N 9 DATE OF BIRTH 1 Male 2 Female IMEADICIAI. EVENTS 16 IJECUBITUS LEVEL: ENTER THE MOST LEVEL Io-5) AS DEFINED IN THE INSTRUCTIONS. I MEDICAL CONDITIONS: DURING THE PAST: 14 PRIMARY PAYDR 1 Medicaid 3 Other 2 Medicare 65}. 15 REASON FOR PRI COMPLETION I453 -I 1. RHCF Application from Hospital 2. RHCF Application from Community 3. Other (Specify: 18 Iinenicm. TREATMENTS: READ THE INETRUC SEX A. Tracheostomy Carefsuetioning (Daily - Exclude self care) 1., . sI'RucSuctIonII'Ig--General (Daily) 1 Yes 2 No A. Comatose C- 01399" .. . . 2 B. Dehydration D. Respiratory Care (Daily) .. c. Internal Bleeding E. Nasal Gastric Feeding . .. .. A D. stasis Ulcer . F- Parenteral Feeding . . G.WcIund.Care I -F. Contractures .. H. Chemotherapy . G. Diabetes Meilitus .. I. Transfusion . . H, Urinary Tract Infection J. Dialysis .. .. .. K. Bowel and Bladder Rehabilitation .. - (SEE 3. Accident .. L. Catheter (lndwelhng or External) K. Ventilator Dependent . . M. Physical Restraints (Daytime Only) .. 49 EATING: av?-l EXAMPLE. PLATE. CUP. 13= Feeds self without supervision or physical assis- 2: 20 MOBILITY: 1 3 2: 21 TRANSFER: tence. May use adaptive equipment. Requires interrnl'i'.ient supervision (that is. verbal encouregemenuguldence) endior minimal physi- cal assistance with minor parts of eating. such as cutting food. butterlng bread or opening mill: carton. Walks with no supervision or human assistance. May require mechanical device (for example. a walker}. but not a wheelchair. Walks with intermittent supervision (that is. verbal cueing and observance). May require human assistance for difficult parts of walking {for example, stairs, ramps). TRANSFERS TOIFROM BATH AND 1: 22 TOILETING: Requires no supervision or physical assistance to complete necessry transfers. May use equipment. such as railings. trapeze. Requires intermittent supervision {that is. verbal cualno. guidance) andror physical assistance for diificuit maneuvers only. HOW THE PATIENT MOVES ABOUT. 3 It 1-. -- SUCH A5 TRANSFER-RING ON AND OFF TOILET. ADJUSTING CLOTHES 1z 2-.- - e,e.H.Avi9Rs. Requires no supervision or physil assistance. May require special equipment. such as a raised toilet or grab hers. Requires inlannilienl supervision for safety or encouragement. or minor physical assistance (for example, clothes adjustment or washing hands). George A LAROCCA PROCESS OF GETTING FOOD BY ANY MEANS FROM THE RECEPTACLE INTO THE BODY (FOR Requires continual help {encouragementiteachingi physical assistance) with eating or meal will not be completed. Totally fed by hand. patient does not manually participate. Tube or parenteral feeding for primary intake of food. (Not just for supplemental nourishments.) walks with constant one-to-one supervision and! or constant physical assistance. Wheels with no supervision or assistance, except for difficult maneuvers (for example. elevators, ramps). "May actually be able to walk. but generally does not move. is wheeled, chairiest or bediest. Relies on some- one to move about. if at all. PROCESS OF MOVING BETWEEN POSITIONS. TOIFROM BED. CHAIR. STANDING, Requires one person to provide constant guidance. steadiness andior physical assistance. Patient may participate in transfer. Requires two people to provide constant supervision physically lift. May need lifting equipment. Cnnot and is not gotten out of bed. PROCESS OF GETTING TO AND FROM A TOILET (OR USE OF OTHER TOILEITNG EQUIPMENT. CLEANSING SELF AFTER ELIMINATION AND continent of bowel and bladder. Requires oonstant supervision andior physical assistance with major! all parts ofthe task, including appliances colostomy, ileostomy. urinary catheter). incontinent of bowel andior bladder and is not taken to a bathroom. incontinent of bowel andlor bladder, but is taken to a bathroom every two to four hours during the day and as needed at night. 23 VERBAL DISRUPTIOH: ev YELUNG. eamne. THREATENING. ETC. 1: 2: 3 II 24 PHYSICAL RGGRESSIOIM ASSAULTIVE OR COMBATIVE TO SELF OR OTHERS WITH INTENT FOR INJURY. No known history. Known history or oocunences. but not during the past week days). Short-lived or predictable disruption regardless of frequency [for example, during specific care rou- tines. such as bathing.) 4 4-. Unpredictable, recurring verbal disruption at least once during the past week (7 clays] for no fore- told reason. Patient is at level #4 above. but does not fulfill the active treatment and assessment qualifiers (in the instructions]. (FOR EXAMPLE HITS SELF. THROWS OBJECTS, PUNCHES, DANGEROUS MANEUVEHS WITH WHEELCHAIR) 1: 2: No known history. Known history or occurrences. but not during the past week days). 3 =Prediclable aggression during specific care rou- tines or as a reaction to normal stimuli (for example. bumped into). regardless of frequency. May strike or fight. oon-594 (91991 4 5 Unpredictable. recurring aggression at least once during the past week (7 days) for no apparent or foretold reason (that is. not first during specific care routines or as a reaction to non-nal stimuli}. Patient is at level as #4 above. but does not fulfill the active treatment and assessment qualifiers {in the George A LAROCCA PAGE 3 NAME: (PLEASE 25 orsnup-nus, INFANTILE on socI.Iu.Lv INAPPROPRIATE BEHAVIOR: on PHYSICAL BEHAVIOR WHICH CFIEATES DISRUPTION WITH OTHERS. (FDR EXAMPLE, UNDRESSENG SELF, STEALING. SMEARING FECES. SEXUALLY DISPLAYING CINESELF TD OTHERS). EXCLUDE VERBAL ACTIONS. READ THE INSTRUCTIONS FOR OTHER EXCLUSIONS. Occurrences of this disruptive behavior at least once during the past week (7 days). 1 No known history. 2 Displays this behavior, but is not disruptive to others {for example, rocking In place). 5 Patient is at level #4 above. but does not fulfill the . active treatment and assessment 3 - Known history or occurrences. but not dunng the qualifiers fin inswwonfl past week. (7 days). 26 HALLUCINATIONS: AT LEAST once DURING THE PAST VISUAL. UR TACTILE PERCEPTIONS THAT HAVE No aAsIs IN EXTERNAL REALITY. 1 Yes 2 No 3 Yes. but does not fulfill the active treatment and psy- chiatric assessment qualifiers (in the instructions). SERVICES 27 PHYSICAL AND OCCUPATIONAL THERAPIESI READ INSTRUCTJONS AND QUALI- FIERB. EXCLUDE NURSES AND OTHER SPECIALIZED THERAPISTS EXAMPLE, SPEECH ENTER THE LEVEL, DAYS AND TIME (HOURS MINUTES) DURING THE PAST (T omrs). A. Physical Therapy (P.T.3 B. Occupational Therapy . LEVEL 1 Does not receive. 4 Receives therapy. but does not fulfill the =Mflintenance . Requires and I3 qualifiers stated in the instructions. (For currently receiving physical anclior oI:- exen'IP'3- Unit' cupational therapy to help stbilize or slow functional deterioration. 3 =Ftestoral|-re Therapy -- Requires and is currently receiving physical ndlor oo- cupational therapy for the past week. DAYS AND TIME PER WEEK: ENTER THE CURRENT NUMBER OF DAYS AND TIME AND DURING THE PAST WEEK I7 DAYS) THAT EACH THERAPY WAS PROVIDED. ENTER ZERO IF AT #1 LEVEL Aaove. READ INSTRUCTIONS As TD CIUALIFIERS IN COUNTING DAYS AND TIME. 28 NUMBER OF PHYSICIAN VISITS: Do NOT QUESTION FOR Hos- PITALIZEIJ -PATIENTS. ZERO). UNLESS cm ALTERNATE LEVEL OF CARE sTATus. ENTER ONLY THE NUMBER or VISITS DURING THE PAST WEEK THAT ADHERE TO THE PATIENT NEED ANT: DOCUMENTATION QIJALIFIERB IN THE INSTRUCTIONS. THE PATIENT MUST BE To ENTER ANY PHYSICIAN VISITS. OTHERWISE ENTER A ZERO. I. DIAGNOSIS 29 PRIMARY PROBLEM: THE MEDICAL THE LARGEST AMOUNT or-' NURSING TIME IN THE HOSPITAL oR CARE TIME IF IN THE COMMUNITY. Iron PATIENTS THIS MAY DR MAY BE THE ADMISSION DIAGNOSIS IUD-9 Code of medical problem If code cannot be located. print medical name here: P055 ASP PNA ooI~I--es-1 terse} George A LAROCCA PAGE 4 VII. PLIANL oI= CARE ISUMMIARY 30 DIRGHOSES AND PROGNOSESE FOR EACH DIAGNOSIS DESCRIBE THE PROGNOSIS AND CARE PLAN IMPLICATIONS. Pnmary Prognosis 1- ADM: FEVER, Secondary {Include Sensory Impairments) 1. ALZHEIMER DEMENTIA 5. HTN 2. CAD sip CABG 6. 3. OSTEOARTHRITIS 4. AFIB 31 REHABILITATION POTENTIAL nuroamnon mom A. POTENTIAL DEGREE OF IMPROVEMENT WITH ADLS WITHIN SEX MONTHS (DESCRIBE IN TERMS OF ADL LEVELS on THE HD-PRII: NIA EI. CURRENT THERAPY CARE PLAN: DESCRIBE THE TREATMENTS (INCLUDING WHY) AND ANY SPECIAL EQUIPMENT REQUIRED. 32 - Please see attached NAME DOSE FREQUENCY ROUTE DIAGNOSIS REQUIRING EACH MEDICATION PLEASE SEE MED DPLDAD 33 TREATMENTS: ALL DRESSINGS. IRRIGATIONS. wouun ems. A. TREATMENTS DESCRIBE NEEDED FREQUENCY 1. FALLISAFETY PRECAUTIONS: Pt ON BEDREST, SKIN: SACRAL AS NEEDED. NEEDS 2-PERSON ASSIST. 2. HOB TO 30 DEGREES, 3. ISO 3. 4. TEDSISCDS. 5. FOLEY: IF REMAINS PLEASE PROVIDE FOLEY CARE. 6. 2ii NC.. 3. NARRATIVE: DESCRIBE SPECIAL DIET. ALLERGIES, ABNORMAL LAB VALUES. PACEMAKER. DIET: NPD AT PRESENT ALLERGIES: RADIDPAQUE AGENTS. HALOPURINOI. 34 RAGEIETHNIG GROUP: CIRCLE THE CODE WHICH BEST IJESCRIEIES THE PATIENTS RACE OR ETHNIC GROUP. while 4 Biackliviispanic 7 American Indian or Alaskan Native 8 American Indian or Alaskan Nativamispanic 2 mmim-Hispanic 5 Asian or Pacific Islander 3 Black 5 Asian or Pacific 9 Other DOH-654 (9:99) ??36320012--> Page 002 4A PATIENT NAME (AND COMMUNITY ADDRESS IF New York State Department of Health RUG llG1oup (print name): CC-B FIHCF Level ol'Cure: El SNF HOSPITAL AND COMMUNNITY AIENT REVI INST A 1' -1 -- ADMINISTRB I CERTIFICATE NUMBER 2 SOCIAL SECURITY NUMBER .,..l7lol0iol0l9l6lHlI l2l2ll0l9l2l5l 3 OFFICIAL NAME OF OF-E OTQKER AGENGYIFACILITY COMPLETING THIS REVIEW Montefiore Medical Center - Weiler/Einstein Division Hospital 11A DATE or: HOSPITAL ADMISSION oR INITIAL AGENCY visit l0l2li0lBl l2l0l0l8l REVIEWED IN LAROCCA 43 COUNTY OF RESIDENCE 5 010' 8' IN HOSPITAL LID. DAY VIE-IR 5 MEDICAL REc:oRo NUMBERICASE NUMBER .ml0l0lHOSPITAL RooM NUMBER 912-A Mlslilzl-|A| 3 NAME OF HOSPITAL Montetiore Medical Center - Moses Division Hospital 93 3 DATE OF BIRTH l4047lI Male I 1 I 2 Female H8) .Ij[;i EEVEANTS 15 necuarrus ENTER THE MOST sevens LEVEL (O-5) AS DEFINED IN THE INSTRUCTIONS. A -5 17 MEDICAL CONDITIONS: ounii-re THE PAST WEEK. READ THE FOR SPECIFIC DEFJMTIONS. 'l Yes 2 No A. Comatose {?7-Ml - 1'2 MEDICAID NUMBER . 13 MEDICARE NUMBER lol9l2l5lAl 14 PRIMARY PAYOR 1 Medicaid 3 Other 2 Medicare 15 REASON FORPRI COMPLETION 1. RHCF Application from Hospital 2. RHCF Application from Community 3. Other (Specify; 18 MEDICAL TREATMENTS: READ THE TIONS FOR QUALIFIERS 1: yes 2 mm, -- A. Traoheostomy Careisuctioning (Dally -- Exclude self care) E3. Suotioning - General (Daily) C. Oxygen (Daily) D. Respiratory Care (Daily) E. Nasal Gastric Feeding B. Dehydration C. internal Bleeding . .. F. Parenteral Feeding G. Wound Care D. Stasis Ulcer .. .. Terminally Ill . F. H. Chemotherapy . . G. Diabetes Mellitus l. Transfusion J. Dialysis Bowel and Bladder Rehabilitation (SEE L. Catheter (indwelling or External) M. Physical Fiestraints (Daytime Only) H. Urinary Tract Infection .. I. l-livlnfection .. J. Accident K. Ventilator Dependent DOH -E94 uz/:4/uo 11:21:56 20 21 22 23 VERBAL DISRUPTION: av YELUNG. aarnwc. THREATENING, em. 24 EXAMPLE. PLATE. CUP, TUBE) 1 Feeds self without supervision or physical assis- tance. May use adaptive equipment. Requires intermittent supervision (that is. verbal cncouragerrtenUgt.t|dance) ndior minimal physi- cal assistance with minor parts or eating, such as cutting food, butte-ring bread or opening milk carton. MOBILITY: How THE PATIENT MOVES Aaour. 1 Walks with no supervision or human assistance. May require mechanical device (for example. a walker). but not a wheelchair. 2 Wallis with intermittent supervision {that is, verbal cuelng and observation). May require human assistance for difficult parts of walking (for example. stairs, ramps). TRANSFERS TDIFROM BATH AND 1 Requires no supervision or physical assistance to complete necessary transfers. May use equipment. such as railings. trapeze. 2 Requires intermittent supervision [that is. verbal cuelng, guidance) anrllor physical assistance for dtfiicutt maneuvers only. TOILETING: PROCESS OF To AND r'iMc 'PROCESS OF MOVING BITWEEN POSITIONS. TOIFRDM BED. CHAIR. STANDING. (EXCLUDE 3: FROM A TOILET (OR USE DF OTHER TOILEFING EQUIPMENT, SUCH A5 BEDPAN). TRANSFERRING ON AND OFF TCIILEF. ADJUSTING CLOTHES - Requires two peopie to provide constant supervision extendecicaremom Page 003 PAGE 2 Requires continual help (encouragementiteachingl physical assistance) with eating or meal will not be completed- Totally fed by hand. patient does not manually participate. Tube or parenteral feeding for primary intake of food. (Not lust for supplemental nourishments) W.-slits with constant one-to-one supervision and} or constant physical assistance. Wheels with no supervision or assistance, except for difficult maneuvers (for example, elevators, ramps). May actually be able to walk, but generally does not move. is wheeled, chairfast or bedfast. Relies on some- one eise to move about, ital all. Requires one person to provide constant guidance. steadiness andior physical assistance. Patient may participate in transfer. andlor physically tilt. May need lilting equipment. Cannot and is not gotten out of bed. CLEANSING SELF AFTER ELIMINATION AND 'l No known history. 2 Known history or occurrences. but not during the past week (7 days). 3 Short-lived or predictable disruption regardless of frequency {tor example, during specific care rou- lines. such as bathing.) PHYSICAL AGGRESSION: 1 No known history. 2 2 Known history or occurrences, but not during the past week {7 clays). 3 Predictable aggression during specific care rou- tines or as a reaction to name! stimuli (for example, bumped into). regardless of frequency. May strike or fight. nan-err lens} 1 2 Requires no supervision or physical assistance. 3 - Continent of bowel and bladder. Requires constant May require special equipment. such as a raised supervision andior physical assistance with major! "lite! 0" Sirab bars. ail parts ofthe tasir, including appliances colostomy. iieostomy, urinary catheter). 2 Requires intermittent supervision for safety or 4 rncunungnt of bower bladder and is Mr encoumgernent. or minor physical assistance (for emmP|e'c'alhEs adjustmentarwasmng hand" 5 incontinent of bowel ancilor bladder. but is taken to a bathroom every two to four hours during the day and as needed at night. 4: 5: ASSAULTIVE on CDMBATIVE To SELF (FOR EXAMPLE HITS SELF. THROWS OBJECTS. PUNCHES. DANGEROUS MANEUVERS WITH WHEELCHAIR) 4: 52 Unpredictable. recurring verbal disruption at least once during the past week days) for no fore- lctid reason. Patient is at level #4 above, but does not fulfill the active treatment and assessment qualifiers (in the instructions). OR WITH INTENT FDR INJUFIY. Unpredictable, recurring aggression at least ""09 during the past week days) for no apparent or foretold reason {that is, not just during specific care routines or as a reaction to normal stimuli). Patient is at level as #4 above. but does not fulfill the active treatment and assessment qualifiers (In the instructions). NAME: mg nugeuoslsre 29 PRIMARY TH OF NURSING TIME IN TH HOSFITALIZED PATIENT George A LAROCCA DISRUPTIVE, INFANTILE DR SDCIALLY INAPPROPRIATE BEHAVIOR: ANTISDCIAL PHYSICAL BEHAVIOR WHICH CFIEATES DISRUPTION WITH OT UNDRESSING SELF. STEALING, SMEARING FECE5. SEXUALLY OTI-IERS). EXCLUDE VERBAL ACTIONS. READ THE INSTRUCTIONS FOR OTHER EX 4 Occurrences of this disruptive behavior at least once during the past week (7 clays). 5 Patient is at level #4 above, but does not fulfill the acttve treatment and assessment qualifiers (in instructions). 1 No lrnovm history. 2 others [for example, rocking In place). 3 Known history or occurrences, but not during the past week. (7 clays). HALLUCIMATIDNS: EXPERIENCED AT LEAST ONCE DURING THE TACTILE PERCEPTIDNS THAT HAVE No BASIS IN EXTERNAL REALITY. 3 Yes, but does not fulfil'! the active treatment and psy- chlatrlc assessment qualifiers (tn the '1=Yes 2=No Tspeeumzecsenweest READ INSTRUCTIONS AND AND OTHER SPECIALIZED THERAPISTS LEVEL, DAYS AND TIME (HOURS PHYSICAL AND OCCUPATIONAL FIEHS. EXCLLIDE REHABILITATIVE NURSES EXAMPLE. SPEECH THERAPIST). ENTER MINUTES) DURING THE PAST WEEK (7 DAYS. A. Physical Therapy (P.T.J B. Occupational Therapy (O.T.) . 1 2 Does not receive. Maintenance Program - Requires and Is currently receiving physical andior oc- cupational therapy to help stabillze or slow functional deterioration. 3 =FtEs!t:rallve Therapy -- Requires and is currently receiving physical andlor oc- cupatlonal therapy for the past week. [0 I DAYS AND TIME PER WEEK: ENTER THE CURRENT NUMBER or DAYS AND TIME (HOURS AND MINUTES) DURING THE PAST WEEK PROVIDED. ENTER zeno n= AT #1 LEVEL ABOVE. REA IN COUNTING DAYS AND TIME. NUMBER OF PHYSICIAN CHILDISH. REFETITIUE OH HERS. ISPLAYING ONESELF TD CLUSIDN5. Displays this behavior, but Is not disruptive to A-ST WEEK, VISUAL, AUDITDRY OR exTandedcare.com Page D04 PAGE 3 4 Receives therapy. but does not fulfill the qualifiers slated in the Instructions. {For example, therapy provided for only two (7 THAT EACH TH ERAPY WAS El AS TO CJUALIFIERS DO NOT ANSWER THIS QUESTION FDR HUS- PITALIZED PATIENTS, ZERO), UNLESS ON ALTERNATE LEVEL OF CARE STATUS. TO THE PATIENT NTER A GUALI-. AND Code of medical problem If code cannot be located, print medical name here: FILE DVT MEDICAL CONDITION HOSPITAL OR CARE 5 THIS MAY OR MAY REQUIRING THE LARGEST AMOUNT IF IN THE COMMUNITY. OT BE THE ADMISSION DIAGNOSIS). RENAL URE not-I-594 (9:99; 11:24:50 Page 005 George A LAROCCA M654 30 EIIAGNDSES AND PROGNDSES: FOR EACH DIAGNOSIS DESCRIBE THE PFIOGNDSIS AND r-'-uw IMPLICATIONS. primary Prugnusls 1. LOWER EXTREMITY DVTIARF secondary {Include Sensory Impairments) HTN SIP GABG STAGE-II SACRAL DECUB cm: CHF PARKINSONS DISEASE AFIB HDEMENTIA 31 REHABILITATION POTENTIAL FROM A. POTENTIAL DEGREE OF IMPROVEMENT WITH AoLs WITHIN SIX MONTHS (DESCRIBE IN TERMS or ADL LEVELS ow THE HC-PHI): B. CURRENT THERAPY CARE PLAN: DESCRIBE THE TREATMENTS (INCLUDING WHY) AND ANY SPECIAL EQUIPMENT REQUIRED. 32 MEDICATIDNS - Please see attached NAME nose FREQUENCY name DIAGNOSIS REQUIRING EACH MEDICATION 33 TREATMENTS: INCLUIJE ALL DRESSINBS, IRFIIGATION5. WOUND CARE. OXYGEN. A. TREATMENTS - DESCRIBE WHY NEEDED FREQUENCY E. NARRATIVE: DESCRIBE SPECIAL DIET, ALLERGIES. ABNORMAL LAB VALUES. PACEMAKER. ZGM NAIPUREE TEXTUREIALL LIQUID DYEIRADIOPAQUE AGENTS 34 RACEIETHNIC GROUP: CIRCLE THE cons WHICH BEST DESCRIBESTHE PATIENTS RACE on En-Ir-Ilc: enoup. J: While -I BIacII.FHIspanlc 7 American Indian or /\IasIraI1 Nalive 2 Wh|IeIHIspanic 5 Asian or Pacific Islander El Arnerican In dlan or Alaskan Natfvell-Ilspanic 3 Black 6 Asian or Pacific 9 Oiher name: may)