Every finding on record at Vcu Health Children's Services at Brook Road

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, for five of 14 residents in the survey sample; Residents #22, #8, #10, #30, and #29. The findings include: 1. For Resident #22 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #8 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #10, the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 32642 4. For Resident #30 (R30), the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. R30 was admitted to the facility on [DATE]. A review of R30's clinical record revealed all required monthly medication regimen reviews. However, a review of the facility's monthly medication regimen review policy failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 5. For Resident #29 (R29), the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. R29 was admitted to the facility on [DATE]. A review of R29's clinical record revealed all required monthly medication regimen reviews. However, a review of the facility's monthly medication regimen review policy failed to reveal time frames for the physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to develop and/or implement a care plan for five of 14 residents in the survey sample, Residents #19, #16, #29, #30, and #10. The findings include: 1. For Resident #19 (R19), the facility staff failed to implement the care plan for the use of bilateral (both left and right) AFOs (ankle/foot orthoses-which are devices for positioning of the ankle/foot). On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on their feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. A review of R19's physician orders revealed, in part: 9/19/22 Apply brace Bilateral AFO until discontinued. Comments: Pt (patient) should wear B (bilateral) AFOs from 8 am - 4 pm when OOB (out of bed) or when in stander. A review of R19's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. She stated R19's care plan was not being followed if the resident was not wearing the AFOs when out of bed. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the care plan should always be followed. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 2. For Resident #16 (R16), the facility staff failed to implement the care plan for the resident's use of bilateral hand splints. On 4/18/23 at 1:56 p.m., R16 was lying in bed, and was not wearing hand splints. On 4/19/23 at 9:52 a.m., R16 was sitting in a wheelchair in the facility school room. The resident was not wearing hand splints. A review of R16's physician orders revealed, in part: 3/25/23 Apply splint Bilateral: Resting Hand Splint Until discontinued. Pt (patient) to wear bilateral .hand splints from 8 am - noon and 1 pm - 4 pm. A review of R16's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the care plan should always be followed. She stated R16's care plan was not being followed for the hand splints. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 3. For Resident #29, the facility staff failed to develop a care plan for the administration of Diazepam (1). A review of R29's physician's orders revealed, in part: 1/24/23 Diazepam solution 0.21 mg/kg (milligrams per kg (kilograms) 1.5 mg per G tube (feeding tube) every 6 hours. The medication was ordered to treat the symptoms of the resident's genetic abnormalities. A review of R29's April 2023 MAR (medication administration record) revealed the resident received the Diazepam as ordered. A review of R29's comprehensive care plan failed to reveal information related to the administration or monitoring of the Diazepam. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. When asked if a high-risk medication like Diazepam should be care planned, she stated: Yes. RN #1 confirmed R29's care plan did not include information related to the risks of Diazepam. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated high-risk medications should have a care plan. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. (1) Diazepam is used to relieve anxiety and to control agitation caused by alcohol withdrawal. It is also used along with other medications to control muscle spasms and spasticity caused by certain neurological disorders such as cerebral palsy (condition that causes difficulty with movement and balance), paraplegia (inability to move parts of the body), athetosis (abnormal muscle contractions), and stiff-man syndrome (a rare disorder with muscle rigidity and stiffness). This information is taken from the website https://medlineplus.gov/druginfo/meds/a682047.html. 4. For Resident #30 (R30), the facility failed to develop a plan for the administration of Lispro (1) (a medication used for the treatment of diabetes). A review of R30's physician's orders revealed, in part: 10/21/22 Insulin Lispro (Humalog) 100 units/ml (milliliter) injection. Give 1-7 units per sliding scale. A review of R30's April 2023 MAR (medication administration record) revealed the resident received the medication as ordered. A review of R30's care plan failed to reveal information related to the administration or monitoring of the Lispro. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. When asked if a high-risk medication like Lispro should be care planned, she stated: Yes. RN #1 confirmed R30's care plan did not include information related to the risks of Lispro. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated high-risk medications should have a care plan. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. (1) HUMALOG (Lispro) is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. This information is taken from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f. 29125 5. For Resident #10, the facility staff failed to develop a care plan to address safety needs, including the use of side rails. On 4/18/23 at 6:57 AM, 4/19/23 at approximately 11:00 AM, and 4/20/23 at approximately 8:00 AM, Resident #10 was observed in bed, with side rails up on both sides. A review of the clinical record revealed an order dated 11/30/21 for Side rails up x4. A Consent for use of side rails dated 10/26/17 documented, the resident was to have full side rails on left and right sides, and was recommended at all times when the resident was in bed. The purpose of the side rails was documented as Fall Risk. Risks and benefits were documented on the consent. A review of the comprehensive care plan failed to address any safety needs for Resident #10, including the fact that they were a fall risk, and for the use of side rails. On 4/19/23 at 10:57 AM, an interview was conducted with RN #1 (registered nurse), the MDS nurse. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 PM, an interview was conducted with LPN #1 (licensed practical nurse). She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. On 4/19/23 at 1:50 p.m., ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the Director of Performance Management, and ASM #3, the Director of Nursing, were made aware of the findings. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about not having a care plan to address safety needs and the use of side rails, ASM #2 stated that there wasn't one but that there should have been one. A policy was requested for developing care plans, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided by the end of the survey.

Based on observation, staff interview, and clinical record review, the facility staff failed to apply orthotic devices as ordered for two of 14 residents in the survey sample, Residents #19 and #16. The findings include: 1. For Resident #19 (R19), the facility staff failed to apply bilateral (both left and right) AFOs (ankle/foot orthoses) (devices for positioning of the ankle/foot) when the resident was out of bed. On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on his feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. A review of R19's physician orders revealed, in part: 9/19/22 Apply brace Bilateral AFO until discontinued. Comments: Pt (patient) should wear B (bilateral) AFOs from 8 am - 4 pm when OOB (out of bed) or when in stander. A review of R19's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 12:00 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there is a communication book at the nurses' station with information about AFOs for each resident. She stated each resident also has a binder inside their closet door with the AFO information there, as well. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated she was responsible for taking care of R19 that day. She stated she checks the physician orders to make sure what AFOs have been ordered by the physician. She stated she was not certain whether or not R19 had been wearing AFOs that morning. She stated sometimes the staff decides to give give the resident a rest from the orthotics. She stated there was no order to do so, and no place to document why this was not being done. On 4/19/23 at 12:57 p.m., RN #2 stated sometimes R19 will not tolerate the AFOs, and they are not applied by the staff. She stated the system does not allow the staff to document a resident's refusal or intolerance. She stated CNAs (certified nursing assistants) are primarily responsible for applying the AFOs, and should alert the nurse if the resident is not tolerating the braces well. She stated the nurse should write a progress note. She stated she could not find where this had been done for R19. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for implementing physician-ordered orthotic devices, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 2. For Resident #16 (R16), the facility staff failed to apply bilateral (both left and right) hand splints as ordered by the physician. On 4/18/23 at 1:56 p.m., R16 was lying in bed, and was not wearing hand splints. On 4/19/23 at 9:52 a.m., R16 was sitting in a wheelchair in the facility school room. The resident was not wearing hand splints. A review of R16's physician orders revealed, in part: 3/25/23 Apply splint Bilateral: Resting Hand Splint Until discontinued. Pt (patient) to wear bilateral .hand splints from 8 am - noon and 1 pm - 4 pm. A review of R16's care plan did not reveal any information related to the bilateral hand splints. On 4/19/23 at 12:00 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there is a communication book at the nurses' station with information about braces and splints for each resident. She stated each resident also has a binder inside their closet door with the information there, as well. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated she was responsible for taking care of R16 that day. She stated she checks the physician orders to make sure what splints have been ordered by the physician. She stated she was not certain whether or not R16 had been wearing hand splints that morning. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for implementing physician-ordered orthotic devices, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 14 residents in the survey sample, Residents #7 and 22. The findings include: 1. For Resident #7 (R7), the facility staff failed to revise the care plan when the resident developed a pressure ulcer. A review of R7's clinical record revealed the resident was receiving treatment for a pressure ulcer. The record contained the following physician's order: Sodium Hypochlorous Acid (Vashe Wound Cleanser) 0.333% Once per day [for pressure ulcer] on Monday, Wednesday, Friday. A review of R7's April 2023 TAR (treatment administration record) revealed the resident was receiving the pressure ulcer treatments as ordered. A review of R7's care plan updated 3/1/23 revealed, in part: 11/22/21 Resident will not experience redness or skin breakdown over the next 90 days. However, the care plan had not been updated to address R7's actual pressure ulcer. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated she is responsible for updating the care plan, and it should include the development of a pressure ulcer. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the MDS nurse updates the care plans for the facility's residents. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about the care plan not being revised to address the development of the pressure injury, ASM #2 stated that it should be, and that being under a new healthcare system and a new electronic medical record system was a learning process for the facility. A policy was requested for reviewing and revising the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 29125 2. For Resident #22 the facility staff failed to review and revise the comprehensive care plan to address the development of an actual pressure wound and the associated treatments. A review of the clinical record revealed a nurse's note dated 8/29/22 that documented, Pt (patient) has pressure injury to sacrum that appears to be a stage 2. NP (nurse practitioner) at bedside to visualize . A review of the physician's orders revealed the following: 1. Dated 1/25/23 for Please use wedge to position (Resident #22) off of [their] back. Side lying only to avoid sacral pressure. 2. Dated 3/13/23 for wound care daily to sacrum for Vashe moistened packing strips for appropriate moisture and antimicrobial activity. Mepilex border/sacral to manage exudate and for cover dressing. Change dressing daily. A review of the comprehensive care plan revealed the following one dated 11/22/21 for Potential for loss of skin integrity secondary to: impaired mobility, incontinence, gastrostomy and/or jejunal tube site, tracheostomy tube site, prolonged wheelchair seating, splint/AFO's/TLSO braces, less/more than ideal body weight, contracture lower extremities, peri-area r/t (related to) intermittent catheterizations, eye irritation, scratching face. The interventions, dated 11/22/21 documented, Assess all skin surfaces with bathing, attends changes. Use appropriate ointments, creams and lotions. Keep peri-area clean and dry. Change attends every 4 hours and prn (as needed). Assess skin for pressure and redness with position changes, after splint removal, and after wheelchair seating. Assess g-tube and trach site with routine care. Document bruising and/or reddened areas and report to therapies and MD (medical doctor) for evaluation and/or treatment. Report wheelchair equipment needs for evaluation and repair to therapy or equipment provider. Advise family of noted skin breakdown or injuries incurred. Document any changes in status of skin surfaces involve and report to MD/therapy. MOM's Magic Paste for reddened areas as ordered. Keep nails trimmed to prevent scratching. Further review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and revised to address an actual pressure injury that developed and associated treatments and interventions. On 4/19/23 at 10:57 AM, an interview was conducted with RN #1 (registered nurse), the MDS nurse. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 PM, an interview was conducted with LPN #1 (licensed practical nurse). She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. On 4/19/23 at 1:50 p.m., ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the Director of Performance Management, and ASM #3, the Director of Nursing, were made aware of the findings. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about the care plan not being revised to address the development of the pressure injury, ASM #2 stated that it should be, and that being under a new healthcare system and a new electronic medical record system was a learning process for the facility. A policy was requested for updating care plans, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided by the end of the survey.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to post the required staff posting for 33 of 33 days reviewed. The findings include: On 4/19/23 at approximately 10:30 AM a tour of the facility was conducted; the required staff posting for the shift was not observed posted. The facility document that was provided as the daily staff posting was reviewed for the period of 3/18/23 through 4/20/23. The document was a combined document of daily staff posting, as-worked schedule, and staff assignments. The document contained the date, shift, and census but it also contained resident names and did not contain staff hours. On 4/19/23 at 10:45 AM an interview was conducted with RN #2 (Registered Nurse) the unit manager. She stated that she believed the document provided was the staff posting form, and that due to it having resident names on it, the document is not posted for visitors to see but is maintained face down at the front desk. She stated she was not sure what information the staff posting was supposed to contain. On 4/19/23 at 11:36 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Performance Management. She stated that this was the document that was provided to meet the request for the staff posting for the last 30 days, which was requested upon the entrance conference on 4/18/23 at 9:00 AM. A policy was requested for staff posting however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided by the end of the survey.

Based on observation, staff interview, clinical record review and review of facility documentation the facility staff failed to maintain infection control procedures during medication pass to prevent the spread of infection for one of 11 residents in the medication pour and pass observation, (Resident #7). Registered Nurse (RN) #2 popped a pill directly into her gloved hand, then placed the pill into a medication cup and administered the medication to Resident #7. RN #2 was observed touching multiple items with her gloved hands, contaminating the gloves, prior to placing the pill directly into her gloved hand. The findings include: Resident #7 was a 5 year old admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/15. The resident was coded as being in a persistent vegetative state. The resident required total care for all areas of activities of daily living and was incontinent. On 10/21/15 at 8:36 a.m., the Medication Administration observation was conducted with RN #2 (Registered Nurse #2). She was observed to prepare the following medications for Resident #7: [MEDICATION NAME]* 10 mg (milligrams) / 5 ml (milliliters) (used for [DIAGNOSES REDACTED]) [MEDICATION NAME] Acid* 350 mg / 7 ml (used for seizures) [MEDICATION NAME]** 400 mg / 4 ml (used for seizures) [MEDICATION NAME]* 4 mg (2 tabs at 2 mg each) (used for [DIAGNOSES REDACTED]) While preparing the medications, RN #2 popped the [MEDICATION NAME] out directly into her gloved hand (which were not sterile, and with which she had touched multiple objects after donning the gloves, before preparing the [MEDICATION NAME]) and then placed the [MEDICATION NAME] in the medication cup. On 10/21/15 at approximately 3:15 p.m., in an interview with RN #2, she stated she did not recall popping the medication directly into her hand, but that she should have popped them into the cup. A review of the facility policy Medication Administration Guidelines documented, Procedure: B. Medications are prepared using clean technique . On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. According to Potter and Perry, Fundamentals of Nursing, 7th Edition, page 713, For safe administration, use aseptic technique and proper procedures when handling and giving medications. * Information obtained from Nurse's Drug Guide 2009, Prentice Hall, pages 153, 461, 1580. ** Information obtained from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 9.html

Based on staff interview, facility document review, and clinical record review it was determined that facility staff failed to document date and location for triggered areas on the MDS (minimum data set) for 8 of 13 residents in the survey sample, Resident's #1, #5, #3, #4, #7, #2, #6, and #10. 1. For Resident #1, the facility staff failed to document the date of information from the clinical record that was utilized to complete the assessment of the triggered areasin Section V of the CAA (care area assessment), on the 4/12/15 admission MDS assessment. 2. For Resident #5, the facility staff failed to document the date of information from the clinical record that was utilized to complete the assessment of the triggered areas in Section V of the CAA (care area assessment), on the 11/16/14 annual MDS assessment. 3. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 1/25/15 for Resident #3. 4. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 2/8/15 for Resident #4. 5. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 1/25/15 for Resident #7. 6. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 5/10/15 for Resident #2. 7. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 5/3/15 for Resident #6. 8. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 9/13/15 for Resident #10. The findings include: 1. For Resident #1, the facility staff failed to document the date of information from the clinical record that was utilized to complete the assessment of the triggered areas in Section V of the CAA (care area assessment) , on the 4/12/15 admission MDS assessment. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) was a quarterly review assessment with an ARD (assessment reference date) of 10/4/15. The resident was coded as being cognitively impaired in the ability to make daily life decisions and never/rarely understanding others with communication. The resident was coded as requiring total care for bathing, transfers, dressing, personal hygiene and eating. A review of the clinical record revealed the most recent comprehensive MDS was the admission MDS with an ARD of 4/12/15. This review revealed in Section V (Care Area Assessment (CAA) Summary), a column, titled Location and Date of CAA documentation. The data contained in this column for triggered areas: Activities and Pressure Ulcer did not contain a date for the information used to complete this section. Section A - CAA results documented that Resident # 1 had triggered for the following CAA areas: Cognitive Loss/Dementia, Communication, ADL (Activities of Daily Living) Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Activities, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance and Pressure Ulcer. The following was documented under the Location and Date column for CAA triggered area Activities: Nursing Daily Documentation, Recreation therapy. The following was documented under the Location and Date column for CAA triggered area Pressure Ulcer: Daily nursing documentation. Review of the CAA worksheets failed to reveal the date of information for triggered areas, Activities and Pressure Ulcer. On 10/21/15 at 12:35 p.m., an interview was conducted with RN (Registered Nurse) #1 the MDS coordinator, regarding the missing dates of information on the CAA summary. She stated that she did not provide dates to CAA areas unless something specific happened for the CAA area to trigger. She stated, If nothing specific causes the care areas to trigger then I will write See daily nursing documentation.' She stated that she uses the RAI (Resident Assessment Instrument) as a resource to complete the CAA summaries. On 10/14/15 at 4:30 p.m., administration was made aware of the above concerns. No further information was presented during the time of survey. Section V of the MDS documents at the top of the page the following instructions: 1. Check column A if the Care Area is triggered. 2. For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Addressed in the Care Plan column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. 3. Indicate in the Location and Date of CAA information column where information related to the CAA can be found. CAA documentation should include information on the complicating factors, risks and any referrals for this resident for this care area. Review of CMS's (Center of Medicare/Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 User's Manual documented, CHAPTER 4: CARE AREA ASSESSMENT (CAA) PROCESS AND CARE PLANNING. 4.5 Other Considerations Regarding Use of the CAAs. Use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision making documentation can be found in the resident's record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. 2. For Resident #5, the facility staff failed to document the date of information from the clinical record that was utilized to complete the assessment of the triggered areas in Section V of the CAA (care area assessment), on the 11/16/14 annual MDS assessment. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set) was a quarterly review assessment with an ARD (assessment reference date) of 9/13/15. The resident was coded as being moderately impaired in the ability to make daily life decisions and sometimes understanding others with communication. The resident was coded as requiring total care for bathing, transfers, dressing, toileting, personal hygiene, and eating. A review of the clinical record revealed the most recent comprehensive MDS was the admission MDS with an ARD of 11/16/14. This review revealed in Section V (Care Area Assessment (CAA) Summary), a column, titled Location and Date of CAA documentation. The data contained in this column for triggered areas: Falls and Pressure Ulcer did not contain a date of the information. Section A - CAA results documented that Resident # 1 triggered the following CAA areas: Cognitive Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Activities, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer and [MEDICAL CONDITION] drug use. The following was documented under the Location and Date column for CAA triggered area Falls: Daily nursing Flow Sheets. The following was documented under the Location and Date column for CAA triggered area Pressure Ulcer: Daily nursing flow sheets. Review of the CAA worksheets failed to reveal the date of information for triggered areas, Falls and Pressure Ulcer. On 10/14/15 at 4:30 p.m., administration was made aware of the above concerns. No further information was presented during the time of survey. 3. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 1/25/15 for Resident #3. Resident #3 was a [AGE] year old most recently admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/15. The resident was coded as severely cognitively impaired in ability to make daily life decisions. Resident #3 was coded as requiring total care for all areas of activities of daily living and was coded as incontinent. A review of the clinical record revealed the annual MDS dated [DATE] the following in Section V - CAA: Section A - CAA results documented that Resident #2 triggered the following CAA areas: Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, [MEDICAL CONDITION] Drug Use, and Physical Restraints. Under the column, Location and Date of CAA documentation was documented alongside Urinary Incontinence, Falls, and Pressure Ulcer Daily nursing flow sheet. No dates identifying which Nursing Flow Sheets were reviewed to complete the MDS assessment were documented. A review of the CAA worksheet failed to reveal a location and date of the information used for areas described above. On 10/21/15 at approximately 2:30 p.m., an interview was conducted with RN (registered nurse) #1, the MDS coordinator. She stated that if the resident did not have an actual concern in the triggered area, she did not include a date because there was no dated event (actual identified pressure). She did not understand that the date of information was specific identifying the source of information reviewed to complete the MDS assessment On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey. 4. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 2/8/15 for Resident #4. Resident #4 was a [AGE] year old most recently admitted on [DATE] with the [DIAGNOSES REDACTED]. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded ass requiring total care for all areas of activities of daily living and as incontinent. A review of the clinical record revealed the annual MDS dated [DATE] the following in Section V - CAA: Section A - CAA results documented that Resident #2 triggered the following CAA areas: Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Mood, State, Activities, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use. Under the column, Location and Date of CAA documentation was documented alongside Urinary Incontinence, Falls, and Pressure Ulcer Daily nursing flow sheet. No dates identifying which Nursing Flow Sheets were reviewed to complete the MDS assessment. A review of the CAA worksheet failed to reveal a location and date of the information used for areas described above. On 10/21/15 at approximately 2:30 p.m., an interview was conducted with RN (registered nurse) #1, the MDS coordinator. She stated that if the resident did not have an actual concern in the triggered area, she did not include a date because there was no dated event (actual identified pressure). She did not understand that the date of information was specific identifying the source of information reviewed to complete the MDS assessment. On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey. 5. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 1/25/15 for Resident #7. Resident #7 was a 5 year old admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/15. The resident was coded as being in a persistent vegetative state. The resident was coded as requiring total care for all areas of activities of daily living and as incontinent. A review of the clinical record revealed the annual MDS dated [DATE] the following in Section V - CAA: Section A - CAA results documented that Resident #2 triggered the following CAA areas: Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use. Under the column, Location and Date of CAA documentation was documented alongside pressure ulcer Nursing Flow Sheet. No dates identifying which Nursing Flow Sheets were reviewed to complete the MDS assessment. A review of the CAA worksheet failed to reveal a location and date of the information used for areas described above. On 10/21/15 at approximately 2:30 p.m., an interview was conducted with RN (registered nurse) #1, the MDS coordinator. She stated that if the resident did not have an actual concern in the triggered area, she did not include a date because there was no dated event (actual identified pressure). She did not understand that the date of information was specific identifying the source of information reviewed to complete the MDS assessment. On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey. 6. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 5/10/15 for Resident #2. Resident #2 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent comprehensive MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 5/10/15. Resident #2 was coded on the MDS in Section C, Cognitive Patterns, as a three indicating that Resident #2 was severely impaired in making decisions regarding tasks of daily life. Further review of Resident #2's MDS annual assessment with an ARD of 5/10/15, revealed in Section V - CAA, that location and dates of information documented under the heading, Location and Date of CAA Information, was missing for four areas; urinary incontinence, activities, feeding tube and pressure ulcers. Section A - CAA results documented that Resident #2 triggered the following CAA areas: Urinary Incontinence and indwelling catheter Activities Feeding Tube Pressure Ulcer Under the column, Location and Date of CAA documentation the following documentation was inserted alongside each triggered area; Daily Nursing Documentation. A review of the CAA worksheet dated 5/10/15 failed to reveal a location and date of the information used for areas described above. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 10/21/15 at 2:25 p.m. RN #1 was asked what should be documented on the CAA worksheet when an area was triggered in Section V of the MDS. RN #1 stated that she understood that the location and date of where information came from should be included, but there were no issues that had occurred in the areas noted and she didn't have any dates. RN #1 further explained, If an area triggers I just write daily nursing documentation. RN #1 was asked what she used as a reference when completing the MDS, RN #1 responded, I use the RAI (resident assessment instrument). RN #1 was asked whether or not the location and date had been provided in the areas of urinary incontinence, activities, feeding tube and pressure ulcer for Resident #2, RN #1 stated that it was not. On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey. 7. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 5/3/15 for Resident #6. Resident #6 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #6's most recent comprehensive MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 5/3/15. Resident #6 was coded on the MDS in Section C, Cognitive Patterns, as a three indicating that Resident #6 was severely impaired with making decisions regarding tasks of daily life. Further review of Resident #6's MDS annual assessment with an ARD of 5/3/15, revealed in Section V - CAA, that location and dates of information documented under the heading, Location and Date of CAA Information, was missing for three areas; urinary incontinence, falls, and feeding tube. Section A - CAA results documented that Resident #2 triggered the following CAA areas: Urinary Incontinence and indwelling catheter Falls Feeding Tube Under the column, Location and Date of CAA documentation the following documentation was inserted alongside each triggered area; Daily Nursing Documentation. A review of the CAA worksheet dated 5/3/15 failed to reveal a location and date of the information used for areas described above. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 10/21/15 at 2:25 p.m. RN #1 was asked what should be documented on the CAA worksheet when an area was triggered in Section V of the MDS. RN #1 stated that she understood that the location and date of where information came from should be included but, there were no issues that had occurred in the areas noted and she didn't have any dates. RN #1 further explained, If an area triggers I just write daily nursing documentation. RN #1 was asked what she used as a reference when completing the MDS, RN #1 responded, I use the RAI (resident assessment instrument). RN #1 was asked whether or not the location and date had been provided in the areas of urinary incontinence, falls and feeding tube for Resident #6, RN #1 stated that it was not. On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey. 8. The facility staff failed to document location and date of the information used to complete Section V of the CAA (care area assessment) for the annual MDS (minimum data set) assessment, with an assessment reference date (ARD) of 9/13/15 for Resident #10. Resident #10 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #10's most recent comprehensive MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 9/13/15. Resident #10 was coded in Section C, Cognitive Patterns, as being independent with decisions regarding tasks of daily life. Further review of Resident #10's MDS annual assessment with an ARD of 5/3/15, revealed in Section V - CAA, that location and dates of information documented under the heading, Location and Date of CAA Information, was missing for two areas; pressure ulcers and pain. Section A - CAA results documented that Resident #2 triggered the following CAA areas: Pressure Ulcers Pain Under the column, Location and Date of CAA documentation the following documentation was inserted alongside each triggered area; Daily Nursing Documentation. A review of the CAA worksheet dated 5/3/15 failed to reveal a location and date of the information used for areas described above. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 10/21/15 at 2:25 p.m. RN #1 was asked what should be documented on the CAA worksheet when an area was triggered in Section V of the MDS. RN #1 stated that she understood that the location and date of where information came from should be included but, there were no issues that had occurred in the areas noted and she didn't have any dates. RN #1 further explained, If an area triggers I just write daily nursing documentation. RN #1 was asked what she used as a reference when completing the MDS, RN #1 responded, I use the RAI (resident assessment instrument). RN #1 was asked whether or not the location and date had been provided in the areas of pressure ulcer and pain for Resident #10, RN #1 stated that it was not. On 10/21/15 at 4:00 p.m. a meeting was held with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above findings. No further information was provided prior to the end of the survey.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner. Expired food items were found during the kitchen/food service observation. The findings include: On 11/13/2013 at 11:00 a.m., a tour of the facility kitchen was completed with the Food Service Manager. The following expired food items were found and verified by the Food Service Manager. One gallon 2% reduced fat milk, expired 11/12/2013. Two boxes (eight ounces each) Gerber rice baby cereal, expired 10/03/2013. On 11/13/2013 at 11:30 a.m., an interview was conducted with the Food Service Manager. She stated "Material management checks it Friday." On 11/13/2013 at 11:45 a.m., an interview was conducted with Material Management Coordinator. She stated the expired food items were "overlooked". On 11/13/2013 at 12:00 p.m., the Director of Nursing was notified of the above findings. According to documents provided by facility, there were only five of the 37 current residents that received oral feedings, and therefore at risk for receiving the expired food items. The facility Policy & Procedure titled "Use of Refrigerators" dated May 1994, documented, "Patient food will be discarded when expired."

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice in the administration of medication for one of seven residents in the medication administration observation; Resident #7. For Resident #7, the facility staff failed to double check the resident's name on the medication ([MEDICATION NAME]) prior to administration. The findings include: On 11/14/13 at 8:26 a.m., the medication administration observation was conducted with LPN #1 (Licensed Practical Nurse #1), who was preparing medication for Resident #7. The following medications were observed: *Cetrizine 10 mg (milligrams) (an [MEDICATION NAME]) *[MEDICATION NAME] 1300 mg (an anticonvulsant) *[MEDICATION NAME] 30 mg (an antiulcer/antisecretory) **Refresh ointment (an eye lubricant) *[MEDICATION NAME] 200 mg (an [MEDICATION NAME]) During this observation, LPN #1 handed the surveyor each package of medication for review. The pharmacy label on the [MEDICATION NAME] contained the name of a different resident, although she checked the medication name and dose against the MAR (Medication Administration Record) for Resident #7 for accuracy. She then put the package back into the bin of the other resident and administered the medications. On 11/14/13 at 2:46 p.m., an interview was conducted with LPN #1. She stated she obtained the medication from Resident #7's bin. It was noted that Resident #7's name was not the name on the medication package or the bin she returned it to. Upon checking the bin for Resident #7, there was a package for [MEDICATION NAME] for Resident #7 in her own bin. LPN #1 stated that since she had to dig to the bottom of the bin to locate it, then she must have inadvertently obtained it from the wrong bin or it would have been on top of the stack at this time. The two bins were located next to each other. When asked about the process for medication administration, she stated "to check the MAR for medication, dose, and time, and check medication allergies [REDACTED]. When asked if she checked for the resident's name on the package of [MEDICATION NAME], she stated, "I guess I didn't." A review of the facility policy, "General Dose Preparation and Medication Administration" revealed, "3.1 Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident." On 11/14/13 at 5:00 p.m., the Administrator, Director of Nursing, Assistant Director of Nursing, and Performance Improvement staff were made aware of the findings. According to Potter and Perry's, Basic Nursing, Essentials for Practice, 6th edition, pages 349-360, "It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication; 2. The right dose; 3. The right patient; 4 The right route; 5. The right time; and 6. The right documentation." *Information obtained from Nurse's Drug Guide 2009 Prentice Hall. Pages 292, 733, 871, and 886. **http://www.drugs.com/drp/refresh-p-m-lubricant-eye-ointment.html

Based on clinical record review, a complaint investigation and staff interview it was determined that for 1 of 11 residents in the survey sample (Resident #1) the facility staff failed to ensure Resident #1 was transferred safely from the Geri-chair to the bed on 1 occasion (6/30/12). Certified Nursing Assistant (CNA) #4 transferred Resident #1 without a mechanical lift and without additional staff assistance. The findings include: Clinical record review revealed, Resident #1 was a [AGE] year old re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's annual Minimum Data Set assessment dated [DATE], coded the resident as unable to make himself understood and unable to understand others. The staff assessment documented he had long and short term memory problems and rarely made decisions. Both of his lower extremities were impaired. He was 61" tall and weighed 118#. Activities of daily living/rehab potential did not trigger as a care area in the Care Area Assessment (CAA) dated 4/22/12. A nurse's note dated 6/30/12 at 1:40 PM, documented that Resident #1 possibly had a fractured left leg. The nurse documented, "pt (patient) leg strange position/ movement when put in bed after lunch..." The nurse documented that the resident was without signs or symptoms of pain or discomfort. The note documented "...Advised resource nurse. Upon talking to CNA, she first noticed leg was hanging out of chair at an 'awkward angle'..." The hospital Discharge Summary dated 7/2/12 documented that Resident #1 "...presented to ED with L (left) midshaft femur fracture with no observed trauma...Pt (patient) with extensive orthopaedic hx (history) including Right hip hemiarthroplasty (hip replacement) and Left proximal femur resection. Lack of history of inciting trauma prior to fracture raised concern for possible vitamin deficiency contributing to bone fragility...Work-up pending for vitamin deficiency...Vitamin D level PENDING (sic)..." On 11/1/12 at 12:25 PM, the nurse who wrote the 6/30/12 (RN #7) nurse's note was interviewed by phone. She stated Resident #1 was his "usual self", laughing and smiling. RN #7 stated the resident usually "keeps his legs under him" (tucked under his thighs). She stated the resident could move himself in the chair with his arms. RN #7 stated that when he was put to bed the resident's lower leg was moving independently. She notified the resource nurse and another nurse to assess the resident. She said the resident's vital signs were normal and he did not express pain or agitation during the assessment. RN #7 said someone told her the resident's left leg was out the side opening in the Geri-chair. She stated did not know when or how it happened. On 11/2/12 at 12:55 PM, the CNA (CNA #4) mentioned in the nurse's note dated 6/30/12 was interviewed by phone. CNA #4 stated Resident #1 was sitting with his legs under his thighs in his usual way. She said she took him to his room and noticed his left leg from the knee down was outside the left opening of the Geri-chair. She asked the resident to move himself over in the chair. CNA #4 said the resident used his arms to move himself over in the chair. CNA #4 stated she straddled her leg outside his legs and used the waist of his pants to pivot him to the bed. She said she noticed the resident's leg while providing incontinence care. She said Resident #1 did not show any signs of pain, such as grimacing. CNA #4 said she did not hear anything during the transfer. Safety/falls was identified on the 4/24/12 care plan as a problem. The care plan documented "...Potential for injury secondary to: a. Lack of safety awareness b. Impaired cognition c. Seizure activity d. Inability to control physical movements e. Physical/structural deformities including lower extremity contractures f. Lack of stability when sitting because of decreased strength in lower extremities..." There were several interventions including "Assess resident's safety needs and provide for protection by implementing measures and resources to prevent injury or falls...Inspect all additional pieces of equipment for good working conditions - seat belts, lap trays, foot and chest straps, Hoyer lift slings, and geri chair (lounge chair)...Provide supervision and/or assistance as needed for safe transfers, or ambulation...". The amount of supervision or assistance needed for a safe transfer was not identified on the 4/24/12 care plan. The Kardex (no date) stated the resident had agitation. The type of transfer and amount of supervision/assistance needed for transfers was not documented on the Kardex. There were no physician's orders for the type of transfer. On 11/1/12 at 8:15 AM, the director of nursing (DON) stated Resident #1's knees were contracted with tightness in his legs. She said he "gets his legs up and sits on his heels". She said he had upper body strength. The occupational therapist (OT) stated the resident's legs were contracted and not strong. The OT said the resident's upper body was strong. On 11/1/12 at 7:25 PM, Registered Nurse (RN) #2 stated Resident #1 does not stand at all. She said he was heavy and was transferred by a hoyer lift before the fracture. She said she confirmed with the resource nurse, (RN #8) that Resident #1 was transferred with the hoyer lift before the fracture. On 11/2/12 at 12:15 AM, Certified Nursing Assistant (CNA) #3 stated she worked on the 11 to 7 shift. She stated Resident #1 was transferred with a hoyer lift because he was so big he can't be manually lifted. CNA #3 said the resident could not stand by himself. CNA #3 said when using a lift a second person was needed to protect the resident and the staff member. She stated Resident #1 had been transferred with a lift for "going on a year now". On 11/2/12 at approximately 12:15 AM, the resource nurse said Resident #1 was always transferred with 2 staff members using a lift because of his weight and height. On 11/2/12 at 8:30 AM, RN #6 said generally when a resident weighed over 50# 2 staff members were needed for transfer. She said Resident #1 was transferred by 2 staff members using a lift because of movement. On 11/2/12 at 8:35 AM, the DON stated it was the facility practice that a lift was used to transfer residents over 50 or 60#. She stated if a resident had a sling they should be transferred with a hoyer lift. She said Resident #1 had a sling and should not be transferred by 1 person. The DON stated she asked CNA #4 about transferring Resident #1 by herself. The DON stated this was not the safest way to transfer the resident. She said CNA #4 said she had done it before and it was not a problem. The DON said she told CNA #4 not to transfer Resident #4 that way again. The DON stated most staff members would "tell you" Resident #1 needed a 2 person transfer because of his behaviors and movement. She said Resident #1 might have enough upper body strength to transfer from the wheel chair to the bed but not from the Geri-chair to the bed. She said Resident #1 may be able to straighten his legs a little but he can not bear weight. The DON was asked to provide documentation regarding the resident's transfers. On 11/2/12 at 9:20 AM, this concern was shared with the Administrator and the DON. The administrator stated Resident #1 had the upper body strength but not the intellectual capacity to transfer. She said she disagreed with the transfer style but nothing in the transfer indicated the resident was harmed. She said she did not think the transfer caused the fracture. On 11/2/12 at 11:25 AM, the DON provided the PT (Physical Therapy) Therapy TCU (transitional care unit) Plan of Care dated 10/6/11 and 5/10/12. The PT Therapy TCU Plan of Care dated 10/6/11 and 5/10/12 stated the resident was dependent for wheel chair to mat transfers. The facility policy titled Hoyer Transfers and reviewed in January 2003 stated, "...Purpose: To provide means of safety lifting (sic) and transferring patients. Policy: Patients unable to assist in transferring or moving self may be transferred or lifted by nursing staff utilizing the Hoyer lift..." COMPLAINT DEFICIENCY

Based on clinical record review and staff interview it was determined that for 1 of 11 residents in the survey sample (Resident #1) the facility staff failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected his functional status. Resident #1 had contractures of his knees and did not bear weight. His annual MDS, dated [DATE] documented the resident required supervision and 1 staff member's assistance for transfers from one surface to another. His quarterly MDS, dated [DATE] documented the resident required extensive assistance of 1 staff member for transfers. The findings include: Clinical record review revealed, Resident #1 was a [AGE] year old re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. His annual and quarterly Minimum Data Set assessments dated 4/24/12 and 10/7/12 respectively, coded the resident as unable to make himself understood and unable to understand others. The staff assessment documented he had long and short term memory problems and rarely made decisions. Both of his lower extremities were impaired. His annual MDS assessment, dated 4/22/12 documented he needed supervision for bed mobility and transfers. He needed the assistance of 1 staff member for transfers. He needed extensive staff assistance for all other activities of daily living. He was 61" tall and weighed 118#. Activities of daily living/rehab potential did not trigger as a care area in the Care Area Assessment (CAA) dated 4/22/12. His quarterly MDS assessment dated [DATE] documented that he needed supervision for bed mobility. He needed extensive assistance of 1 staff member for transfers. He was totally dependent on staff assistance for all other activities of daily living. He was 61" tall and weighed 133#. Safety/falls were identified on the 10/19/12 and 4/24/12 care plans as a problem. There were several interventions including "Inspect all additional pieces of equipment for good working conditions - seat belts, lap trays, foot and chest straps, Hoyer lift slings and geri chair (lounge chair)". The 4/24/12 care plan was updated on 6/30/12 to include a femur fracture. Activities of daily living and the type of transfer were not identified as a problem in the 4/24/12 or 10/19/12 care plans. The Kardex (no date) stated the resident had agitation. The type of transfer was not documented on the Kardex. There were no physician's orders for the type of transfer. The resident attended school from 6:00 AM to 2:30 PM, during the week. On 11/1/12 at 8:15 AM, the director of nursing (DON) stated Resident #1's knees were contracted with tightness in his legs. She said he had upper body strength. The occupational therapist (OT) stated the resident's legs were contracted and not strong. The OT said the resident's upper body was strong. On 11/1/12 at 7:25 PM, Registered Nurse (RN) #2 stated Resident #1 does not stand at all. She said he was heavy and was transferred by a hoyer lift before the fracture. She said she confirmed with the resource nurse, RN #8 that Resident #1 was transferred with the hoyer lift before the fracture. On 11/2/12 at 12:15 AM, Certified Nursing Assistant (CNA) #3 stated she worked on the 11 to 7 shift. She stated Resident #1 was transferred with a hoyer lift because he was so big he can't be manually lifted. CNA #3 said the resident could not stand by himself. CNA #3 said when using a lift a second person was needed to protect the resident and the staff member. She stated Resident #1 had been transferred with a lift for "going on a year now". On 11/2/12 at approximately 12:15 AM, the resource nurse said Resident #1 was always transferred with 2 staff members using a lift because of his weight and height. On 11/2/12 at 8:30 AM, RN #6 said generally when a resident weighed over 50# 2 staff members were needed for transfer. She said Resident #1 was transferred by 2 staff members using a lift because of movement. On 11/2/12 at 8:35 AM, the DON stated it was the facility practice that a lift was used to transfer resident's over 50 or 60#. She stated if a resident had a sling they should be transferred with a hoyer lift. She said Resident #1 had a sling and should not be transferred by 1 person. The DON stated most staff members would "tell you" Resident #1 needed a 2 person transfer because of his behaviors and movement. She said she did not know how the transfer section of the annual MDS could be accurate. She said Resident #1 might have enough upper body strength to transfer from the wheel chair to the bed but not from the Geri-chair to the bed. The DON was asked to provide documentation regarding the resident's transfers. The DON said the nurse responsible for coding the MDS was not currently at work. On 11/2/12 at 11:25 AM, the DON provided the PT (Physical Therapy) Therapy TCU (transitional care unit) Plan of Care dated 10/6/11 and 5/10/12. She stated she thought the transfer on the MDS was mis-coded or inaccurate based on the PT evaluation. The PT Therapy TCU Plan of Care dated 10/6/11 and 5/10/12 stated the resident was dependent for wheel chair to mat transfers. The Centers for Medicare and Medicaid Resident Assessment MDS 3.0 Manual (pages G-10 and 11) document "...Examples for G0110B, Transfer ... 2. Staff must supervise the resident as she transfers from her bed to wheelchair daily. Staff must bring the chair next to the bed and then remind her to hold on to the chair and position her body slowly. Coding: G0110B1 would be coded 1, supervision. G0110B2 would be coded 1, setup help only. Rationale: Resident requires staff supervision, cueing, and reminders for safe transfer. This activity happened daily over the 7-day look-back period. 3. Mrs. H. is able to transfer from the bed to chair when she uses her walker. Staff place the walker near her bed and then assist the resident with guided maneuvering as she transfers. The resident was noted to transfer from bed to chair six times during the 7-day look-back period. Coding: G0110B1 would be coded 2, limited assistance. G0110B2 would be coded 2, one person physical assist. Rationale: Resident requires staff to set up her walker and provide non-weight-bearing assistance when she is ready to transfer. The activity happened six times during the 7-day look-back period. 4. Mrs. B. requires weight-bearing assistance of one staff member to partially lift and support her when being transferred. The resident was noted to have been transferred 14 times in the 7-day look-back period and each time required weight-bearing assistance. Coding: G0110B1 would be coded 3, extensive assistance. G0110B2 would be coded 2, one person physical assist. Rationale: Resident partially participates in the task of transferring. The resident was noted to have transferred 14 times during the 7-day look-back period, each time requiring weight-bearing assistance of one staff member. 5. Mr. T. is in a physically debilitated state due to surgery. Two staff members must physically lift and transfer him to a reclining chair daily using a mechanical lift. Mr. T. is unable to assist or participate in any way. Coding: G0110B1 would be coded 4, total dependence. G0110B2 would be coded 3, two+ persons physical assist. Rationale: Resident did not participate and required two staff to transfer him out of his bed. The resident was transferred out of bed to the chair daily during the 7-day look-back period..."

Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to ensure the previous 15 months of MDS assessments were maintained on the active clinical record and were readily available and accessible to the staff for 8 of 10 residents in the survey sample ( Resident # 1, # 5, # 9, # 3, # 6, # 2, # 4 and # 8). 1. Resident #1 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. 2. Resident #5 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. 3. Resident #9 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. 4. Resident #3 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. 5. Resident #6 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. 6. For Resident #2, facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-28-11 was maintained on the active clinical record and/or was readily available and accessible to staff. 7. For Resident #4, the facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-14-11 was maintained on the active clinical record and/or was readily available and accessible to staff. 8. For Resident #8, the facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-14-11 was maintained on the active clinical record and/or was readily available and accessible to staff. The findings included: 1. Resident #1 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff Resident #1 was a seven year old who was admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD (Assessment Reference Date) of 10/30/11. The MDS coded the resident as being cognitively impaired in ability to make daily decisions; as being totally dependent on staff for transfers, dressing, eating, hygiene, and bathing; and coded as incontinent of bowel and bladder. On 11/9/11, the clinical record review was conducted. The MDS (Minimum Data Set) assessment book which was kept at the nurse's station for the staff use was used to review the MDS assessment portion of the clinical record. This review revealed Resident #1's annual MDS assessment with an ARD (Assessment Reference Date) of 8/7/11 and quarterly MDS assessment with an ARD of 10/30/11 were not printed in their entirety. The printed portion of the quarterly assessment contained only the Section A (Identification Information) and Section Z (Assessment Administration- Signature page). The annual assessment also contained the Section V (Care Area Assessment CAA Summary). On 11/9/11 at 10:15 a.m., an interview was conducted with LPN #2 (Licensed Practical Nurse #2), the assistant MDS coordinator. When asked about the location of the MDS assessments. She stated, "the facility went electronic in July, and MDS's from July to the present are in the computer." When asked if nurse's had access to the MDS assessments on the computer, she stated, "No." On 11/9/11 at 10:20 a.m., an interview was conducted with LPN #4 (Licensed Practical Nurse #4). She stated the MDS assessments were in a book at the front nurse's station. When asked if she had access to the entire assessment on the computer as the assessments in the book were not complete and only portions. She was observed unsuccessfully attempting to access MDS assessments on the computer. On 11/9/11 at approximately 10:45 a.m., an interview was conducted with RN #3 (Registered Nurse #3) the MDS coordinator. She stated, "staff do not have access to the MDS's (assessments) on the computer. The facility went to a new electronic system in July and since July, only Section A, the signature page, and the CAA's section (Care Area Assessment) are printed."then She restated, "Staff do not have access to the MDS assessments on the computer. We have to work on that." On 11/9/11 at 4:30 p.m., the administrative staff were made aware of the findings. No further information was provided by the end of the survey. 2. Resident #5 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. Resident #5 was a [AGE] year old who was admitted on [DATE] with a readmission on 9/22/11 with the [DIAGNOSES REDACTED]. The most recent MDS was an admission assessment with an ARD (Assessment Reference Date) of 10/5/11. The MDS coded the resident as being cognitively impaired in ability to make daily decisions; as being totally dependent on staff for transfers, dressing, eating, hygiene, and bathing; and coded as continent of bowel and occasionally incontinent of bladder. On 11/9/11, the clinical record review was conducted. The MDS assessment book which was kept at the nurse's station for the staff use was used to review the MDS assessment portion of the clinical record. This review revealed Resident #5's admission (re-admission) MDS assessment with an ARD of 10/5/11, and quarterly MDS assessment with an ARD of 7/24/11 were not printed in their entirety. The printed portion of the quarterly assessment contained only the Section A (Identification Information) and Section Z (Assessment Administration- Signature page). The admission assessment also contained the Section V (Care Area Assessment CAA Summary). Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 3. Resident #9 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. Resident #9 was a [AGE] year old who was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD (Assessment Reference Date) of 9/18/11. The MDS coded the resident as being cognitively impaired for daily decisions; as being totally dependent on staff for transfers, dressing, eating, hygiene, and bathing; and coded as incontinent of bowel and bladder. On 11/9/11, the clinical record review was conducted. The MDS assessment book which was kept at the nurse's station for the staff use was used to review the MDS assessment portion of the clinical record. This review revealed Resident #9's quarterly MDS assessment with an ARD of 9/18/11 was not printed in its entirety. The printed portion of the MDS contained only the Section A (Identification Information) and Section Z (Assessment Administration- Signature page). Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 4. Resident #3 did not have the previous 15 months of MDS (minimum data set) assessments maintained on the active record and or readily available/accessible for staff. Resident #3 was originally admitted on [DATE]. There was a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The most current MDS was a quarterly assessment dated [DATE] which coded Resident #3 as totally dependent on staff for all activities of daily living. Resident #3 was coded as having no short or long term memory loss, but had some limited impairment in making daily life decisions. Review of the clinical record revealed the MDS assessment information was kept in a separate binder. Upon review of the assessment information in the binder for Resident #3, the quarterly MDS assessment dated [DATE], and the current quarterly assessment (10/16/11) contained only the Section A (Identification Information) and Section Z (Assessment Administration- Signature page). Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 5. Resident #6 did not have minimum data set (MDS) information/assessments readily available/accessible to staff. Resident #6 was recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most current MDS was a quarterly assessment dated [DATE] which coded Resident #6 as having both long and short term memory impairment and as being severely impaired in the ability to make daily life decisions. Resident #6 was coded as being totally dependent on staff for all activities of daily living. Review of the clinical record revealed the MDS information was kept in a separate binder. Upon review of the assessment information in the binder for Resident #6, a significant change assessment dated [DATE], and the current quarterly (10/30/11) contained only the Section A (Identification Information) and Section Z (Assessment Administration- Signature page). The significant change assessment contained the Section V (Care Area Assessment CAA Summary). Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 6. For Resident #2, facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-28-11 was maintained on the active clinical record and/or was readily available and accessible to staff. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive MDS (minimum data set), an annual assessment, with an ARD (assessment reference date) of 12-19-10 coded the resident as having long and short term memory impairment and being severely impaired for daily decision making. Resident #2 was coded as rarely/never being understood, rarely/never understanding of others and absent of spoken words. Resident #2 was coded as totally dependent on staff for ADLs (activities of daily living) and being incontinent of bowel and bladder in addition to requiring intermittent catheterization for bladder emptying. Upon review of the clinical record on 11-9-11, the MDS assessments were not located. When asked where the MDS assessments were kept, LPN #2 indicated that the MDS assessments were located in another binder. Upon review of this binder, the most recent quarterly assessment dated [DATE] was located, however only Section A, (identification information) and Section Z (assessment administration) were printed and available for review. This quarterly assessment was then viewed on a facility provided computer by this surveyor. Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 7. For Resident #4, the facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-14-11 was maintained on the active clinical record and/or was readily available and accessible to staff. Resident #4 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive MDS, an annual assessment, with an ARD (assessment reference date) of 5-22-11 coded the resident as having short and long term memory impairment and as severely impaired for daily decision making skills. The resident was coded as rarely/never being understood, rarely/never capable of understanding others and absent of spoken words. Resident #4 was coded as totally dependent on staff for ADLs (activities of daily living) and incontinent of bowel and bladder. The clinical record for Resident #4 was reviewed on 11-9-11. The MDS assessments were not contained within this record. LPN #2 advised the surveyors the MDS assessments were located in another binder. Upon review of this binder, the most recent quarterly MDS assessment dated [DATE] was located, however only Section A, (identification information) and Section Z (assessment administration) were printed and available for review. This quarterly assessment was then viewed on a facility provided computer by this surveyor. Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. 8. For Resident #8, the facility staff failed to ensure that the most recent MDS (minimum data set), a quarterly assessment, dated 8-14-11 was maintained on the active clinical record and/or was readily available and accessible to staff. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent comprehensive MDS (minimum data set) an annual assessment, with an ARD (assessment reference date) of 2-27-11 coded the resident as "1", for both long and short term memory and as moderately impaired for daily decision making skills. The resident was coded as usually understanding of others and usually capable of making self understood. (Resident was equipped with a communication board with visual cueing.) Resident #8 was coded as totally dependent on staff for ADLs (activities of daily living) and being incontinent of bowel and bladder. The clinical record for Resident #8 was reviewed on 11-9-11 and again on 11-10-11. The quarterly MDS dated [DATE] was not contained within the clinical record. LPN # 2 advised surveyors on 11-9-11 that the MDS assessments were kept in a separate binder. Upon review of this binder on the morning of 11-10-11, the most recent quarterly assessment dated [DATE] was located, however only page 1 of Section A, (identification information) and Section Z (assessment administration) were printed and available for review. This quarterly assessment was then viewed on a facility provided computer by this surveyor. Further investigation and interviews (see #1) revealed the assessments beginning in July 2011 could only be viewed on the computer and clinical staff did not have access to this computer program to view the assessments. No further information was provided by the end of the survey.