Other·May 23, 2018

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during an the Abbreviated Survey and investigation for the following: CA00570515 CA00567224 CA00566177 Representing the California Department of Public Health: 38961 HFEN 38831 HFEN 31651 HFES 35286 HFEN 11112 HFES 35737 HFEN The investigation resulted in findings of Substantial Non-Compliance and an Immediate Jeopardy for F 760 was called on 1/25/18 at 6:50 p.m. The investigation findings included Substandard Quality of Care and high scope and severity for F 684, F 725 and F 726. At the time of the exit conference on 2/8/18 at 8:50 a.m. the IJ situation was NOT removed. 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG

F584 Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) SS=E ID PREFIX TAG DEFICIENCY) COMPLETE DATE 02/27/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide residents with housekeeping and maintenance services necessary to maintain a clean, comfortable and homelike environment when 12 of 45 resident rooms had the following: 1. Cluttered closets that contained soiled linen, bags with disposable unused briefs, pillows without pillow cases, wheelchair cushions, wheelchair foot rests, and unlabeled wash basins with personal care items. 2. Unlabeled bed pan and urinal on the bathroom floor. 3. Soiled briefs in trash cans without liners. 4. Unmade beds and soiled tissue paper visible next to a night stand. 5. Hand washing bed room sinks in two rooms with slow drains and one with a leak. These failures provided an unclean and unhomelike environment for the residents in the affected rooms and placed them at risk for cross contamination from improper storage of soiled linen. Findings: During an interview with Licensed Nurse (LN) 2, on 1/10/18 at 12:05 p.m., LN 2 stated the Residents were having lunch and all resident rooms were expected to be clean, with all beds made and clutter free at that time. 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an observation and concurrent interview with LN 1, on 1/10/18 at 12:10 p.m., the restroom for room 17 had a trash can without a liner and a bed pan on the floor. During an observation and concurrent interview with LN 2, on 1/10/18 at 12:12 p.m., room 16 A, 16 B, and 16 C had one closet space designated for three residents. The clothes were shoved in without adequate space, there were articles of clothing off their hangers and on the floor. The closet stored 3 wheelchair cushions and a bag of unused disposable briefs. LN 2 stated the closet was cluttered and messy. The over bed tables for room 16 A, B and C were soiled with food marks and drink marks. During an observation and concurrent interview with LN 2, on 1/10/18 at 12:18 p.m., room 15 A, 15 B, and 15 C had one closet space designated for three residents. There was a bag of unused disposable briefs on the floor of the closet, and a linen hamper with exposed personal soiled linen that smelled like urine. LN 2 stated, "It smells like urine." The bathroom trash can had no liner and contained a brief soiled with fecal material. The room smelled like stool from the soiled brief. LN 2 stated, "The CNA is responsible for bagging the briefs and throwing them away. I smell the brief and contents from the trash can." The over bed tables for bed A and B were soiled with drink stains. Resident 17 was sitting in her wheelchair inside the room and stated she was waiting for the CNA to make her bed. Resident 17 stated the CNA had to do an entire bed strip that morning and the CNA had not had time to make the bed. During an observation and concurrent interview with LN 1, on 1/10/18 at 12:30 p.m., the restroom for room 25 had a trash can without a 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE liner. During an observation and concurrent interview with LN 2, on 1/10/18 at 12:32 p.m., room 14 A, 14 B and 14 C had one closet space designated for three residents. The closet stored a folded up walker that took up the space designed for clothes to be hung. There was one unused disposable brief, a wash basin with a box of disposable gloves, and a large black plastic bag filled with soiled personal clothes belonging to one of the residents in the room all sitting on the floor of the closet. LN 2 stated, "Soiled linen cannot be left inside the closet." The closet stored a laundry basket that was entirely full with clothes spilling out. During an observation and concurrent interview with LN 2, on 1/10/18 at 1 p.m., room 8 A and 8 B had one closet space designated for two residents. The closet had one wash basin with personal care items sitting on the floor of the closet. LN 2 stated the wash basin belonged to room 45 and Resident 45's belongings should not be stored on the floor. During an observation and concurrent interview with LN 2, on 1/10/18 at 12:50 p.m., room 11 A, 11 B and 11 C had one closet space designated for three residents. LN 2 stated, "This closet is also cluttered." The closet stored pillows, wheelchair foot rests, one folded up walker, and a laundry basket overfilled with soiled clothes. The bed for the Resident in room B was unmade. When an Emergency Medical Technician (EMT) arrived with Resident 33 on a gurney and stepped out of the room requesting to have the bed made. Resident 33 remained on the gurney in the hallway while a CNA came to the room and prepared the room. During an observation of room 11 and 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE concurrent interview with Certified Nursing Assistant 1, on 1/10/18 at 1:22 p.m., CNA 1 stated, "The [wheelchair] foot rests are not supposed to be on the floor. They are touching the pillow on the floor. The pillow should not be there either. There is soiled personal laundry that is not properly contained. It was already like that when I got here at 7 a.m. I just have not had the time to fix this." During an observation and concurrent interview with LN 2 and Resident 74, on 1/10/18 at 1:30 p.m., room 9 A, B and C had one closet space designated for three residents. The closet contained clothes belonging to the residents. There were clothes on the floor, multiple unused disposable briefs and a large sealed cardboard box on the floor of the closet. Inside the bathroom there was a urinal that was unlabeled. LN 2 stated the closet was messy and the urinal could not be left inside the bathroom. Resident 74 stated staff jammed clothes into the closet because of the lack of space and pointed out to a leak in the handwashing sink of the room. Resident 74 stated, "The water constantly drips and will get on the countertop and floor. The other day I almost slipped." During an observation and concurrent interview with LN 2 and CNA 2 on 1/10/18 at 1:45, Room 7 A, B and C had one closet space designated for three residents. The closet was storing a laundry basket holding soiled linen. CNA 2 stated the linen inside the laundry basket needed to be put in a bag because of infection control. CNA 2 stated there was odor and she could smell it. CNA 2 stated, "I haven't had time to fix the closet or bag the clothes." During an observation and concurrent interview with LN 2, on 1/10/18 at 1:50 p.m., Room 4 A and B had a trash can without a liner with a 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE soiled brief inside. The closet designated for two residents had articles of clothing on the floor. LN 2 stated the closet looked messy and the brief should have already been thrown out. During an observation and concurrent interview with LN 2, on 1/10/18 at 1:55 p.m., Room 12 A and B had a slow draining hand washing sink. A bag of unlabeled incontinent wipes sat on top of the toilet tank. LN 2 stated wipes could not be left on top of the toilet tank. During an observation and concurrent interview with LN 1, on 1/10/18 at 1:55 p.m., Room 46 did not have closet doors available and had loose flooring on the closet floor. During an observation and concurrent interview with LN 2, on 1/10/18 at 2 p.m., Room 13 A, B and C had a slow draining sink. The closet space was designated for three residents. The floor of the closet had clothes on the ground that came off the hangars, wash basins and two wheelchair cushions. During an observation and concurrent interview with LN 2, on 1/10/18 at 2:05 p.m., Room 5 A, B and C had an unlabeled bed pan on the floor of the restroom, incontinent wipes on the toilet tank and crumpled tissue paper on the bathroom floor. There was no trash can liner and the can contained trash. LN 2 stated the bathroom looked dirty and the room was still messy. During an observation and concurrent interview with LN 2, on 1/10/18 at 2:10 p.m., Room 1 A, B and C had one unmade bed and crumpled tissue paper next to the night stand. There were incontinent wipes on the toilet tank and a no trash can liner with trash inside the trash can. 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE The facility policy and procedure titled, "Maintenance Service" dated 1/1/02, indicated, "Purpose: To protect the health and safety of residents, visitors, and Facility Staff. Procedure: I. The Maintenance Department is responsible for maintaining the building ...in a safe and operable manner at all times ...II. Functions of the Maintenance Department may include, but not limited to A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards ..." The facility policy and procedure titled, "Housekeeping-Resident Rooms" dated 9/16, indicated, "To promote the quality of life for resident by providing clean and sanitary living spaces ...B. Wastebaskets and ashtrays are cleaned and emptied ...D. Top and sides of over bed tables are damp wiped ...Furniture and furnishings of room are straightened as needed ...G. The resident's restroom is cleaned ...II. After Resident Discharge ...C. Bed stripping: i.The mattress and all part of the bed are cleaned and disinfected according to Facility procedures. Ii. The bed is remade with clean linen, blankets, pillow and bedspread ..."

F684 SS=I Quality of Care CFR(s): 483.25

F684 02/27/2018 § 483.25 Quality of care Quality of care is a fundamental principle that 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 3 of 3 sampled residents with wound care and unresolved pain (Resident 83, 82 and 84) when: 1. Resident 83 had verbal and physical expressions of pain from a surgically debrided wound (surgical removal of dead, damaged, or infected tissue) from a Stage IV Pressure Ulcer (localized injury to the skin and and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shearing.) Wound care had not been provided as ordered by the physician; pain management had not consistently been provided; and Resident 83 was transferred to the acute care hospital for appropriate care of the wound, infection, and pain. 2. Resident 82 and Resident 84 were not given requested pain medication before, during, or after wound care treatments were rendered. These failures resulted in Residents enduring prolonged and unrelieved pain. Findings: During an observation on 2/3/18, at 11: 47 AM, in Resident 83's room, Resident 83 was 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE observed lying on his right side holding himself by the hospital bed side rail. At the foot of his hospital bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings on top. Resident 83 was observed grimacing (facial expression of severe pain) and anxious as the Licensed Nurse (LN 6) administered his 8 AM medication late at 11:47. Resident 83 stated to LN 6, "I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done." LN 6 stated, "I know." LN 6 stated Resident 83 complained of pain earlier that morning and was not given pain medication because of "stomach issues." Resident 83 took his 8 AM medications [at 11:47 a.m.] then LN 6 walked out of the room without performing an assessment of Resident 83's pain. A Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated, "I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound. The CNA walked out of the room with the uneaten lunch meal. Resident closed his eyes and put his head against the side rail grimacing. During an interview with Resident 83, on 2/3/18, at 12 PM, he stated he was admitted to the facility on 1/25/18 for wound care. Resident 83 stated, "The doctor [surgeon] did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. I'm in pain 8/10 [measures of pain intensity 8- Physical activity severely limited, can read and converse with effort, nausea and dizziness may occur] and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE afraid of my wound getting worse. It's horrible, why did they bring me here if the nurses don't know how to care for my wound?" A review of the clinical record for Resident 83, the Medication Administration Record (MAR) dated 2/3/18, 8 AM, medication reconciliation (the process of reviewing the physician orders with observed medications administered to Resident 83 including drug name, dosage, frequency, and route administered, written on the MAR, compared to physician's order to check for accuracy) was done. The medication order, "MS [Morphine Sulfate, a narcotic ordered for severe pain] Contin 15 mg (milligrams) (1) tablet, extended release oral every day." The MAR indicated LN 6 had not administered the MS Contin pain pill as ordered. The MAR indicated, "Norco 5-325 mg (1) tablet oral as needed for pain was signed as given. During an interview with LN 6, on 2/3/18, at 2 PM, she reviewed the MAR and confirmed the findings and stated, "I don't know how I missed that." [giving the pain medication to Resident 83]. The "MAR" dated 2/18, had no pain monitoring for Resident 83. LN 6 confirmed the lack of documented monitoring, and stated the standard was to monitor pain levels every shift and stated that was not done for Resident 83. During a review of the clinical record for Resident 83, the "Minimum Data Set," (MDS) assessment (a comprehensive assessment tool used to identify physical and psychosocial abilities of the resident) dated 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of "15" (a score of 13 to 15 cognitive intact). The MDS section "J-Health conditions" pain assessment was not complete. The MDS 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE section "M-Skin conditions" unhealed pressure ulcers was not completed. During a review of the clinical record for Resident 83, a pain and/or wound care plan was not developed. A BRADEN scale document (assessment tool used to determine a resident's risk of developing or worsening pressure ulcer) was not completed, the document was left blank. The "Weekly Pressure Injury/Ulcer Progress report" (assessment tool) was not completed, the document was left blank. LN 6 confirmed the findings. During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated, "It's too much for one nurse to do. . .pain assessments are left out." During an interview with LN 11, on 2/6/18, at 9:32 a.m., LN 11 reviewed the clinical record and was unable to find a pain assessment, a wound assessment, pain or wound care plan. LN 11 stated, "The MDS is not complete." LN 11 stated Resident 83 did not receive assessments for his admission healthcare needs. Review of Resident 83's GACH clinical record titled, "Progress Notes" dated 2/5/18 indicated, "Assessment and Plan ...BIBA [brought in by ambulance] from SNF [skilled nursing facility] for a sacral wound that patient says is not being taken care of at the nursing home ...Not currently taking any antibiotics ...Patient [Resident 83] stated for last 2 to 3 days there is worsening drainage and foul smelling odor from wound ...Decubitus ulcer [pressure ulcer] of coccygeal [tailbone] region, stage 4 with infection. Plan: IV zosyn [an antibiotic] and vancomycin [an antibiotic] ...wound consult 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE placed, surgery [MD] consulted ...will likely need wound vac once infection clearing and healing and also plastic surgery referral ..." 2. During an observation on 2/4/18, at 11:34 AM, Resident 82 was laying on her bed turned to her right side, LN 6 informed Resident 82 she was ready to perform the treatment for the pressure ulcer to her left buttocks. LN 6 asked the CNA 1 to hold Resident 82 onto her right side and then exposed Resident 82's bottom. A wound was observed to the left buttocks and another wound on the right buttocks. LN 6 began to clean a white ointment from both wounds using warm soapy water. LN 6 stated the treatment read "zinc oxide to left stage II pressure sore." Resident 82 was observed grimacing and stated, "Ouch it hurts, it hurts, it hurts." Resident 82 verbalized pain ten times during the wound treatment and LN 6 continued the treatment without offering pain relief medication. LN 6 applied "zinc oxide ointment" to both left and right stage II wounds. Resident 82 stated, "Can you cover it [wound] with something? Every time they [staff] move me, change me it [wound] really hurts." LN 6 did not ask Resident 82 about pain intensity, duration, or any other assessment questions. LN 6 finished the treatment dressing and CNA 1 repositioned Resident 82 in her bed. Resident 82 stated to LN 6 "Can I have something for pain?" LN 6 stated "I will tell your nurse." LN 6 did not perform a pain assessment or give the resident pain medication. LN 6 stated, "We don't have a treatment [order for the stage II pressure ulcer for the right buttocks]." LN 6 continued with her treatments and did not notify the medication nurse of Resident 82's pain medication request. During an interview with Resident 82, on 2/4/18, at 11:47 AM, she stated Resident 82 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated, "I have pain 8/10" [measures of pain intensity 8- Physical activity severely limited. Able to read and converse with effort. Nausea and dizziness may occur.] "I have had the two sores for over two months . . ." Resident 82 stated she stays on her side the majority of the time in an attempt to heal the wounds and because of the pain. She stated, "I started with one wound now I have two. I don't want more. The nurses come once or twice a week and put something on my sores. But most of the time no one does anything for them, that's why they don't heal. It's horrible you can't get anyone to help you. I have to stay in bed. I can't get up or do anything because of the pain [to pressure ulcers]." During an interview with LN 6, on 2/6/18, at 8:06 AM, LN 6 was asked about the pain medication requested by Resident 82 on 2/4/18, at 11:34 AM. LN 6 reviewed the clinical record and was unable to find documentation of pain medication administration for resident 82. LN 6 stated, "Oh, I got busy and forgot." During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated "It's too much for one nurse to do. . .pain assessments are left out." During an observation on 2/6/18, at 2:54 PM, Resident 82 was on her bed lying on her right side. LN 15 informed Resident she was getting ready to perform the wound treatment to both stage II wounds. LN 15 stated, "[Resident 82] are you in pain?" LN 15 told Resident 82 she was getting ready to do the wound treatment. Resident 82 stated, "Yes, I'm always in pain." LN 15 stated, "Do you want something for pain before we start, or would you be okay without it?" Resident stated, "Oh yes that would be good [have pain medication]." Resident 82 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE requested to be pre-medicated with something for pain. LN 15 stated, "Do you think we can try to do the treatment and see how you do?" Resident 82 quietly stated, "Oh, okay we can try." LN 15 began the treatment procedure with Resident 82 making verbal expressions of pain "It hurts, it hurts." Resident 82 was observed grimacing during the treatment procedure. LN 15 stated "I know, this looks like it hurts. I'm sorry." Resident 82 stated, "Please can you cover it. The sheets, every touch hurts it [wounds]. I can't be on my back because it makes it hurt more. I'm in pain all the time 7/10 (pain scale of 7- difficulty in concentration, interferes with sleep, Resident can still function with effort). Resident asked, "Did you cover it?" LN 15 stated "yes." Resident 82 stated, "Oh, thank God. I have been suffering for over two months with this." LN 15 stated, "I will tell your nurse that you need a pain pill." LN 15 left Resident 82's room, did not inform the medication nurse Resident 82 was requesting a pain medication and continued with her treatments. During an interview with Certified Nursing Assistant (CNA) 1, on 2/6/18, at 9:05 AM, CNA 2 stated "she [Resident 82] has had those wounds on her bottom for a long time. But they are getting worse. They are bigger and she has pain when we clean her or move her. She will ask us to not touch or press on that area because she says she hurts. We offer to get her up and she refuses. She hurts." During an interview with LN 15, on 2/6/18, at 4:30 PM, LN 15 was asked about the pain medication requested by Resident 82 on 2/6/18, at 2:54 PM. LN 15 reviewed the clinical record and was unable to find documentation of pain medication administration for resident 82. LN 15 stated, "I got busy and forgot to tell the nurse. This Tylenol is not going to take care of 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the pain expressed. It's like throwing skittles (candy) at the pain." During a review of the clinical record for Resident 82, the MAR dated 2/18, indicated, "Tylenol 325 mg (2 tabs) totaling 650 [milligrams] mg oral every 4 hours for pain in left hip." The MAR indicated Resident 82 had not received the pain medication "Tylenol" for the month of February. During a concurrent interview and record review on 2/6/18, at 4:30 p.m., Resident 84's Physician Orders dated 2/18, indicated Resident 82 had one pain medication prescription order which was plain "Tylenol." No other pain medication orders were documented. LN 15 confirmed these facts. The "MAR" dated 2/18, had no pain monitoring documented for Resident 84. LN 15 confirmed the findings and stated the standard is to monitor pain levels every shift and that was not done for Resident 82. During an interview with CNA 3, on 2/5/18, at 3:10 PM, CNA 3 stated Resident 82's stage II wounds (on right and left buttocks) were open. She stated Resident 82 required extensive assistance with all care needs and was unable to transfer and reposition self. During an observation of wound care on 2/6/18, at 10:52 AM, Resident 84 was assisted onto his bed to perform the wound care to his stage III pressure ulcer. LN 15 began the wound treatment and Resident 84 stated "It hurts, it hurts all the time and I'm not a cry baby. Resident 84 made statements of complaints of pain eight times during the care. LN 15 stated "Where." Resident 84 placed his hand on his bottom. LN 15 stated "do you want me to tell your nurse that you want something for pain." Resident 84 stated "Yes, it hurts, it 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE hurts." Resident noted grimacing during treatment procedure. LN 15 stated "I will tell your nurse." LN 15 completed the wound treatment and walked out of the room. LN 15 continued with her wound treatments and did not notify the medication nurse of Resident 84's pain medication request. During an interview with Resident 82, on 2/5/18, at 3:20 PM, Resident 84 stated, "I have a sore and I don't know how I got it." During an interview with LN 15, on 2/5/18, at 3:50 PM, she stated Resident 82's wound was open and the treatment order was no longer appropriate. She stated "The wound is a stage III [pressure ulcer]." During an interview with the LN 11, on 2/6/18, at 9:32 a.m., she reviewed the clinical record and was unable to find a pain assessment and pain or wound care plan. She provided no additional information. During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated "It's too much for one nurse to do. . .pain assessments are left out." During an interview with LN 15, on 2/6/18, at 4:30 PM, she was asked about the pain medication requested by Resident 84, at 10:52 AM. LN 6 reviewed the clinical record and was unable to find documentation of pain medication administration for Resident 84. LN 15 stated "I got busy and forgot to tell the nurse. This Tylenol is not going to take care of the pain expressed. It's like throwing skittles (candy) at the pain." During a review of the clinical record for Resident 84, the "Physician Order Sheet" dated 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 2/18, indicated "Unstageable pressure ulcer to coccyx (tailbone) measuring 1.1 x 0.7 x UTD [unable to determine] [depth] clean with normal saline [sterile salt water], pat dry, apply zinc oxide [is a mineral. An ointment for the skin used to treat diaper rash, minor burns, severely chapped skin, or other minor skin irritations] to peri [around] wound, apply [that removes dead tissue from wounds so they can start to heal ] to wound bed and cover with foam." The Physician order indicated, "Tylenol extra strength, 500 mg" one tablet every six hours as needed for pain. During a concurrent interview and record review, Resident 84's "MAR" dated 2/18, indicated Resident 84 had not received medication for pain, "Tylenol 500 mg" for the month of February. The MAR had no pain monitoring for Resident 84. LN 15 confirmed these findings and stated the standard was to monitor pain levels every shift and LN 15 verified that was not done for Resident 84. During a review of the clinical record for Resident 84's MDS assessment dated 1/31/18, indicated under the section, "Brief Interview for Mental Status (BIMS)" a score of "3" (a score of 0-7: severely cognitive impaired). During a concurrent interview with LN 6 and record review for Resident 84, on 2/4/18, at 10:50 a.m. LN 6 reviewed the clinical record and was unable to find documentation of a pain and/or wound care plan, she stated one was not developed. A BRADEN scale (assessment tool used to determine a resident's risk of developing or worsening pressure ulcer) dated 1/31/18, indicated a score of 17 (total score of 12 or less represents high risk). The MDS dated 1/31/18, section G, indicated Resident 84 required extensive bed mobility assistance with one person assist needed and extensive 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE assistance with transfers required. LN 6 stated the Braden scale was completed incorrectly and did not reflect Resident 84's condition accurately. The MDS dated 1/31/18, section, "M-Skin conditions" indicated unhealed pressure ulcers coded as a "1." The "Weekly Pressure Injury/Ulcer Progress report" dated 1/31/18, indicated, "Unstageable pressure ulcer." The treatment record indicated Resident 84 did not receive wound treatments to his pressure ulcer on 2/2/18, 2/3/18 and 2/4/18. LN 6 confirmed the findings and stated the facility had no treatment nurse to perform the wound treatments. The facility policy and procedure titled, "Pain Management" dated 11/16, indicated, "Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. . . A licensed Nurse will assess each resident for pain when there is pain, exacerbation of pain. The Licensed Nurse will complete a Pain assessment for resident identified as having pain . . . The Licensed Nurse will assess the resident's pain based on non-verbal cues. (Examples grimacing, restless, not eating). The nurse will advise the Attending Physician, so the Attending physician can consider ordering pain medication to alleviate symptoms. The Licensed Nurse will administer pain medication as ordered and document medication administered on the MAR. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale . . . The shift pain score will indicate the highest pain level that occurred on that shift. Nursing staff will implement timely interventions to reduce an increase in severity of pain. . . " 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 DEFICIENCY) COMPLETE DATE 02/27/2018 SS=H CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 2 of 3 sampled Residents (Resident 83, Resident 82) who had wound care orders, received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when: 1. Resident 83 did not have care and treatment of a stage IV pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shearing) requiring a negative pressure wound vacuum treatment (NPWT) system as ordered by the 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE physician. Resident 83's wound vacuum was not working properly, and Licensed Staff were not trained on the equipment. Resident 83 was transferred to the acute care hospital for proper application of a wound vacuum to treat the Stage IV pressure ulcer, and infection of the wound; including new antibiotic therapy. 2. Resident 82 developed a second pressure ulcer of the right buttocks which was not identified and treated timely. This failure resulted in a potential worsening of the second pressure ulcer and pain with potential infection for Resident 82. Findings: 1. During an observation in Resident 83's room on 2/3/18, at 11: 47 a.m., Resident 83 was observed lying on his right side holding himself by the bed rail. At the foot of his bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings sitting on top of the cart. Resident 83 was observed grimacing (facial expression of severe pain) and anxious and jittery as the licensed nurse administered his medication scheduled for 8 a.m., at 11:47 a.m. for treatment of Diabetes Mellitus, and Hypertension (High blood pressure). Resident 83 stated to Licensed Nurse (LN) 6, "I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done." LN 6 stated, "I know." LN stated to Resident 83, "Take your pills." The medications administered at 11:47 a.m. did not included a pain pill. Once Resident 83 took his 8 a.m. medications LN 6 walked out of the room. LN 6 had not answered Resident 83's question regarding what would happen next regarding the wound care. A 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated, "I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound." The CNA walked out of the room with the uneaten lunch meal. Resident closed his eyes and put his head against the side rail grimacing. During an interview with Resident 83, on 2/3/18, at 12 p.m., the resident stated he was admitted to the facility on 1/25/18 for wound care. Resident 83 stated, "The doctor [surgeon] did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine [Wound Vacuum] this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. From the first day I came here the nurses keep saying they don't know how to do the wound care. One nurse will come and do the treatment and in a few hours or by the next shift a nurse will come and say the machine [NPWT] is not working and they remove the wound bandages and leave it with nothing on. It's horrible, why did they bring me here if the nurses don't know how to care for my wound." During an interview with Family Member (FM) 1, on 2/3/18, at 12 p.m., FM 1 stated the nurses would tell her and Resident 83 they don't have the treatment supplies for the wound and they don't know how to perform the treatment. FM 1 stated she did not understand why the facility accepted Resident 83 if the staff did not know how to care for his needs. During a concurrent interview and observation of the treatment cart supplies, on 2/3/18, at 12:28 p.m. with LN (6), LN 6 stated, "At around 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10 a.m., I noticed the wound vac [NPWT] was not working properly. I checked it and noticed the suction tubing was placed on the healthy skin area and not on the wound. The wound had a tan colored soaked wound dressing." LN (6) stated she removed the wound vac and the dressing and packed the wound with a wet- todry dressing (a moist saline gauze dressing is put in the wound and allowed to dry.) LN 6 stated that's what he has on the wound at this time. I have not called the doctor because I have been busy with my medication pass." She reviewed the wound supplies in the treatment cart and stated, "We do not have the wound supplies to perform the wound care. I don't know why they (Facility) accepted [Resident 83] when we [Licensed Nurses] don't know how to perform the wound vac treatment." LN 6 stated she had not been trained on how to perform a wound treatment using the wound vacuum. LN 6 stated, "I don't know what I'm doing with that [NPWT]." During an interview with LN 6, on 2/3/18, at 12:50 p.m., LN 6 stated Resident 83 was being sent to the hospital because the facility did not have wound supplies and trained staff to perform the wound treatment. Resident was transferred to the hospital by ambulance at 12:50 p.m. on 2/3/18 (Nine days after the resident was admitted to the facility for treatment of a pressure ulcer requiring the NPWT [wound vacuum] device. During a review of the clinical record for Resident 83, the "Face Sheet (Resident 83 Demographics)" indicated Resident 83 was admitted to the facility on 1/25/18. Review of Resident 83's "Minimum Data Set," (MDS) assessment -(a comprehensive assessment tool used to identify physical and psychosocial abilities of the resident), dated, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of "15" (a score of 13 to 15 means no cognitive impairment in memory or judgement). Review of the hospital transfer form dated 1/25/18, indicated, "Reason for placement: Wound care . . . LUQ [left upper quadrant] colostomy, abdominal; incision, st. [stage] 4 perianal [area around the anus] full thickness wound." Review of Resident 83's physicians order dated 1/25/18, indicated, "apply nickel-thick collagenase santyl ointment [is a sterile enzymatic debriding ointment] to the devitalized [weakened] necrotic [dead] tissue and wound bed. Apply white versa foam [dressing used to help promote graft take, for tunnels and undermining, while protecting delicate tissue] to the wound base and undermining [is deep tissue (subcutaneous fat and muscle) damage around the wound margin] covered by black granufoam [a wound dressing that promotes wound healing] NPWT-125 mm hg [millimeter of mercury is a manometric unit of pressure] low intensity continues suction. Change on Monday, Wednesday and Friday." The treatment record indicated the treatment was completed on Monday 1/29/18, Tuesday 1/30/18, and Wednesday 1/31/18 with no documented reason why the physicians order was not followed. A second order indicated, "Monitor [17] stitches for signs and symptoms of infection (mid lower abdomen) by shift" starting 1/25/18. The document contained information the monitoring was not conducted for nine of 19 shifts from 1/25/18 to 2/3/18. During an interview and concurrent record review with LN 6, on 2/3/17, at 2:07 p.m., LN 6 reviewed Resident 83's clinical record. LN 6 was unable to find documentation of a wound 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE assessment and a documented Braden skin risk assessment for Resident 83. She stated the Braden [a scale for Predicting Pressure Ulcer Risk, is a tool to identify the risk for a resident's development of a pressure ulcer] assessment was not completed and it should have been completed on assessment and the weekly skin assessments were completed weekly and none were completed for Resident 83. During a review of the clinical record for Resident 1, the "Clinical Notes Report" dated 1/25/18, at 9:13 p.m., indicated, "Resident admitted . . . Resident [83] alert and oriented X3, able to make needs know[n] . . .has Dx [diagnosis] of perirectal cellulitis . . . colostomy pouch intact, 17 stitches to lower mid abdomen . . . Resident [83] has wound vac [NPWT] to peri-anal . . . wound vac working well..." The "Clinical Notes Report" dated 1/29/18, indicated, "Order calls for versa type foam to wound bed and tunneling. None available at this time. . . MD [medical doctor] stated was okay to still change wound vac dressing at previously ordered intervals [Monday, Wednesdays, and Fridays] using black foam only until versa foam is available." The "Clinical Notes Report" dated 2/2/18, indicated, "Resident 83 returned from wound clinic [with] n.o. [new order] on wed [Wednesday] 1/31/18 n.o. to begin today . . . Q [every] Monday and Every Friday. . ." The "Treatment Administration Record" dated 2/1/18, indicated Resident 83 had not received the prescribed treatments on 2/2/18 as prescribed by the physician. During an interview with LN (6), on 2/3/18, at 12:17 p.m., she stated, "I noticed the wound 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE vac wasn't suctioning, so we removed it . . . and put a wet-to-dry gauze." LN 6 stated she removed the prescribed treatment and changed it without calling for a doctor's order. She stated, "I don't know why they admitted him [Resident 83]. We don't know how to do the dressing. At least I have never done one. We haven't received training on the wound vac and we don't have nurses that know how to do that [NPWT]." During an interview with LN 10, on 2/3/18, at 3:30 p.m., No sorry she stated, "I was never trained on that [NPWT], so I would not know how to do the treatment." During an interview with LN 3, on 2/3/18, at 3:39 PM, she stated, "I have never been trained and I am not comfortable doing the [NPWT] dressing change." During an interview with the Proctor (P 3) she reviewed the education training records and stated, "We do not have where the licensed nurses were educated on how to perform the [NPWT] treatment." During an interview with the Director of Nurses (DON), on 2/4/18, at 12:43 p.m., she stated the facility had not educated the LNs on how to perform the NPWT treatment. Review of Resident 83's medical record from the acute care hospital titled, "History and Physical (H&P)" dated 2/3/18, indicated, "Patient [Resident 83] Presents with wound infection." The H&P indicated Resident 83 was started on two antibiotics to treat the perirectal Stage IV wound infection of the sacrum. 2. During a concurrent observation and interview with Licensed Nurse (LN 6), on 2/4/18, at 11:34 a.m., Resident 82 was laying 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE on her bed turned to her right side. There was no pressure relieving device observed on the bed. LN 6 informed Resident 82 she was ready to perform the treatment to the pressure ulcer on the left buttock. LN 6 asked CNA 1 to hold Resident 82 onto her right side, and the residents bottom was then exposed. A wound was observed on the left side of Resident 82's bottom, and a second wound on the right side of her bottom. LN 6 began to clean a white ointment from both wounds using warm soapy water. LN 6 stated the treatment order on the indicated the treatment was to apply zinc oxide to the left [buttock] stage II pressure sore. She stated she would stage Resident 82's right buttocks wound as "a stage II." LN 6 stated Resident 82 did not have a treatment order for the stage II wound to the right buttocks. LN 6 measured both wounds and stated, "The left buttocks stage II measures 4 cm (centimeter) X [by] 2 cm and the right stage II measures 2 cm X 2 cm." LN 6 stated she would apply zinc oxide to the right buttocks pressure ulcer and to the left pressure ulcer. LN 6 stated she would call the doctor "when I get a chance, I will call the doctor" to inform him of the new wound to the right buttocks. LN 6 applied zinc oxide to the new pressure ulcer without a physician order. LN 6 stated she did not know when the right buttocks wound had developed. LN 6 further stated the facility did not have a treatment nurse and treatments and wound assessments were not being performed. During an interview with Resident 82, on 2/4/18, at 11:47 a.m., she stated, "I have had the two sores for over two months . . ." Resident 82 stated she stayed positioned on her side the majority of the time in an attempt to heal the wounds and because of the pain. She stated, "I started with one wound now I have two. I don't want more. The nurses come once or twice a week and put something on my 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE sores. But most of the time no one does anything for them, that's why they don't heal. It's horrible you can't get anyone to help you. I have to stay in bed. I can't get up or do anything because of the pain [of the pressure ulcer]." During an interview with Certified Nursing Assistant (CNA) 2, on 2/6/18, at 9:05 a.m., CNA 2 stated, "She [Resident 82] has had those wounds on her bottom for a long time. But they are getting worse. They are bigger and she has pain when we clean her or move her. She will ask us to not touch or press on that area because she says she hurts. We offer to get her up and she refuses. She hurts." During a review of the clinical record for Resident 82, the "Clinical Notes Report" dated 1/24/18, at 11:14 p.m. indicated, "Writer was notified by CNA that Resident [82] has open area. Upon assessment Resident has pressure ulcer stage 2 to left butt. MD was notified and writer received order to cleanse with warm soap and water and apply zinc oxide BID [twice a day]." Review of Resident 82's "Minimum Data Set (MDS) assessment" dated 12/13/17 indicated, the Brief Interview for Mental Status (BIMS) score was 13 (on a scale of 0-15 with 15 indicating no cognitive memory deficit). The section under, "Functional Status Section G" indicated Resident 82 required extensive assistance, one person assistance with bed mobility, transfers, moving to and from areas, dressing, toilet use, personal hygiene, and bathing. Section G, 0400, indicated Resident 82 had a functional limitation in Range of Motion to her upper and lower extremities, and uses a wheelchair for mobility. Section H0300/ H0400, indicated under urinary, "Always incontinent" and "frequently incontinent" of 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE bowel. Section "M0300" under skin conditions indicated the current number of unhealed Pressure ulcers as "2" present since 11/2/17. The facility weekly skin breakdown report dated 11/22/17, indicated, "Stage II pressure ulcer healed to left and right buttocks." The "Treatment Record" dated 2/1/18 indicated "Pressure Ulcer- (stage II Left Buttocks) cleanse left buttocks wound with warm soapy water, pat dry apply thin layer of zinc oxide 20% ointment twice a day and PRN [as needed] for incontinence episodes for 14 days then re-evaluate." The Treatment Record for 2/1/18, 2/2/18 and 2/3/18 contained no nurse signatures, indicated the treatment to the left buttocks stage II was not completed on 2/1/18, 2/2/18 and 2/3/18. There were no nurse initials or entries documented for these dates. LN 6 confirmed these findings and stated, "The treatment was not done." LN 6 reviewed the clinical record and was unable to find documentation of the wound on the record of the right buttocks wound. LN 6 stated someone had to know about the right buttocks wound and no one notified the physician the wound was left untreated. During an interview with LN 6 on 2/3/18, at 11: 47 a.m., LN 6 confirmed the treatment record for Resident 82 was missing documentation of monitoring for nine shifts and stated, "The treatment was not done." During an interview with LN 6, on 2/4/18, at 11:42 a.m., she reviewed the clinical record and was unable to find documentation of the weekly pressure ulcer reports (assessments) and Braden Risk Scale (skin breakdown assessment) document for Resident 82. LN 6 stated a weekly pressure ulcer report and a Braden Risk Scale assessment was not 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE completed. The facility policy and procedure titled, "Pressure Injury Prevention" dated 8/12/16 indicated, "To provide interventions for residents identified as high risk for developing pressure injuries. . . I. A risk assessment (Braden Scale) for developing pressure injuries will be completed upon admission and weekly for four weeks after admission, quarterly and when there is a significant change in condition. .." The facility policy and procedure titled, "Pressure injury and Skin Integrity Treatment" dated 8/12/16, indicated, "To provide guidelines for the treatment of pressure injury and other skin integrity conditions to facilitate healing. Treatments to pressure injuries and other skin integrity problems will be proven as ordered by the physician . . . A licensed Nurse will initiate a Pressure Report (SK- 02- form A) when a resident is admitted with a pressure injury or if a pressure injury develops. A licensed Nurse will initiate a Skin Ulcer Progress Report when a resident is admitted with . . . skin ulcer. A Skin integrity Progress Report will be initiated when a resident is admitted with or develops a skin problem such as . . . surgical wound. The Pressure Injury Progress Report, Skin Ulcer Progress Report or Skin Problem Progress Report will be updated weekly by the Licensed Nurse. Treatments to pressure injuries or other skin integrity problem will be ordered by the physician. . . The physician and family will be notified when there is a change in the condition of the pressure injury or skin integrity problem in order to insure that treatments and interventions are appropriate. . . Treatments administered will be documented on the Treatment Administration Record." 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG

F690 Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 SS=D DEFICIENCY) COMPLETE DATE 02/27/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a resident was provided treatment and services to maintain continence and to prevent skin breakdown for one of 85 Residents (Resident 10) when a bowel and bladder assessment was not completed and interventions to keep resident clean and dry from urine and stool were not implemented. This failure resulted in a recurring Stage 2 pressure ulcer (shallow wound with a reddish base that develops from pressure or friction) to Resident 10's right buttock and placed her at risk for developing urinary tract infections. Findings: During an observation and concurrent interview with Resident 10, on 1/11/18 at 4:15 p.m., Resident 10 was lying on top of an air mattress, with a brace on the left leg and on the right extremity an above the knee amputation. Resident 10 stated there were instances when she pressed the call light and did not receive help from staff for more than 30 minutes. Resident 10 stated she had suffered a fall in the facility two months ago that resulted in a leg fracture. Resident 10 stated she was afraid of getting up to use the restroom for fear of falling. Resident 10 stated she had trouble getting help from staff during the p.m., and night shift. Resident 10 stated, "I am having to poo and pee on my diaper, it is really upsetting to have to do this but I don't want to fall. I don't 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE trust them [staff, to assist in time to make it to the restroom]." Resident 10 stated she did not like using the bed pan because it was uncomfortable to sit on, especially while waiting for long periods of time before staff came to help. Resident 10 stated she had a sore on her right buttock. Resident 10 stated she felt the urge to urinate but was hard for her to control the urge which resulted in her urinating in her disposable brief. Resident 10 stated she felt the urge to defecate and was defecating in her disposable brief. Resident 10 stated she had not received any scheduled bathroom or toileting assistance from staff and was having to "go on her brief." The facility face sheet (document with resident profile information) indicated Resident 10 was admitted to the facility on 10/1/17 with a fracture to the left femur (long bone of the leg), right above the knee amputation, Stage 2 pressure ulcer to the right buttock, and diabetes mellitus. Resident 10 did not have a diagnosis of bladder or bowel incontinence listed. During a review of Resident 10's clinical record titled, "Minimum Data Set (MDS) (an assessment used to identify resident level of care and memory recall which drives care planning decision) assessment" dated 11/13/17, indicated Resident 10 had no cognitive (pertaining to short and long term memory) impairment. Section H Bladder and Bowel under HO200 Urinary Toileting Program indicated no trail toileting program had been attempted on admission/entry or reentry since urinary incontinence was noted in the facility. Section HO300 Urinary Continence indicated Resident 10 was always incontinent of urine. Section HO400 Bowel Continence indicated Resident 10 was always incontinent of bowel. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Section MO300 of the MDS indicated Resident 10 had a "Stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed ...Date of oldest Stage 2 pressure ulcer ...11/3/17." During a review of Resident 10's clinical record titled, "Care Plan Report" undated, indicated, "Totally incontinent of bowel and bladder ...Goals [Resident 10] will maintain maximum control of bladder. The number of incontinent episodes will be reduced over the next 90 days ...GOAL DATE 3/9/18. Interventions Check for incontinence; change if wet/soiled ...Frequency 3 Times Daily Starting 10/23/17 ...Resident does not want to participate in a toileting program ...Staff will assist resident with changing brief per resident request ...Ask resident if she needs to be changed." During a review of Resident 10's clinical record titled, "Care Plan Report" undated, indicated, "Potential for (further) skin breakdown related to (muscle weakness) RISK FACTORS ANEMIA, DIABETES (impaired glucose metabolism), MUSCLE WEAKNESS, PVD (peripheral vascular disease) ...11/3/17 stage 2 on right buttock ...Goals. Resident will remain free from (further) skin breakdown by next review X 3 months ...GOAL DATE: 2/9/18 ...Interventions. Check skin for redness, skin tears, swelling, or pressure areas and report any sings of skin breakdown ...Use pillows, pads, or wedges to reduce pressure on heals and pressure points; turn and reposition [every] 2 hours, DO NOT MASSAGE SKIN over pressure areas ...Keep resident clean and dry at all times ...Low air loss mattress ..." During a review of Resident 10's clinical record titled, "Care Plan Report" dated 12/13/17, indicated, "Stage 2 pressure ulcer to right buttock. RISK FACTORS ANEMIA, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE DIABETES, MUSCLE WEAKNESS, PVD, LEFT ARM [FRACTURE], EDEMA, NEUROPATHY (nerve damage causing nerve pain), HYPOTHYROIDISM (slow working thyroid gland responsible for body metabolism), MED'S, PAIN ...Goals. Ulcer will be healed by 1/12/18 ... Interventions ...Perform nutritional screening ...Use pillow, pads, or wedges to reduce pressure on heals and pressure points; turn and reposition [every] 2 hours and [as necessary] ...Assess and record the size of [length x width x depth] of skin discoloration, edema and pain status ...Frequency 1 Times Weekly Starting 10/23/17 ...Check for incontinence; clean and dry skin if wet or soiled ...use pressure reducing mattress and pads when sitting ..." During an interview and concurrent record review with Licensed Nurse (LN) 11, on 1/18/18 at 11:30 a.m., LN 11 stated Resident 10 was readmitted to the facility on 10/1/17, with a Braden scale (scale is to help health professionals, assess a patient's risk of developing pressure ulcers) of 14 which meant Resident 10 was high risk for skin breakdown. LN 11 stated Resident 10's care plan indicated a potential for further skin breakdown and the required interventions listed were the following: 1. monitor skin for redness, 2. Do not massage skin over pressure areas, 3. Keep resident clean and dry at all times and 4. Use pillow pad to reposition. LN 11 stated Resident 10 was initially admitted to the facility with pressure ulcer on the right buttock that healed and later reopened. LN 11 stated Resident 10's treatment record indicated the sore on the right buttock reopened on 11/3/17. LN 11 stated the former treatment nurse (TN 1) completed a treatment for Resident 10 but did not document an assessment of Resident 10's pressure ulcer. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE LN 11 stated a weekly assessment was necessary to reflect the progress of the pressure ulcer. During an interview and concurrent record review with TN 1, on 1/23/18 at 11:06 a.m., TN 1 stated she obtained a treatment order for Resident 10's stage 2 pressure ulcer right buttock area on 11/13/17. TN 1 stated, "There is no wound assessment completed and there are no notes to reflect it. I just think to do it, I may have overlooked it. It can get real busy." TN 1 stated Resident 2's pressure ulcer healed on 11/19/17 and reopened again sometime in December [2017]. TN 1 stated Resident 10's care plan interventions were the following: 1. Turn and reposition, 2. Use of a low air loss mattress, 3. The treatment application and 4. To be kept dry. TN 1 stated, [Resident 10] shared with her that a former certified nursing assistant who worked during the evening shift gave her anxiety because she would not change Resident 10's soiled brief. TN 1 stated there was a problem with staffing during the p.m., and night shift. TN 1 stated, "Staffing can become a problem when the need of a resident is higher than what the amount of staff available can provide." TN 1 stated, "I believe [Resident 10's] pressure ulcer was avoidable." During a review of Resident 10's clinical record titled "Clinical Note Entry" dated 11/19/17 at 11:49 a.m., indicated, "Late Entry: Resident had [Stage] 2 pressure area is healed now ..." During a review of Resident 10's clinical record titled, "SKIN BREAKDOWN REPORT WEEKLY" dated 12/13/17, indicated, "Acquired ...Buttock ...right ...Stage 2 [pressure ulcer] ...Length =2.5 Width = 1.5 ...Pressure Ulcer 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Preventive Measures: Pressure relieving device for bed Turning/repositioning program ..." During a review of Resident 10's clinical record titled, "SKIN BREAKDOWN REPORT WEEKLY" dated 1/10/17, indicated, "Acquired ...Buttock ...right ...Stage 2 [pressure ulcer] ...Length = .2 Width = .2 ...Pressure Ulcer Preventive Measures: Pressure relieving device for bed Turning/repositioning program ..." During an interview and concurrent record review with LN 11, on 1/23/18 at 2:15 p.m., LN 11 stated Resident 10 was not offered a toileting program to keep her clean and dry. LN 11 stated Resident 10 never got a bowel and bladder assessment to work with her difficulties. LN 11 stated she was the nurse responsible to complete the bowel and bladder assessments. LN 11 stated Resident 10 missed getting a bowel and bladder assessment on a quarterly basis. LN 11 stated Resident 10 did not like to use the bed pan and no other strategies were developed to help Resident 10 stay clean and dry. LN 11 stated Resident 10's pressure ulcer was avoidable and could have been prevented if other strategies to help Resident 10 maintain clean and dry were attempted. LN 11 stated, "Nothing else was attempted, I didn't think about it." During an interview and concurrent record review with CNA 4, on 1/23/18 at 3 p.m., CNA 4 stated Resident 10 did not use the toilet or the bed pan because she was incontinent of bowel and bladder. CNA 4 stated Resident 10 received incontinent care. The facility policy and procedure titled, "Perineal Care" dated 1/1/12, indicated, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE "Purpose To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need ...VI. Was perineal area thoroughly with solution. VII. Turn resident on side to cleanse anal and buttock areas. VIII. Dry perineal and buttock area thoroughly. Apply lotion to buttocks and back if needed. Reposition resident ..." The facility policy and procedure titled, "Bowel and Bladder Training/Toileting Program" dated 7/1/14, indicated, "The purpose of the Bowel and Bladder Training/Toileting Program is to ensure that residents who are incontinent of bowel and/or bladder receive appropriate treatment and services to minimize urinary tract infection and to restore as much normal bowel and/or bladder function as possible in order to prevent skin breakdown/irritation, improve resident morale, and restore resident dignity and self-respect. In addition, after the removal of a urinary catheter, services are provided to restore or improve normal bladder function to the extent possible. Policy. The facility will ensure that each resident who is incontinent of bowel and/or bladder is identified, assess, and provided appropriate treatment and services to achieve or maintain as much normal bladder and/or bowel functions as possible. Furthermore, prevent and maintain normal bladder and /or bowel functions for continent residents ...II. Procedure A. Assessment i. Using the Bowel and Bladder Evaluation and Interventions Form ...the Licensed Nurse will assess residents bowel and bladder status within fourteen (14) days of admission, quarterly, annually, upon significant change of condition ... B. Interventions i. Using the suggested interventions listed on the Bowel and Bladder Evaluation and Interventions Form 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ...the Licensed Nurse will determine the best choice of non-pharmacological and pharmacological according to the type of incontinence ..."

F693 SS=E Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 02/27/2018 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide appropriate treatment and management of a gastrostomy tube (GT) (opening through the skin into the stomach with insertion of a tube used to administer food, fluids or medication) for two of three sampled residents (Resident 26 and Resident 76), when Licensed Nurses (LN) failed to ensure the GT was patent by aspirating the gastric contents or instilling air through the GT prior to administering medications and fluids into the GT. This failure placed Resident 26 and Resident 76 at risk for potential aspiration and medical complications. Findings: During an observation and concurrent interview on 1/31/18 at 2:06 p.m., in Resident 26's room, LN 8 prepared medication for GT administration. LN 8 entered the room and exposed Resident 26's GT. LN 8 connected a 60 ml (milliliter, a liquid measure) syringe to the GT and prepared to flush the GT with water. LN 8 was interrupted and asked if she was required to check the GT for placement in the stomach. LN 8 removed the syringe and stepped out to the medication cart to obtain a stethoscope. LN 8 stated she had forgotten to check for GT placement before administering medications and water. During an observation and concurrent interview on 2/3/18 at 12:48 p.m., in Resident 76's room, LN 4 flushed Resident 76's GT with 60 ml of water. LN 4 stated she forgot to check for 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE placement of the GT (that the tube was in the stomach). LN 4 went out of Resident 76's room and went to the medication cart to get her stethoscope. LN 4 returned to the room, attached a 60 ml syringe to the GT and pushed air from the syringe into the GT while listening with the stethoscope over Resident 76's upper abdomen. LN 4 stated she was supposed to check for placement of the GT first and then flush with water. LN 4 did not aspirate (pull back on the plunger of the syringe attached to the tube) to check for residual contents (contents of the stomach). During an interview on 2/3/18 at 1:30 p.m., in the conference room, the Vice President of Clinical Operations (VPCO) 2 stated, "Before flushing the tube with water the nurse should aspirate the tube to check for gastric content, then instill the water through the tube into the stomach." The VPOC 2 stated the nurses needed to follow the correct procedure. Review of Resident 76's clinical record titled, "Physician's Orders" dated February, 2018, indicated,"Check Tube [GT] placement (Monitor) G-tube, Check & record gastric residual..." The facility policy and procedure titled, "Gastrostomy & Jejunostomy Placement and Patency Check, Dislodging/Pulling Out" dated 12/1/12, indicated, "To verify correct tube placement and patency before initiating enteral feeding, hydration and medication administration. Procedure: Auscultation ...Using a 60 ml syringe, pull syringe plunger back and fill with 10-20 ml of air. Connect the syringe to the end of the feeding tube. Put on stethoscope and place bell or diaphragm of the stethoscope over the left upper quadrant of the abdomen while rapidly injecting the air. Withdraw gastric contents... Note: This procedure is for checking 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE gastrostomy tube placement... Connect the syringe to the end of the gastrostomy tube. Slowly pull back the syringe to aspirate contents... Return aspirated contents to the stomach..."

F725 SS=F Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 02/27/2018 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide sufficient numbers of Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to provide nursing care to 87 of 87 sampled residents (Residents 1 through 87) when: 1. Resident wound treatments were not completed, and/or completed late, due to insufficient staffing of LNs. (cross reference F 684, F 726) 2. Medications were not administered per physicians order, and/or administered late, due to insufficient staffing of LNs. (cross reference

F 760) 3. Residents were served meal trays by family members in the dining room when there were no staff available to assist the resident's with meal trays. These failures affected residents ability to maintain their highest practicable physical, mental, and psychosocial well-being and placed residents at risk for complication of wound healing, adverse effects of late or missed medications and safety hazards of meal trays served by concerned family members without staff supervision. Findings: 1. During an interview and concurrent record review on 2/3/18 at 3 p.m., LN 4 stated she was assigned to do the resident wound treatments for station 1. LN 4 stated, "We have no treatment nurse. I have not done the 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE treatments but I'm staying over [working late] so I can do them later. I can't do everything, it's too much. I'm working a 16 hour shift today." LN 4 stated Station 1 residents, Resident 77, Resident 33, and Resident 39 had wound treatments for pressure ulcers. LN 4 stated, "I'm going to do them [wound treatments] on the p.m. shift. We don't have enough nurses." Review of Resident 77's Treatment Administration Record (TAR) dated February 2018, indicated, "Pressure Ulcer [wound created by pressure, friction or shearing forces on the skin] Left Buttock Inferior - Clean with NS [normal saline, a salt water solution] and apply medical honey daily. Apply A & D [an ointment containing vitamins A and D] daily to periwound area [tissue surrounding the wound], cover with calcium alginate [a dressing material that absorbs drainage] and dry dressing. Schedule: 7-3 [day shift hours between 7 a.m. and 3 p.m.]. Pressure Ulcer Right Buttock Clean with NS and apply medical honey daily, Apply A & D daily to periwound area, cover with calcium alginate and dry dressing. Schedule: 73 [day shift hours between 7 a.m. and 3 p.m.]." Review of Resident 33's TAR dated February 2018, indicated, "Clean wound bottom right foot with 4 X 4 [four inch by four inch gauze square] and saline [NS], pat dry, apply xeroform gauze [a type of vaseline wound dressing] secure with tape...Schedule 7-3." Review of Resident 39's TAR dated February 2018, indicated, "Monitor non-blanchable [pink skin turns white when pressed but does not quickly return to pink color indicating poor blood circulation to the skin] redness to coccyx [tailbone]for S/S [signs and symptoms] of further complication and notify MD with any changes. Schedule: 7-3, 3-11 [evening shift hours between 3 p.m. and 11 p.m.], 11-7 [night 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE shift hours between 11 p.m. and 7 a.m.]...Cleanse coccyx stage 1 [pressure ulcer, skin is intact with non-blanchable redness] with warm soapy water, pat dry, apply a thin layer of Calmoseptine ointment [skin protectant] daily and prn [as needed] for incontinence episodes. Schedule: 7-3." On 2/3/18 at 3:18 p.m., a review of the TARS for Station 2 and Station 3 dated February 2018 indicated missed wound treatments for the following residents; Resident 29, Resident 32, Resident 51, Resident 55, Resident 63, Resident 67, Resident 23 and Resident 84. Review of Resident 29's TAR dated February 2018, indicated, "Stage III P/U [pressure ulcer that extends through the skin and subcutaneous tissue] to sacrococcyx [tailbone area]...Cleanse with NS, pat dry, apply Calmoseptine every shift and prn...Schedule: AM [7-3], PM [3-11], NOC [11-7]. " The TAR for Resident 29's pressure ulcer treatment was not signed as administered by the LN for the PM and the NOC shifts on 2/1/18 and 2/2/18. Review of Resident 32's TAR dated February 2018, indicated, "Monitor for signs and symptoms of infection every day starting 1/18/18. Schedule: 7-3." The TAR for Resident 32's which indicated monitoring for infection, was not signed [as administered] by the LN for 2/1/18. Review of Resident 51's TAR) dated February 2018, indicated, "Monitor for Signs and Symptoms of Infection by shift: Left Hip...Inner Left Thigh...Right and Left Buttock...Right Knee...Schedule: 7-3, 3-11, 11-7." The TAR for Resident 51's monitoring for infection was not signed [as administered] by the LN for the 3-11 shift or the 11-7 shift on 2/1/18 and 2/2/18. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Review of Resident 55's TAR dated February 2018, indicated, "Monitor for Signs and Symptoms of Infection by shift-right knee...monitor discoloration to right wrist...left side of abdomen...Schedule: 7-3, 3-11, 11-7." The TAR for Resident 55's monitoring for infection and discoloration was not signed as monitored by the LN for the 3-11 shift and the 11-7 shift on 2/1/18 and 2/2/18. Review of Resident 63's Treatment Administration Record (TAR) dated February 2018, indicated, "Arterial Ulcer [wound caused by poor circulation] left lower leg/foot...Cleanse with NS, pat dry on the superior half apply medical honey and on the posterior half apply santyl [an ointment to aid healing], apply non adhesive dressing and cover with Kerlix [gauze wrap] daily. Schedule: 7-3." The TAR for Resident 63's arterial ulcer treatment was not signed as administered by the LN on 2/1/18. Review of Resident 67's TAR) dated February 2018, indicated, "Pressure Ulcer - every two days starting 8/7/17...Sacral Coccyx Unstageable Pressure Ulcer [bottom of the wound bed is covered by necrotic [dead] or organic matter making it impossible to determine how deep and wide the wound is]. Cleanse with NS, pat dry and apply hydrocolloid dressing. Schedule: 7-3 on 2/1/18." The TAR for Resident 67's pressure ulcer treatment was not signed [as administered] by the LN on 2/1/18. Resident 67's TAR further indicated, "Dressing change every day starting 8/21/17...Cleanse right BKA [below the knee amputation] with NS, Apply 4 X 4, Kerlix (gauze) and Ace Wrap [elastic bandage]. Schedule: 7 - 3. Wound Care right stump [end of amputated right leg] every day start 10/27/18...Cleanse with NS pat dry and pack with wet to dry dressing [gauze dampened with NS and covered with a dry 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE dressing]. Schedule: 7-3." The TAR for Resident 67's right stump wound care and dressing change was not signed [as administered] by the LN on 2/1/18. Resident 67's TAR further indicated, "Wound Care left heel every day starting 12/28/17...UTD [unable to determine stage of wound] to left heel, cleanse with NS, pat dry and apply skin prep to area. Schedule: 7-3." The TAR for Resident 67's left heel wound care was not signed as administered by the LN on 2/1/18. Review of Resident 23's TAR) dated February 2018, indicated, "DTPI [deep tissue pressure injury] to right medial [middle] heel ...cleanse with NS, pat dry, apply skin prep and leave open to air QD [every day]. Schedule: AM...Excoriation to coccyx: apply Calmoseptine Cream to clean dry skin every shift and prn." The TAR for Resident 23's right heel wound care was not signed [as administered] by the LN on 2/2/18 and 2/3/18. The treatment to the coccyx wound was not signed [as administered] by the LN on the 3-11 shift or 117 shift on 2/1/18 and was not signed for any shift on 2/2/18 and 2/3/18. On 2/4/18 at 10:44 a.m., during an interview and concurrent record review, LN 6 stated no wound assessment of Resident 23's heel and coccyx wounds had been done by a LN since 12/8/17. LN 6 stated, "We have to do a wound assessment once a week. We haven't had a nurse [treatment nurse] so I don't know why the assessment wasn't done. All I can say is that we don't have enough nurses." On 2/4/18 at 11:26 a.m., during an interview and concurrent record review, LN 6 stated, "The treatment to the right heel [Resident 23's heel] and the coccyx is not signed so it wasn't done for 2/2/18 and 2/3/18. We didn't have a treatment nurse." 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Review of Resident 84's TAR dated February 2018, indicated, "G-tube site [gastrostomy tube-area on abdomen where a tube inserted through the skin into the stomach to provide food, fluids or medications exits the body], Cleanse with NS pat dry, cover with dry dressing every day starting 1/19/18. Schedule: 7-3. Unstageable pressure ulcer to coccyx...clean with NS, pat dry, apply zinc oxide to peri wound, apply collagenase santyl [material to clean the wound and aid healing] to wound bed and cover with foam. Schedule: 73." The TAR for Resident 84's G-tube site care and coccyx wound care was not signed [as administered] by the LN on 2/12/18, 2/3/18, or 2/4/18. On 2/5/18 at 2:46 p.m. during an interview and concurrent interview, LN 15 stated the treatment to Resident 84's G-tube site and coccyx was not done on 2/2/18, 2/3/18 and 2/4/18. LN 15 stated, "I guess they [the facility] didn't have enough nurses." 2. On 1/24/18 at 11:45 a.m., during an interview and concurrent record review, the Medical Records Director (MRD) stated she was responsible to audit all of the resident MARs and TAR's in the facility. The MRD stated, "These are non-negotiable audits." The MRD explained the audits were completed on a daily basis and given to the nurses daily to complete. The MRD stated the nurses' documentation was audited each time the MAR's were left with blank entries, circled initials on medications not administered and without a documented reason why. The MRD stated the audit also included medications prescribed for and given on an as needed basis which had no documented reason why the medications were not given. The MRD stated for all three nursing stations, the MARs 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE contained many missing entries. The MRD stated the facility had been without a consistent Director of Nursing (DON) since September 2017, and stated the lack of entries had increased over this time period. The MRD stated she had given the results to the DON but the documented omissions continued. On 1/25/18 at 8:50 a.m., the Interim DON (IDON) stated the nurse was to call the pharmacy and notify the physician when a medication was not available to be administered. The IDON stated the LN was responsible to document on the residents MAR and nursing progress notes. The IDON stated the nurse was to reorder medications at least 5 days prior to running out of the medication. The IDON stated she noticed the medication pass with three nurses was a heavy load. The IDON stated, "We need four nurses on the a.m., and p.m., shift and three nurses for the NOC (night) shift. It is a heavy load." The IDON stated she spoke to the Administrator about her observation and did not know what the response would be. On 1/26/18 at 3 p.m., during an interview, LN 8 stated Resident 7 did not receive her Brimonidine Tartrate [eye drops to reduce pressure in the eye] medication for treatment of glaucoma [eye disorder which can cause blindness if untreated] on 1/26/18 at 8 a.m., because it had not yet been delivered from the pharmacy. LN 8 stated, "We are not following orders and her glaucoma is not being treated as it should." LN 8 stated she had not yet called the physician to notify of the missed medication or the pharmacy to request delivery of the medication because she did not have time to do so. On 1/26/18 at 3:05 p.m., during an interview, LN 8 stated Resident 3's Jardiance which was 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ordered [medication] to treat Resident 3's diabetes, had not been delivered from the pharmacy. LN 8 stated she had not called the physician to inform him about the medication unavailability because she did not have time to do so. LN 8 stated she had just finished her afternoon medication pass and had no time to make the calls to the physician. On 1/27/18 at 9:50 a.m., during a medication pass observation and concurrent record review with LN 4 at medication cart 1, six medications were administered late to Resident 52. LN 4 stated Resident 52 received his 8 a.m., dose of Baclofen 10 mg (used to treat muscle spasms), Aspirin 81 mg, Lisinopril 20 mg (used to treat high blood pressure and heart failure), Fexofenadine HCL [hydrochloride]180 mg (antihistamine used to relieve allergy symptoms), Gabapentin 600 mg (nerve pain medication and anticonvulsant [anti-seizure]), Fluoxetine 20 mg (treat major depressive disorder, bulimia nervosa (an eating disorder) obsessive-compulsive disorder, panic disorder, and premenstrual dysphoric disorder (PMDD) at 9:50 a.m. LN 4 stated the medications were being administered late (1 hour and 50 minutes past the scheduled time of 8 a.m.). On 1/27/18 at 8:45 a.m., during a medication pass observation, LN 12 performed a fingerstick to check blood sugar value on Resident 30. Resident 30 was lying in bed with an empty breakfast tray. Resident 30 stated, "I already ate." LN 12 performed the fingerstick with results of 572. LN 12 stated, "I will have to call his doctor, he is a brittle diabetic" (Resident 30's blood sugar values were hard to control). Review of Resident 30's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated blood sugar check four times daily at 6 a.m., 11:30 a.m., 4:30 p.m., and 8 p.m. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 30's finger stick blood sugar check was done 2 hours and 45 minutes past the physician ordered scheduled time. On 1/27/18 at 10:05 a.m., during a medication pass observation and concurrent interview LN 4 stated Resident 40 received his 7 a.m. dose of Calcium-Vitamin D 600 mg, 8 a.m., dose of Eliquis (used to prevent strokes) 5 mg, Carvedilol (treat heart failure and high blood pressure) 3.125 mg, Cyanocobalamin (treatment of pernicious anemia [inability to adequately absorb Vitamin B) 500 mcg [micrograms-unit of measure], Docusate Sodium (used to treat constipation) 100 mg, Finasteride (treat male pattern baldness and enlarged prostate) 5 mg, Isosorbide Dinitrate (nitrate that dilates (widens) blood vessels, making it easier for blood to flow through them and easier for the heart to pump; treat and prevent chest pain )10 mg, Probiotic ( dietary supplement (1 cap), Folic Acid (vitamin B complex) 0.4 mg, Lisinopril 10 mg, Hydrocortisone (treat inflammation) 20 mg, at 10:05 a.m. LN 4 stated the all of the medications for Resident 40 were administered late. On 1/28/18 at 12 p.m., LN 2 arrived at medication cart 1. LN 2 stated he was assigned to pass medications to Resident 50 at 8 a.m. LN 2 stated he did not administer all of Resident 50's 8 a.m. medications because he was called away from the medication cart to assist another resident. LN 2 stated when he returned to medication cart 1 Resident 50's medications were over an hour late so he did not administer the 8 a.m. medications. LN 2 reviewed Resident 50's MAR and confirmed he had not administered Resident 50's 8 a.m. medications including clopidogrel (medication that inhibits the stickiness of blood platelets and is used to decrease the risk of stroke and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE heart attack) 75 mg, Humulin 70-30 [injection](a mix of quick acting and intermediate acting insulin, a hormone that lowers blood sugar levels) 20 units subcutaneously (injected below the upper layer of the skin), metformin HCL (a medication used to control blood sugar) 500 mg, Senokot (a medication used to treat constipation) 8.6 mg, Metoprolol Tartrate (a medication to treat high blood pressure) 25 mg, and Propafenone HCL (a medication to treat irregular heart rhythms) 300 mg. On 1/31/18 at 1:07 p.m., during a medication pass observation and concurrent interview, LN 8 prepared medication for Resident 18. LN 8 stated Resident 18's antibiotic was due at 11 a.m. and was being administered late. On 1/31/18 at 1:05 p.m., during a medication pass observation and concurrent interview, LN 7 stated Resident 85 received her 8 a.m. dose of Keppra (medication used to treat seizures) 1,000 mg, Memantine (medication for dementia) HCL 2 mg per ml (5 ML) oral solution and Aspirin 81 mg chewable at 1:05 pm. LN 7 stated the medications were administered late. On 1/31/18 at 4 p.m. during an interview at Station 1, LN 7 stated she was an on-call nurse for the facility. LN 7 stated, this was her second day at the facility on medication cart 1. LN 7 stated many of her medications due for 8 a.m. administration were given more than an hour past the scheduled time. LN 7 stated Residents were at risk for harm due to delayed medication administration. LN 7 stated, "This medication pass is heavy, and we need two nurses for the pass." LN 7 started to cry and stated, "I am overwhelmed and I am not coming back." On 2/3/18 at 12:52 p.m., during an observation and a concurrent interview, LN 13 obtained 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 30's blood sugar by performing a fingerstick (One hour and 22 minutes after the scheduled time for fingerstick and insulin administration according to the results of the blood sugar ordered). LN 13 stated Resident 30's Blood sugar value was 420 mg/dl (milligrams per deciliter). LN 13 did not administer insulin to Resident 30. On 2/3/18 at 1 p.m. Resident 30 was observed eating lunch in his room. Review of Resident 30's "Physician Order Sheet" indicated, "Novolog Latex-Free 100 unit/ml [units per milliliter], Sliding Scale [insulin is administered according to the resident's blood sugar levels] If above 400 call MD [physician]...order date: 1/28/18...schedule 6 a.m., 11:30 a.m., 4:30 a.m., 8 p.m...." On 2/3/18 at 4:55 p.m., during an interview and concurrent record review at medication cart 3, LN 13 stated she gave 15 units of insulin to Resident 30 at 3:30 p.m. for his blood sugar result of 420 at 12:52 (which was scheduled to be done at 11:30 a.m.). On 2/6/18 at 3:50 p.m., during an interview, Proctor (P) 3 stated she observed the 8 a.m. medication pass with LN 15 that morning. P 3 stated the 8 a.m. medication pass was completed at 11:30 a.m., two and one half hours after the scheduled time frame allowed for medication administration. P 3 stated 35 of 37 residents received their medications more than an hour past the scheduled time. Late medication included: for Resident 11 an anticoagulant (a blood thinner) due twice daily and a medication for diabetes given once daily; for Resident 39, Resident 44 and Resident 83 medications for high blood pressure to be given once daily; for Resident 84 an anti-seizure medication to be given twice daily; for Resident 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 16 an antibiotic to be given twice daily; for Resident 85 a diuretic medication (given to increase urine production and elimination for multiple medical conditions including high blood pressure) to be given once daily; for Resident 46 a narcotic pain medication to be given every 6 hours. The facility policy and procedure titled "Medication-Errors" dated 1/1/12, indicated, "Medication Error means the administration of medication: ... B. At the wrong time ..." Review of Professional Reference, "Institute for Safe Medication Practices Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults," 2017, indicated, "Types and Causes of Insulin Errors. A variety of error types have been associated with insulin therapy, including...dose omissions, and improper patient monitoring. Many errors result in serious hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar)...Other factors that contribute to serious hypoglycemia include inappropriate timing of insulin doses with food and poor coordination of blood glucose testing with insulin administration at meal times. Hyperglycemia commonly results from...insulin...dose omissions..." A facility policy titled, "MedicationAdministration," undated indicated, "...Procedure...B. The Licensed Nurse will prepare medications within one hour of administration...i. Medications may be administered one hour before or after the scheduled medication administration time." 3. On 1/17/18 at 11:40 a.m., during a meal observation in the dining room, 14 residents were sitting at tables waiting for their lunch to be served. Family Member (FM) 2 and FM 3 removed resident lunch trays from the meal 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE cart in the dining room and placed trays in front of residents seated at the dining room tables. On 1/17/18 at 12:50 p.m., during an interview, FM 2 stated her mother was a resident in the facility and she often helped her during meal times. FM 2 stated she took her mother's tray out of the meal cart in the dining room at lunch and set the tray up for her mother. FM 2 stated she took two other trays from the meal cart and gave those to two residents in the dining room. FM 2 stated, "I saw that other family member did it - she passed trays and so I did not think it would be a problem." FM 2 stated she wanted to help the staff and residents. On 1/17/18 at 1 p.m., during an interview, FM 3 stated her mother was a resident in the facility. FM 3 stated, "I always help to pass out trays. They [facility] do not have enough staff." On 1/17/18 at 5:45 p.m., during an interview, LN 13 stated, "We do not have enough staff to feed residents in the dining room." On 1/19/18 at 12:20 p.m., during a meal observation, eight residents were eating lunch in the dining room. No LN or CNA was present in the dining room. On 1/19/18 at 12:22 p.m., during an observation and concurrent interview, CNA 4 entered the dining room. CNA 4 stated he had previously been in the dining room but had left to deliver a meal tray to a resident room. CNA 4 stated he should not have left the dining room occupied with residents unsupervised. On 1/19/18 at 12:30 p.m., during an interview the Director of Staff Development (DSD) stated CNA 4 should not have left the residents in the dining room unsupervised. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE On 1/19/18 at 2:25 p.m., during an interview, CNA 4 stated he was the only CNA in the dining room at lunch and he had to leave to deliver trays to other residents while also being assigned to supervise the dining room. CNA 4 stated, "This [delivering trays outside of the dining room] has been happening for about one month." CNA 4 stated residents that eat in the dining room are on regular (regular texture) diets and on mechanical soft (foods with softer texture for residents with chewing or swallowing difficulties). CNA 4 stated one CNA was not sufficient to do his assigned duties: supervise the dining room while residents were eating, deliver trays to residents in their room and get items from the kitchen.

F726 SS=G Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 02/27/2018 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide sufficient Licensed Nursing (LN) staff with specific competencies required for one of 87 sampled residents, Resident 83, when LN staff was not trained how to care for Resident 83's physician ordered Negative Pressure Wound Treatment (NPWT, a specialized wound treatment system that utilizes negative pressure and a pump device to promote wound healing of severe wounds). This failure resulted in delayed wound healing, infection of the wound bed, pain, stress and anxiety for Resident 83, when physician ordered treatment of the wound was not provided and Resident 83 was transferred to the general acute care hospital (GACH) for treatment. Findings: 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 83's clinical record titled, "Face Sheet (Resident 83 Demographics)" indicated Resident 83 was 79 years old and was admitted to the facility on 1/25/18. Resident 83's clinical record titled, "Physician Orders" dated February 2018 indicated Resident 83 had diagnoses that included Type II Diabetes (disorder that interferes with insulin, a hormone that controls blood sugar levels), colostomy (an opening of the intestines to the outside of the body) and an open wound on the buttocks. Resident 83's transfer form from the GACH to the Skilled Nursing Facility (SNF) dated 1/25/18, indicated "Reason for placement: wound care . . . st. [stage] 4 [wound extends through the skin, through the muscle, down to the bone) perianal [area around the anus] full thickness wound." Review of Resident 83's clinical record titled, "Clinical Notes Report" dated 1/25/18, at 9:13 p.m., indicated "Resident [Resident 83] admitted ...Resident alert and oriented X 3 [knows who he is, where he is and what time it is], able to make needs known ...Resident has wound vac [NPWT] ...wound vac working well ..." Resident 83's clinical record titled, "Minimum Data Set," (MDS, a resident assessment tool), dated 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of 15 out of a possible 15 points which indicated Resident 83 was cognitively intact (memory and reasoning ability was intact). On 2/3/18, at 11: 47 a.m., during an observation and concurrent interview in Resident 83's room, Resident 83 was lying on 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE his right side, holding himself off his backside by grabbing onto the hospital bedside rail. At the foot of his hospital bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings on top of the cart. Resident 83 was observed grimacing (facial expression of severe pain) and stated he was worried about his wound dressing as LN 6 administered his 8 a.m. medications(over three hours after the medications were due). Resident 83 stated to LN 6, "I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done." LN 6 stated, "I know." LN 6 stated Resident 83 had requested pain medication. Once Resident 83 took his 8 a.m. medications LN 6 walked out of the room without providing Resident 83 an explanation of what was going to happen with his open wound. At that time a Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated "I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound." The CNA walked out of the room with the uneaten lunch meal. Resident 83 closed his eyes and put his head against the side rail grimacing. On 2/3/18, at 12 p.m., during a concurrent interview with Resident 83 and Resident 83's Family Member (FM) 1, Resident 83 stated he was admitted to the facility on 1/25/18 for wound care. Resident 83 stated "The doctor [surgeon] did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE From the first day I came here the nurses keep saying they don't know how to do the wound care. One nurse will come and do the treatment and in a few hours or by the next shift a nurse will come and say the machine [NPWT] is not working and they remove the wound bandages and leave it with nothing on. It's horrible. Why did they bring me here if the nurses don't know how to care for my wound?" FM 1 stated the nurses tell her and Resident 83 they don't have the treatment supplies for the wound and they don't know how to perform the treatment. FM 1 stated she did not understand why the facility accepted Resident 83 if the staff did not know how to care for his needs. On 2/3/18 at 12:17 p.m. during an interview, LN 6 stated, "At around 10 a.m., I noticed the wound vac [NPWT] was not working properly. I checked it and noticed the suction tubing was placed on the healthy skin area and not on the wound and the wound had a tan colored soaked wound dressing." LN 6 stated, "I removed the wound vac [NPWT], the dressing, and packed the wound with a wet to dry dressing [saline soaked gauze covered with a dry dressing] and that's what he has on the wound at this time. I have not called the doctor because I have been busy with my medication pass." LN 6 reviewed the wound supplies in the treatment cart and stated, "We do not have the wound supplies to perform the wound care. I don't know why they [Facility] accepted [Resident 83] when we [Licensed Nurses] don't know how to perform the wound vac [NPWT] treatment. I have never been educated on how to perform a wound treatment like that. I don't know what I'm doing with that [NPWT]. We haven't received training on the wound vac and we don't have nurses that know how to do that [provide care for a resident with a NPTW]." Resident 83's physicians order dated 1/25/18, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated "Apply nickel-thick collagenase santyl ointment [is a sterile enzymatic debriding ointment] to the devitalized [poor blood flow] necrotic [dead] tissue and wound bed. Apply white versa foam [dressing used to promote tissue growth] to the wound base and undermining [deep tissue damage around the wound margin] covered by black granufoam [a wound dressing that promotes wound healing] NPWT-125 mmhg [millimeter of mercury - a measurement of pressure] low intensity continuous suction. Change on Monday, Wednesday and Friday." Resident 83's treatment record indicated the treatment was completed on Monday 1/29/18, Tuesday 1/30/18, and Wednesday 1/31/18 with no documented reason why the physicians order was not followed. Resident 83's clinical record titled, "Treatment Record" dated February 2018 indicated Resident 83's NPWT dressing change was scheduled for Friday 2/2/18. The "Treatment Record" was not initialed by the LN for 2/2/18 which indicated the wound treatment was not completed on 2/2/18 by the LN. On 2/3/17, at 2:07 p.m., during a concurrent interview and record record, LN 6 reviewed Resident 83's clinical record and was unable to find documentation of wound assessment and Braden (a scale for predicting a resident's risk for developing pressure ulcers) skin risk assessments. LN 6 stated the Braden skin risk assessment was not completed and it should have been completed by a LN on admission and the weekly skin assessments should be completed weekly and none were completed for Resident 83. Review of Resident 83's "Clinical Notes Report" dated 2/3/18 at 2:07 p.m. indicated, "Upon Med pass resident [Resident 83] wound vac was not 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE draining, wound vac dressing was removed and covered with clean wet to dry dressing. MD was made aware and gave orders to transfer resident out to acute hospital for wound management." The "Clinical Notes Report" Review of Resident 83's Physician Orders dated 2/3/18 at 11:50 a.m. indicated, "Transfer to [GACH] for wound management." Review of Resident 83's GACH clinical record titled, "ED [Emergency Department] Provider Notes" dated 2/3/18 at 2:39 p.m., indicated, "Discussion: Large sacral wound not getting proper wound care. Concerned for infection. Elevated inflammatory markers [laboratory results that indicate infection and inflammation]. Will need IV [intravenous, medication is injected into a vein] abx [antibiotics] and will consult surgery." On 2/3/18 at 3:30 p.m., during an interview, LN 10 stated, "I was never trained on that [NPWT], so I would not know how to do the treatment." On 2/3/18 at 3:39 p.m., during an interview, LN 3 stated, "I have never been trained and I am not comfortable doing the [NPWT for Resident 83] dressing change." On 2/3/18 at 5:50 p.m., during an interview, Proctor (P) 4 reviewed the facility LN education records and stated, "We do not have where the licensed nurses were educated on how to perform the [NPWT] treatment." P 4 stated he was unable to find any in-service training records that indicated LNs were trained to provide care to residents with a NPWT system. On 2/4/18 at 12:43 p.m., during an interview, the Director of Nurses (DON) stated the facility did not educate the LNs on how to perform the 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE wound care using the NPWT system. Review of Resident 83's GACH clinical record titled, "Progress Notes" dated 2/5/18 indicated, "Assessment and Plan ...BIBA [brought in by ambulance] from SNF [skilled nursing facility] for a sacral wound that patient says is not being taken care of at the nursing home ...Not currently taking any antibiotics ...Patient [Resident 83] stated for last 2 to 3 days there is worsening drainage and foul smelling odor from wound ...Decubitus ulcer [pressure ulcer] of coccygeal [tailbone] region, stage 4 with infection. Plan: IV zosyn [an antibiotic] and vancomycin [an antibiotic] ...wound consult placed, surgery [MD] consulted ...will likely need wound vac once infection clearing and healing and also plastic surgery referral ..."

F760 SS=L Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 02/27/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record and professional reference review, the facility failed to ensure 45 of 94 residents (Residents 1, 2, and 3; Resident 4, Residents 7 and 8; Residents 11 and 12; Resident 14, Resident 16, Residents 18 through 27; Residents 29 and 30; Residents 34 and 35; Resident 37, Resident 39, Residents 43 and 44; Residents 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 49 and 50; Resident 52, Residents 56 and 57; Resident 60, Resident 66, Residents 70 and 71; Resident 75, Resident 78 and Residents 80 through 85) were free from significant medication errors when: 1. Physician prescribed medications for Resident 1 were not administered as ordered. Resident 1 was given 2 of 6 doses of Cefadroxil 500 milligrams (mg) (antibioticmedication prescribed to treat bacterial infections), for the diagnosis of Cellulitis (infection of the tissues below the skin) without subsequent physician notification of the missed medications. This failure resulted in medications not given for a known bacterial infection and led to Resident 1's transfer to the General Acute Care Hospital (GACH) with the diagnosis of sepsis (systemic infection). 2. Licensed Nurse (LN) 1, LN 2, and LN 9 failed to use the appropriate needle attachment made for use with Insulin Flex Pens (a dial-a-dose, pre-filled insulin pen for discreet mealtime management) when LN's withdrew insulin out of the pen using a non-intended syringe with needle. This practice was not in accordance with the directions for use of the Insulin Flex Pens and placed residents on Insulin at risk for unsafe administration of medications. 3. The Facility LNs (LN 1, LN 2, LN 3, LN 4, LN 5, LN 6, LN 7, LN 8, LN 9, LN 10, LN 13 and LN 14 ) assigned to administer medications using three of three medication carts failed to administer multiple medications as prescribed for scheduled and prn (as needed) medications affecting multiple residents (Resident 3, Resident 4, Resident 7, Resident 8, Resident 9, Resident 12, Resident 14, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 28, Resident 29, Resident 30,Resident 40, Resident 50, Resident 56, Resident 57, Resident 60, Resident 66, Resident 70, Resident 71, Resident 78, Resident 80, Resident 81, Resident 82) on numerous occasions. On multiple occasions there was no follow up by the nursing staff to ensure availability and accessibility of medications for timely and accurate administration. There were no open dates on Insulin Flex pens used for multiple residents. These failures placed residents at risk of serious harm from medications given or not given as prescribed; and from Insulin medication administered from Flex Pens not dated with the potential to affect resident's blood sugar stability. 4. Physician orders written for the month of January 2018 were not carried over to the clinical record for residents for continued administration or discontinuance of the ordered medication in time for the February 1, 2018 administration of medications. As a result of this failure, multiple significant medications were not administered as ordered for 3 of # of residents (Resident 5, Resident 6, and Resident 13). This placed Resident 5, Resident 6 and Resident 13 at risk for harm from significant medication errors. Because of these failures and the identified serious actual harm to Resident 1 and potential serious harm to all residents with prescribed medications, an Immediate Jeopardy Situation was called on 1/25/18 at 6:50 p.m. with the facility administrator and the Interim Director of Nursing (DON). The facility submitted an interim Action Plan (AP) to address the safe administration of medications for the 1/25/18 8 p.m., 1/26/18 midnight and 1/26/18 morning medication administration that included Interim 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE DON proctoring the medication passes. The Flex pens were removed from accessibility and use as part of the interim AP. The facility submitted APs on 1/26/18, 1/30/18 and 1/31/18 that were reviewed and unacceptable. The District Office management staff teleconferenced multiple times with the Administrator and IDON to explain the need to develop an Action Plan that effectively addressed the multi-factorial, system failures. The facility was directed to determine a system of proctoring each licensed nurse for medication administration and determine competency and safety parameters. On 2/1/18 at 12: 04 p.m. the facility submitted an action plan that was acceptable. The survey team continued to find significant medication errors following the acceptance of the AP. The facility failed to implement the AP and an exit conference was done on 2/8/18 at 8:50 a.m. without removing the IJ situation. The Administrator and corporate Vice President of Operations were present at the time of the exit. Findings: 1. During an observation and concurrent interview with Resident 1, on 1/11/18 at 1:25 pm, Resident 1 was in his room lying on his bed with an air mattress (special mattress designed to conduct a flow of air and to promote skin circulation). Resident 1 was awake, alert and appropriately responded to questions. Resident 1 stated he was admitted to the facility on 1/3/18 for wound management of his right buttock pressure ulcer and was on oral antibiotics to treat the infection. Resident 1 was observed with amputations of both his legs and he confirmed he had undergone an above the knee amputation (AKA) on his right leg and below the knee amputation (BKA) on his left leg. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE The facility face sheet (document with resident profile information) indicated Resident 1 was admitted on 1/3/18 at 9:47 a.m. The January 2018 Physician Order Sheet for the facility indicated Resident 1 was prescribed Cefadroxil (antibiotic to treat cellulitis - an infection of the tissues underneath the skin) 500 mg's 1 capsule oral two times daily for three days starting 1/3/18. The Physician Order Sheet indicated the Cefadroxil was to be administered at 8 a.m. and 8 p.m. Resident 1's Medication Administration Record (MAR) generated from the Physician Order Sheet indicated Cefadroxil 500 mg 1 capsule oral was to start on 1/3/18 at 8 p.m. and an electronically generated capital letter 'E' (indicating [End] completion of drug regimen) on 1/6/18 8 a.m. (for a total of five doses to be given). The Delivery Manifest (document provided with the pharmacy delivery of medications) for the facility for Resident 1's Cefadroxil 500 mg capsule, quantity 6 indicated delivery on 1/5/18 at 1:51 a.m. Resident 1's MAR indicated the Cefadroxil was not administered on 1/3/18 at 8 p.m., 1/4/18 at 8 a.m., 1/4/18 at 8 p.m. The MAR indicated the Cefadroxil was administered on 1/5/18 at 8 a.m. and 1/5/18 at 8 p.m. The MAR entry for 1/4/18 at 8 p.m. was marked with a circle (indicating not administered) and the reverse of the MAR page documented the following: "Cefadroxil 500 mg, called pharmacy to get code, but not available in Cubex [a locked container of medications which may be needed on short or emergency notice and and can be opened with a code from the pharmacy]". During an observation and concurrent interview with Director of Staff Development (DSD licensed nurse in charge of training all staff), on 1/19/18 at 3:10 p.m. the Cefadroxil bubble pack prescribed for Resident 1 was identified and contained four capsules of the medication. The 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE DSD stated Resident 1 should have been administered all six doses of the antibiotic Cefadroxil and the bubble pack should have been empty. During an interview and concurrent record review of Resident 1's MAR and Physician Order Sheet, on 1/19/18 at 3:35 P.M. the Interim Director of Nursing (IDON) stated the antibiotic Cefadroxil was not administered as ordered. The IDON stated the MAR did not accurately reflect the prescription for Cefadroxil. The IDON stated one of the risks for not administering Cefadroxil as ordered could be complication of the infection. IDON did not comment on the expectation for nurses to clarify orders because the IDON stated her employment start date with the facility was on 1/12/18, after the incident with Resident 1. During an interview and concurrent record review of Resident 1's MAR and Physician Order Sheet dated 1/3/18 on 1/22/18 at 1:15 p.m. LN 1 stated he was the medication administration nurse for Resident 1 for the mornings of 1/4/18, 1/5/18 and 1/6/18. LN 1 stated Resident 1 should have received six doses of Cefadroxil and did not. LN 1 stated of 1/6/18 and was the reason he did not administer the Cefadroxil on 1/6/18. LN 1 stated that the 1/4/18 8 a.m. dose was not given because the medication was not available. LN 1 stated he should have called the physician for clarification and did not. LN 1 stated a new MAR should have been generated based on the physician clarification but was not. LN 1 agreed the original MAR was not accurately transcribed from the Physician Order Sheet and the inaccuracy should have been identified. LN 1 stated the Cefadroxil was not in the Cubex and not delivered to the facility until 1/5/18 and a new MAR should have been 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE generated and was not. The facility face sheet for Resident 1 indicated he was admitted on 1/3/18 with the following diagnoses: unstageable pressure ulcer of the right buttock, cellulitis left lower limb, left femur fracture, right above the knee amputation, left below the knee amputation, diabetes (abnormal blood sugar), chronic kidney disease stage 3 (moderately severe damage to the kidneys). The "History and Physical Exam" clinical record dated 1/4/18 indicated Resident 1 "... was transferred to the SNF [Skilled Nursing Facility] for short term rehab and wound care" Resident 1's clinical record titled, "Minimum Data Set (MDS) (an assessment used to identify resident level of care which drives care planning decision) assessment dated 1/10/18, indicated Resident 1 had no cognitive (pertaining to short and long term memory) impairment. Resident 1's clinical record titled, "ANTIBIOTIC OR CONTROLLED DRUG RECORD" undated, indicated, "Cefadroxil 500 mg CAPSULE [quantity] 6 CAP ...TAKE ONE CAPSULE BY MOUTH 2 TIMES A DAY FOR 3 DAYS." The document indicated the antibiotic was signed for on 1/5/18 at 8 a.m., and 8 pm. Resident 1's clinical record titled, "Progress Notes" dated 1/10/18 at 3:56 p.m. created by Primary Care Physician (PCP) indicated, "Chief Complaint: Follow up visit ...patient had loose bowel movements last week that has improved now, he is taking antibiotics and compliant with medications ...SKIN; skin ulcer on his back is slightly worsened in size and appearance with surrounding skin erythema (redness) It is 27.5 X 15 cm and has ++ exudative layer of necrotic tissue ..." 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 1's "Clinical Notes" dated 1/13/18 at 1:19 a.m., indicated, "[temperature] 102.0 (normal temps 97-99 degrees Fahrenheit) ...RESIDENT DOES HAVE A FEVER TYLENOL 325 MG TWO TABS GIVEN THIS IS A MALE ADULT WITH BILATERAL AMPUTATIONS [RELATE TO] MRSA RESIDENT IS CLEARED FROM ISOLATION ABLE TO MAKE NEEDS KNOWN ..." Resident 1's "Clinical Notes" dated 1/14/18 at 1:04 p.m., indicated, "resident was noted to be uncomfortable and restless, [oxygen saturation] 90% (normal value 90-100) and has cough ...resident sent to [acute care] for further eval ..." During an interview with, Resident 1's PCP 1 on 1/23/18 at 3:34 p.m., stated he visited Resident 1 within 3 days of his admission to the facility. PCP 1 stated Resident 1 was a challenge due to his various illnesses and was a "high risk patient." PCP 1 stated Resident 1 did not want to be in the facility and wished to return home but required skilled nursing services due to his medical needs. PCP 1 stated Resident 1 had a previous history of a wound infection. PCP stated he visited Resident 1 for a second time and noticed the wound was larger. PCP 1 stated he ordered wound cultures and continued wound care. PCP 1 stated Resident 1 was on ordered antibiotic Cefadroxil 500 mg two times a day for 3 days for the treatment of his wound. PCP 1 stated the facility did not inform him Resident 1 did not complete the antibiotic treatment as ordered. PCP 1 stated Resident 1's infection could have worsened to sepsis and the infection itself could have increased the size of the wound because of the antibiotic not being administered. PCP 1 stated he ordered Resident 1 be transferred to the acute care hospital on 1/14/18 for possible sepsis. PCP 1 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated he was "disappointed" when he saw Resident 1's wound was larger on his second visit on 1/10/18 at 3:56 p.m. On arrival to the Acute Care Hospital (ACH) the Emergency Department (ED) RN documented ED Nursing Note: "Pt [patient] arrived from SNF with c/o [complaint of] SOB [shortness of breath] cough; has a wound on the SACRUM [tailbone] area getting treated by wound RN in the SNF ..." The Active Hospital Problems listed " (principal) Sepsis WO [without] acute organ dysfunction; pressure ulcer of back unstageable; pneumonia; HTN [hypertension]; DM [diabetes mellitus] 2 W [with] peripheral neuropathy. The ACH records indicate Resident 1 was discharged from the hospital on 1/24/18 to continue care at SNF 2. 2. During an observation and concurrent interview on Station Two, with LN 9 on 1/24/18 at 11:20 a.m., LN 9 was drawing insulin from a Novolog (fast acting insulin - starts to work 15 minutes after being injected) Flex pen (used to inject insulin) 100 unit (measurement) / (per) ml (milliliter) for Resident 10 using an insulin syringe with needle and was asked about the process for using a Flex pen. LN 9 stated, "After taking the insulin pen out of the medication cart, I identify the resident and dosage on the MAR. I take the insulin pen to the resident's room with an alcohol swab. I swab the area where I will inject the ordered dose of insulin." LN 9 stated "We [facility] do not have insulin needles for the insulin [Flex] pens." LN 9 stated, "I was told by [LN 1] during medication training to use insulin syringes to withdraw insulin from the insulin [Flex] pens." LN 9 stated, "I have been withdrawing insulin from the insulin pens since January 6, 2018." On 1/25/18 at 7:05 a.m., during a clinical record review, Resident 2's MAR indicated Resident 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 2's blood sugar value was 457; according to the sliding scale (a scale of ranges identified by a blood sugar check for which the physician has ordered a dose of Insulin to be administered) 12 units of insulin was to be administered using the Novolog Flex pen. During a medication (med) pass observation on 1/25/18 at 7:28 a.m. in Station 1, LN 2 prepared the medications for Resident 2. The MAR for Resident 2 indicated she was prescribed Novolog Flex pen 100unit/ml. The MAR indicated Resident 2 was on a Sliding Scale for the administration of a fast acting Insulin (Insulin effect to lower blood sugar is within 15 minutes). The form indicated, "Blood sugar is less than 60 or greater than 500 notify MD, Blood sugar is 70-200, 0 units [no Insulin to be given], Blood sugar is 201-249, 2 units, Blood sugar is 250-299, 4 units, Blood sugar is 300- 349, 6 units, Blood sugar is 350-399, 8 units, Blood sugar is 400-449, 10 units, Blood sugar is 450-499, 12 units of Insulin Subcutaneous [SQ] three times daily starting 1/11/2018." The MAR indicated to administer Novolog for Resident 2 with the insulin Flex pen. LN 2 was unable to locate the correct needle for the Flexpen in Station 1 Medication Cart. LN 2 interrupted the med pass to walk to Station 2 and ask Station 2 LN for Flex pen needles. Station 2 LN indicated she did not have any Flex pen needles on her cart. LN 2 then walked to Station 3, and Station 3 LN indicated she did not have any Flex pen needles on her cart. LN 2 then walked to the Central Supply Office and spoke to the Director of Staff Development (DSD - licensed nurse in charge of facility staff training) who stated the facility was out of Flex pen needles. LN 2 then walked back to Station 1 and asked LN 6 to order Flex pen needles immediately from the pharmacy. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE LN 2 then walked back to Station 1 Med cart to resume the med pass. LN 2 located an insulin syringe and needle, uncapped the needle and inserted the needle into the Flex pen and withdrew Novolog insulin from the Flex pen. LN 2 then administered the insulin by injection to Resident 2 using the same syringe with needle used to withdraw the Insulin from the Flexpen. During a medication pass observation on 1/25/18 at 8:17 a.m., LN 2 prepared medications for Resident 11. The MAR for Resident 11 indicated she was prescribed Novolog Flex pen 100 unit/ml insulin pen subcutaneous four times daily starting 11/29/17. The MAR indicated, "Notes: Insulin Aspart (Novolog) 100 units/ml injection. Inject SQ 30 minutes before meals (bolus),[blood sugar values] less than 150- no coverage, 150200=2 units, 201-250=4 units, 251-300= 6 units, 301-350=8 units, 351-400 10 units, above 400 call MD. Also notify MD if less than 60. The MAR indicated to administer Novolog for Resident 11 [by way of] insulin Flex pen. On 1/25/18 at 8:10 a.m., the MAR indicated Resident 11's Blood sugar value was 391 and 10 units of insulin was to be administered using the Novolog Flex pen. LN 2 located an insulin syringe and needle, uncapped the needle and inserted this into the Flexpen and withdrew Novolog insulin from the Flex pen. LN 2 then administered the insulin to Resident 11. During an interview with LN 2 on 1/25/18 at 3:25 p.m., LN 2 stated, "Since I have been working here we have run out of pen needles for the residents' Flex pens on two or three occasions. I have been using the insulin syringes to withdraw insulin from the Flex pens when pen needles were unavailable. I felt that my residents needed their insulin and I used 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE my nursing judgement to withdraw insulin from the Flexpen using an insulin syringe. I alerted the Central Supply staff on two occasions of the need to order Flex pen needles." LN 2 stated Central Supply staff was responsible for ordering needed medical supplies. LN 2 stated it was possible the residents may not be getting the correct dose of insulin when drawing insulin from the Flex pen using an insulin needle and syringe rather than the specific needle intended for use with the Flex pen. LN 2 stated the DSD and Central Supply staff were aware the pen needles were needed for the current morning medication pass on 1/25/18. During an interview with on 1/26/18 at 11:25 a.m., LN 4 explained the process of administering insulin by using a Flex pen. LN 4 stated the facility had run out of Flex pen needles in the past. LN 4 stated, when the facility did not have Flex pen needles, she uncapped the Flex pen, then using an insulin syringe, inserted the syringe into the Flex pen, pushed air into the pen to match the amount of insulin to be withdrawn. LN 4 stated after withdrawing the insulin from the Flex pen she administered the insulin to the residents using the syringe with needle [the same needle used to withdraw the insulin from the flex pen used to inject the Insulin into the resident]. LN 4 stated, "I have been using the insulin syringes [to withdraw from the flex pen] for a week. "LN 4 stated she had used the syringes to draw both Novolog and Lantus (long acting) insulin for residents. LN 4 stated it was possible the insulin dose was not correct when drawing from the Flex pen in this manner and the residents may not have received the correct dose. LN 4 stated she should have notified the Director of Nursing (DON) about not having Flexpen needles and the needles should have been ordered. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A document titled, "Novolog Flex Pen Quick Guide," " https://www.novolog.com/type-2diabetes/justheard-about-novolog-2/novolog/using-flex...," indicated, "Step 1...Pull off the pen cap...Remove the protective tab from the needle and screw it onto your Flex Pen tightly. It is important that the needle is placed on straight...Never place a disposable needle on your Flex Pen until you are ready to take the injection..." ...Step5...Remove the needle from the Flex Pen after each injection to prevent infection, insulin leakage and to ensure proper dosing."..."If Flex Pen is not working...Screw on a new Novofine needle." Review of Professional Reference, "Institute for safe medication practices," 2017, "Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults" indicated, "Insulin as a High-Alert Medication," "Medications that are associated with the highest risk of injury when used in error are known as high-alert medications...A variety of a type of errors have been associated with insulin therapy, including....incorrect use of insulin delivery devices...Many errors result in serious hypoglycemia (low blood sugar values or hyperglycemia (high blood sugar values)...Misuse of insulin pen devices...Insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen's cartridge. This practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air..." 3. On 1/24/18 at 10:30 a.m., a review of the Medication Administration Records (MAR)'s for residents residing on Station 3 was conducted. The MARs consisted of a computerized generated schedule of physician ordered 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medications. The listed medications included dosing, scheduled times for administration and directions about the physician's orders. Each medication listed was followed by a box corresponding to the day of the month and for the shift the medication was ordered to be administered. The box was for the LN to initial after a medication was administered or not administered. The back of the MAR indicated, "NURSE'S MEDICATION NOTES." There were columns and rows available for LNs to enter the time a medication was not administered with the reason why a medication was not administered. During the review, numerous discrepancies were identified on 23 of 30 residents' (Resident 3, Resident 4, Resident 7, Resident 8, Resident 14, Resident 18, Resident 19 Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 29, Resident 30, Resident 50, Resident 71, Resident 78, Resident 81, Resident 82) MARs. The discrepancies consisted of blank entries, circled LN initials when a medication was not administered and no corresponding reason documented as to why the medication was not administered, and documented entries indicating medications were not available from the pharmacy. On 1/24/18 at 10:30 a.m., a preliminary review of the Medication Administration Record (MAR) was conducted for station 1. The MAR review identified numerous discrepancies for 14 of 28 residents (Residents 11, 13, 15, 35, 36, 38, 40, 41, 42, 43, 44, 45, 46 and 73). The identified discrepancies consisted of blank entries, which were not initialed by the LN to indicate the medication was administered; and circled LN initials indicating a medication was not administered with no corresponding written explanation for the omitted medications. Medications that were not initialed as 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE administered by the LNs included medications for treatment of high blood pressure, heart disease, diabetes, seizures, infection and medication to prevent formation of blood clots. During an interview with Licensed Nurse (LN 9) on 1/24/18 at 11:25 a.m., and concurrent record review, LN 9 looked at the MAR's for the residents in Station 3 and stated, "We have to document the reason for not administering a medication. I see there are multiple blank entries on a lot of residents." LN 9 stated the documentation should have been written on the back of the MAR indicating the reason why a medication was circled as not given. LN 9 stated the MAR's should not be left blank for any medication with a scheduled time to be given. During an interview and concurrent record review with the Medical Records Designee (MRD), on 1/24/18 at 11:45 a.m., the MRD stated she was responsible to audit all of the resident MARs and Treatment Administration Records (TAR's) in the facility. The MRD stated, "These are non-negotiable audits." The MRD explained the audits were to be completed on a daily basis and given to the nurses daily to complete. The MRD stated the nurse's documentation was audited each time the MAR's were left with blank entries, circled initials on medications not administered without a documented reason why. The MRD stated the audit also included medications prescribed for and given on an as needed basis which had no documented reason why the medications were not given. The MRD stated for all three nursing stations, the MARs contained many missing entries. The MRD stated the facility had been without a consistent DON since September 2017, and stated the lack of entries had increased over this time period. The MRD stated she had given the results to the DON but 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the documented omissions continued. During an observation and concurrent interview with LN 9 on 1/24/18 at 10:55 a.m., LN 9 took a blood pressure cuff (BPC) (medical device used to measure blood pressure) and stethoscope (device used to hear heart and breath sounds)to Resident's 57's room. LN 9 placed the BPC to Resident 57's right upper arm to take his blood pressure and received a reading of 144/72, which was within the parameter to give the blood pressure medication. LN 9 initialed on the MAR for 8 a.m. administration dose as given. LN 9 did not circle and document on back of MAR that medication was given outside of the prescribed time of 8 a.m. [two hours 55 minutes past 8 a.m.]. LN 9 stated, "We can pass medication one hour before and one hour after medication is due. I am late passing medications because I had a lot of interruptions this morning." During an observation and concurrent interview with LN 9 on 1/24/18 at 11:30 a.m. on Station Two medication cart, LN 9 was unable to locate the 8 a.m. medication, Januvia (oral antidiabetic medication) 50 mg (milligram) tablet for Resident 60. LN 9 stated, "This medication [Januvia] needs to be ordered." LN 9 stated medication is ordered at the end of the shift. When asked about the process for reordering medications, LN 9 stated, "I don't know how many days before reordering medication because I am barely new here [employed at the facility]." During an interview with the DSD, on 1/24/18 at 1 p.m., the DSD stated, "Whoever discovers medication that need to be reordered must notify the pharmacy. We [facility] also have a Cubex (machine that have emergency medication stocked) that has some medication in it but can only be accessed after notifying 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE pharmacy." During an observation and concurrent interview on 1/24/18 at 1:40 p.m. in Station Two, LN 9 found a plastic bag at the bottom of the medication cart on Station Two. The bag contained a pack of nine tablets for Resident 60. A label on the plastic bag had "Januvia 50 mg tablets, take one tablet daily written on it." LN 9 stated, "The 8 a.m. dose was missed because it was misplaced in the medication cart." During a medication pass observation on medication cart 3 on 1/25/18 at 7:06 a.m., LN 3 stated Resident 4's Methotrexate (medication used to treat rheumatoid arthritis that has not responded to other treatments) was not in the medication cart. LN 3 proceeded to prepare Resident 4's Metoprolol ER (extended release) (medication used to lower high blood pressure) and dispensed it into a medication cup. LN 3 entered Resident 4's room and handed Resident 4 the medication cup containing the blood pressure medication. LN 3 stated she had not taken Resident 4's blood pressure. LN 3 walked to Resident 4's bedside and was handing Resident 4 the medication cup which contained the blood pressure medication; when LN 3 was asked if she should take the blood pressure before giving Resident 4 the medication, she replied "Oh...I haven't taken it." LN 3 took the medication cup back from the residents hand then proceeded to take the blood pressure on Resident 4. When asked what the result could have been if LN 3 had administered the blood pressure medication without first taking the residents blood pressure, LN 3 stated Resident 4's blood pressure could have dropped further if the blood pressure had been low. LN 3 stated she should have taken the residents blood pressure before deciding to give her the medication. The 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE prescribed Methotrexate was not administered. During a review of the clinical record for Resident 4's physician orders titled, "January 2018 Medications" indicated, Methotrexate (10 [milligram-unit of measure] MG) Oral Two Times Weekly to be administered for Rheumatoid Arthritis scheduled to be administered on Thursdays at 8 a.m., and 8 p.m. The date of 1/25/18 was a Thursday. During a medication pass observation of LN 3 assigned to medication cart 3, on 1/25/18 at 7:24 a.m., there was one medication not administered as ordered by the physician for Resident 7. LN 3 stated she was not able to administer "Brimonidine Tartrate." (Medication used to treat glaucoma --a condition of increased pressure within the eyeball which could cause gradual loss of sight) because the prescription label on the container was peeled off. LN 3 stopped the medication pass and went to the medication room in search of a spare eye drop medication for Resident 7. LN 3 returned to the medication cart and stated, "We do not have it [Brimonidine eye drops] available." Resident 7 did not receive the ordered eye drops for the 8 a.m. dose. During a review of the clinical record for Resident 7 titled, "January 2018 Physician Order Sheet" indicated, "Brimonidine Tartrate .2% (1 drop) Drops Right Eye" for Glaucoma scheduled to be administered two times daily at 8 a.m., and 8 p.m. During a medication pass observation with LN 3, on 1/25/18 at 7:58 a.m., there was one medication not administered as ordered by the physician for Resident 3. LN 3 stated Resident 3's Jardiance F/C (a once-daily oral medication that is used to control blood glucose levels in Type II Diabetes Mellitus) was not available. LN 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 3 continued the medication pass without locating the medication and without administering the medication to Resident 3. During a review of the clinical record for Resident 3 the document titled, "January 2018 Physician Order Sheet" indicated, "JARDIANCE F/C 25 mg (1 tab) Tablet Oral" for Diabetes to be administered every day at 8 a.m. During a review of the clinical record for Resident 3 titled, "Clinical Notes Report" dated 1/25/18 at 9:37 p.m., indicated, "Jardiance 25 mg was not given at 8 a.m., MD notified." During a medication pass observation with LN 3, on 1/25/18 at 8:20 a.m., there was one medication not administered as ordered by the physician for Resident 69. LN 3 stated she did not have Resident 69's Lisinopril (medication to treat high blood pressure) 10 mg in the medication cart and would have to call the pharmacy and request an access code for the "Cubex" (medication dispenser). LN 3 stated there were only certain medications that were available in the Cubex. During an interview with the Interim Director of Nursing (IDON) on 1/25/18 at 8:50 a.m., the IDON stated, "Our pharmacy is non-compliant with the medication delivery. They do not deliver within the time stipulated under Title 22 (California Code of Regulations). I have identified this problem when I started working here." (The IDON began working in the facility on 1/12/18) The IDON stated the pharmacy was to deliver a medication within 4 hours of being ordered by the physician. The IDON stated the pharmacy who supplied the facility medications was not a local pharmacy and was located several hours away from the facility. The IDON stated the pharmacy did not have 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE contracts with local pharmacies to expedite the medication delivery. The IDON stated the nurse was to call the pharmacy and notify the physician when a medication was not available to be administered. The IDON stated the nurse was responsible to document on the residents MAR and nursing progress notes. The IDON stated the nurse was to reorder the medication at least 5 days prior to running out of the medication. The IDON stated she noticed the medication pass with three nurses was a heavy load. The IDON stated, "We need four nurses on the a.m., and p.m., shift and three nurses for the NOC (night) shift. It is a heavy load." The IDON stated she spoke to the Administrator about her observation and did not know what the response would be. During an interview and concurrent record review, with LN 3 on 1/25/18 at 10 a.m., LN 3 stated Resident 69 did not have the 8 a.m., scheduled dose of Lisinopril 10 mg for the treatment of hypertension (high blood pressure). LN 3 stated not having the medication as ordered could result in poor blood pressure control. LN 3 stated if a medication was not available, the nurses were supposed to call the pharmacy. LN 3 stated the pharmacy would provide a Cubex code in order to access and pull the medication from the Cubex. LN 3 stated not every medication was available in the Cubex. LN 3 stated if the medication was not in the Cubex the pharmacy would have to deliver the medication. LN 3 stated she would have to call the doctor to inform him the medication was unavailable and document in the resident record. During an interview and concurrent record review, with LN 3 on 1/25/18 at 3:25 p.m., LN 3 stated Resident 4's dose of Methotrexate had circled initials on 1/4/18 and on 1/18/18. LN 3 stated she worked with Resident 4 on 1/18/18 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE and the Methotrexate was unavailable then. LN 3 stated she had not documented a call made to the pharmacy or to the physician. LN 3 stated she had called Resident 4's physician on 1/25/18 around 3 p.m., to inform him about the missed dose of Methotrexate on 1/25/18, but had not received a return call. LN 3 stated, "We are having problems with the pharmacy." LN 3 stated she did not inform anyone from the facility's administrative staff about the problem she was having with the pharmacy delivery of medications. LN 3 stated the MAR's for the residents in station 3 had a lot of blanks on the document but was unable to explain why. LN 3 stated, "We all have to document in the MAR we cannot have these blanks. During an interview and concurrent record review with LN 3, on 1/25/18 at 3:55 p.m., LN 3 stated Resident 3's 7 a.m., blood glucose value was 149 and increased to 300 at 11 a.m. LN 3 stated Resident 3 had labs drawn in November 2017 which indicated Resident 3 had a Hgb A1C (hemoglobin A1C) (Blood test that provides information about a person's average levels of blood glucose, over the past 3 months) of 8.1. LN 3 stated according to the laboratory record normal values for Hgb A1C ranged from 4.6 to 6.2. LN 3 stated Resident 3's Hgb A1C indicated poor blood glucose control and Resident 3 would not benefit from missing her diabetes medication. LN 3 stated, "From the look on her MAR, it looks like the [Jardiance] was circled [as not given] on 1/23/18. There is no documentation of what steps were taken." A review of the clinical record for Resident 3 titled, "January 2018 Medications" indicated, "JARDIANCE F/C (film coated) 25 mg" (medication used to treat diabetes) had circled initials on 1/23 as not administered without a documented reason why. A review of the clinical record for Resident 3 titled, "Clinical Notes Report" dated 1/25/18 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE at 9:37 p.m., indicated, "Jardiance 25 mg was not given at 8 a.m. ..." During an interview and concurrent record review with LN 3, on 1/25/18 at 4:15 p.m., LN 3 stated Resident 69's Lisinopril (medication used to treat high blood pressure) was pulled from the Cubex and administered to Resident 69. LN 3 stated she did not remember at what time she administered Resident 69's Lisinopril. LN 3 stated she did not document the Lisinopril was pulled out from the Cubex. LN 3 stated it was important to document in the MAR each time a medication is administered after being pulled out from the Cubex in order to let other nurses know where the medication came from. Resident 69's clinical record titled, "January 2018 Physician Order Sheet" indicated, "LISINOPRIL (GIVE 10 MG) ORAL" for Hypertension scheduled to be administered daily at 8 a.m. On 1/25/18 at 4:20 p.m., a request was made to LN 3 for a report of the medications pulled from the Cubex for Resident 69 on 1/25/18. LN 3 did not provide the report. On 1/25/18 at 5 p.m., a request was made to the DSD for a report of the medications pulled from the Cubex for Resident 69 on 1/25/18. The DSD did not provide the report. A second request was made for the report on 1/26/18 and the IDON did not provide the report. During a medication pass observation and concurrent interview with LN 11 assigned to medication cart 3, on 1/25/18 at 4:35 p.m., LN 11 prepared Resident 80's Novolog Flex pen (used to inject insulin) 100 unit (measurement)/ (per) ml (milliliter) for administration. LN 11 obtained the pen from the medication cart and dialed the insulin dose on the insulin flex pens 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE dial to 12 units. LN 11 proceeded to Resident 80's room for to complete the insulin administration. Prior to the administration of insulin LN 11 was asked to verify the insulin flex pen open date. LN 11 looked at the insulin Flex pen and was unable to find a date the insulin pen was opened. LN 11 stated Resident 80 would not be getting her 12 units of insulin since the pen did not have an open date. During an observation of medication cart 3 and concurrent interview with LN 11, on 1/25/18 at 4:45 p.m., LN 11 was asked if there were additional flex pens in use for other residents. LN 11 took out 10 flex pens from the top drawer of the medication cart. LN 11 pointed out four insulin Flex pens belonging to Resident 30. LN 11 stated Resident 30 had a Lantus Solostar (long acting insulin) Pen 100 unit/ml that was in use and was not labeled with an open date. LN 11 stated Resident 30 had two Novolog Flex pens 100 unit/ml that were in use and were not labeled with an open date. LN 11 stated Resident 30 had a Toujeo Solostar (long acting insulin) 300 unit/ml that was in use and was not labeled with an open date. LN took out six additional insulin pens from the medication cart drawer. Three pens belonged to Resident 80 and three pens belonged to Resident 3. LN 11 stated all of the pens taken from the medication cart were being used for Resident 3, Resident 30 and Resident 80, and they were all undated while in use. LN 11 stated she did not know why the insulin pens were not dated with an open date. LN 11 stated the insulin pens needed to have an open date written but could not explain why. LN 11 pointed out one insulin pen belonging to Resident 80. The pen was a Lantus Solostar Pen 100 unit /ml, the pen indicated, "Opened 11/7/17" (more than 60 days ago). During an interview with LN 7, on 1/31/18 at 4 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE p.m. at Station 1, LN 7 stated she was an oncall nurse for the facility. LN 7 stated, this was her second day at the facility on medication cart 1. LN 7 stated many of her medications due for 8 a.m. administration were given more than an hour past the scheduled time. LN 7 stated Residents were at risk for harm due to delayed medication administration. LN 7 stated, "This medication pass is heavy, and we need two nurses for the pass." LN 7 started to cry, stated, "I am overwhelmed and I am not coming back." During an observation at medication cart 1 and concurrent interview, on 1/25/18 at 5:00 p.m., LN 4 was asked if there were additional Flex pens in use. LN 4 took out 11 Flex pens from the top drawer of the medication cart. LN 4 pointed out two insulin Flex pens belonging to Resident 16. LN 4 stated Resident 16's pens included a Lantus Solostar (long acting insulin) pen 100 unit/ml and a Novolog Flexpen 100 unit/ml that were in use and were not labeled with the date the pens were opened. LN 2 stated two of the 11 Flex pens belonged to Resident 43, two pens belonged to Resident 11 and three pens belonged to Resident 49. LN 4 stated the pens belonging to Resident 43, Resident 11 and Resident 49 were not marked with the date the pens were opened for use. LN 4 identified two pens that had no pharmacy label that indicated the resident's name, date the prescription was filled, name of medication and dosage to be administered. LN 4 removed the two unlabeled pens from the medication cart. LN 4 stated she did not know why the insulin pens were not marked with the date they had been opened. LN 4 stated the insulin pens expired 28 days or 42 days from the date of opening, depending on which insulin pen was used. LN 4 stated the insulin pens needed to be marked with the open date to ensure expired medications were not administered to 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE residents. LN 4 stated all the pens should have been dated by staff when opened. LN 4 stated the two unlabeled pens should not have been placed on the cart; they should have been discarded. During an observation and concurrent interview with the IDON, on 1/25/18 at 4:48 p.m., the IDON approached LN 11 and looked at the ten opened insulin pens from medication cart 3 and stated the nurses were supposed to date the insulin pens each time the pen was opened for the first time. The IDON stated, "They should know better." During a telephone interview with the Pharmacy Consultant (PC 1), on 1/25/18 at 5:30 p.m., the PC 1 stated his last visit to the facility was during the first week of January 2018. PC 1 stated he did not recall looking at the insulin pens during his visit. PC 1 stated all insulin vials including flex pens needed to be dated with the open date. PC 1 stated manufacturers guidelines provided recommendations for insulin to be used best within 28 to 32 days of being opened. The PC 1 stated if insulin vials or pens were not dated there would be a potential for someone to administer insulin that was no longer effective. The PC 1 stated insulin Flex pens required to be used as indicated in manufacturer's guidelines. PC 1 stated nurses could use another form of syringe to withdraw insulin from the Flexpen if there was an emergency and if this was the only measure of insulin availability for the resident. The PC 1 stated it was not recommended to use insulin Flex pens in this manner. The PC 1 stated first choice is for the nurse to use the Flex pen as directed. The PC 1 stated he was aware of the multiple MAR discrepancies for each resident for station 1, 2 and 3. The PC 1 stated he had spoken to the previous Administrator of the facility and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE communicated the identified discrepancies. The pharmaceutical information from www.novolog.com dated 6/17, indicated "...Novolog is a fast or rapid acting type of insulin taken shortly before mealtime. It works quickly to control the rapid rise in blood sugar after meals. Fast-acting insulin closely mimics the body's natural release of insulin at mealtime..." The pharmaceutical information www.accessdata.fda.gov/drugsatfda.pdf dated 2015, indicated "...Novolog should generally be given immediately within 5-10 minutes prior to start of a meal..." Review of professional reference, "American Diabetes Association Diabetes Care 2004 Jan; 27(supply 1): s106-s107. https://doi.org/10.2337/diacare.27.2007.S106" indicated, "Rapid-acting insulin analogs should be injected within 15 min before a meal or immediately after a meal. The most commonly recommended interval between injection of short-acting (regular) insulin and a meal is 30 min." Review of Professional Reference, "Institute for Safe Medication Practices Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults," 2017, indicated, "Types and Causes of Insulin Errors. A variety of error types have been associated with insulin therapy, including...dose omissions, and improper patient monitoring. Many errors result in serious hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar)...Other factors that contribute to serious hypoglycemia include inappropriate timing of insulin doses with food intake,...and poor coordination of blood glucose testing with insulin administration at meal times. Hyperglycemia commonly 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE results from...insulin...dose omissions..." On a facility policy titled, "Medication Ordering and Receiving from Pharmacy" dated April 2008, indicated, "...A...2)...a. Reorder medication five days in advance of need to assure an adequate supply is on hand...b. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions of use." On a document titled, "Medication Ordering and Receiving from Pharmacy," dated April 2008, indicated ..."c. promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor." A facility policy titled, "MedicationAdministration," undated indicated ...Procedure...B. The Licensed Nurse will prepare medications within one hour of administration...i. Medications may be administered one hour before or after the scheduled medication administration time."...iii. "Holding Medications" A. "Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) the responsible Licensed nurse. B. the Licensed Nurse will document on the back of the MAR, noting the time and reason the medication was held...VI. Medication Rights...B. The seven "rights" of medication are: ...iv. the right time." 4. During a medication pass observation and concurrent interview of LN 13, on 2/1/18 at 5:20 a.m., LN 13 was approached by Resident 63 and asked for a dose of Benadryl for his complaint of itching. LN 13 looked through Resident 63's medications and told him he did not have Benadryl ordered. Resident 63 insisted that he had Benadryl because he had received it the day before. The IDON passed 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE by Resident 63 when he asked for her to help the nurse find his order of Benadryl. The IDON stated, "He has an order of Benadryl, I will look through his chart." The IDON looked through Resident 63's record and confirmed the order of Benadryl. The IDON stated, "There it is, the order was not transcribed, it was not recapped." The IDON stated the monthly medication recapitulation (recap) had not been completed by the licensed nurses for the month of February 2018. During a reconciliation of Resident 14's medication, on 2/1/18 at 7:30 a.m., Resident 5's hard chart contained a hand written order entered by Physician 1 on 1/30/18. The order indicated, "1. D/C (discontinue) Heparin (blood thinner), D/C Doxycycline (antibiotic) 2. Chest X-Ray f/u (follow up) Pneumonia (lung infection) 3. CBC (complete blood count) (blood test used to evaluate your overall health) Chem 7 (Chemistry 7) (a blood test evaluating kidney, function, blood acid, base balance and blood sugar levels) STAT (immediately) 4. Prednisone (steroid) 20 mg PO (by mouth) x 7 days 5. Start Augmentin (antibiotic) ...PO BID (twice a day) x 10 days." During an observation of nursing station 3, on 2/1/18 at 7:45 a.m., Resident 6's hard chart was standing in a rack on the nursing desk with a document flagged out of the chart. The record was reviewed and identified the document was a physician order hand written by the physician on 1/30/18. The order indicated "1. Increase Lasix (diuretic-water pill) 40 mg po daily 2. KCL (potassium supplement) 10 meq po daily 3. Chest X Ray R/O (rule out) Pneumonia 4. CBC, Chem 7 in AM." During review of Resident 6's clinical record titled, "Clinical Notes Report" dated 2/1/18 at 10:50 p.m., indicated, "[Physician] ORDERED 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE POTASSIUM 10 MEQ QD AND ORDERED TO INCREASE LASIX 60 MG FOR 7 DAYS QD AND CONTINUE RESIDENT ON CURRENT ORDER FOR LASIX AFTER 7 DAYS. ORDER CARRIED OUT." During an interview and concurrent record review with the Vice President of Clinical Operations for Southern California (VPCOSC) on 2/1/18 at 8:22 a.m., the VPCOSC stated the orders written by the Physician for Resident 6 and Resident 14 were not carried out by the nurse and the monthly recap of the physician orders were not done. The VPCOSC stated she was not familiar with the facility and she did not know who in the facility was responsible to complete the monthly recaps. The VPCOSC stated the recaps should be completed at least two to three days prior to the end of the month. The VPCOSC stated, "When there is any new order after the recap is done the LN who receives the new order needs to process the order and [medical records clerk] should also audit the medical record. The VPCOSC stated the failure to carry out an order given by a physician could lead to errors. During review of Resident 5's clinical record titled "Clinical Notes Report" dated 1/30/18 at 1:51 p.m., indicated, "[Physician 1] visited the resident and gave nurse order to discontinue heparin 5000 units. Order carried out. RP notified and agreed. During review of Resident 5's clinical record titled "Clinical Notes Report" dated 2/1/18 at 7:47 p.m., indicated, "Informed [Physician 1] regarding orders that were not carried out. [Physician 1] ok to start order. Also informed him of x-ray result. Informed resident of orders, order carried out. Labs pending." During an interview, and concurrent record 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE review with LN 11 on 2/1/18 at 3 p.m., LN 11 stated she did not know how the distribution of the monthly recaps was done between the nurses. LN 11 stated, "You are going to have to ask the IDON about that." (The IDON was not available for interview, and LN 11 stated she did not know where the IDON had gone.) LN 11 stated the nurse assigned to the resident would be responsible to note and carry out physician orders. LN 11 stated LN 3 worked on 1/30/18 during the morning shift and LN 14 worked on 1/30/18 during the evening shift. LN 3 was not available for an interview on 2/1/18. During an interview, and concurrent record review with LN 14, on 2/1/18 at 3:15 p.m., LN 14 stated she worked on the evening shift on 1/30/18 and did not see the orders written by the physician for Resident 5 or Resident 6. During a concurrent interview with the MRD and the Chief Clinical Officer (CCO), on 2/1/18 at 3:45 p.m., the MRD and the Chief Clinical Officer (CCO), the MRD stated the LN's were responsible to note and carry out the orders given to them by the physicians. The MRD stated the nurses were responsible to enter the orders into the computer system. The MRD stated the nurse relieving the first nurse who took the physician order should carry out what orders the receiving nurse was unable to complete. The MRD stated the LN's were responsible for completing the monthly recapitulation (recap) (transcribing the monthly orders accurately onto the following month's orders) of all resident orders. The MRD stated, "Ideally if I am told that there is a recap nurse, I will print out the orders for recap three days in advance. If I am not I will print them on the day before the new month begins. I printed out the orders knowing that the orders were not recapped. I printed out the orders and put out the new MARs on 1/31/18 at 11 p.m." The 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE MRD stated she knew the orders printed had not been recapped by the LN's. The CCO stated the facility was working out a system to implement and correct this issue. Because of these failures and the identified serious actual harm to Resident 1 (Finding 1 above) and potential serious harm to all residents with prescribed medications as indicated in Findings 2 and 3 above, an Immediate Jeopardy (IJ) Situation was called on 1/25/18 at 6:50 p.m. with the facility Administrator and the Interim Director of Nursing (DON). The facility submitted an interim written Action Plan (AP) to address the safe administration of medications for the 1/25/18 8 p.m., 1/26/18 midnight and 1/26/18 morning medication administration that included the Interim DON proctoring the medication passes for all residents. The Flex pens were removed from accessibility and use as part of the interim action plan. The facility submitted written Action Plans on 1/26/18, 1/30/18 and 1/31/18 that were reviewed and unacceptable. During this time the District Office management staff teleconferenced with the Administrator and IDON multiple times to explain the need to develop an Action Plan that addressed the multi-factorial, system failures resulting in unsafe medication administrations. The facility was directed to determine a system of proctoring each licensed nurse for medication administration and determine competency and safety parameters and to submit a written AP as soon as possible following the calling of the IJ on 1/25/18 to the District Office. The written AP submitted on 2/1/18 was reviewed and approved. The AP described a comprehensive plan of training, skills checks and proctoring of all facility licensed nurses that passed medications. The AP addressed facility 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE failures in order to achieve medication administration safety for all residents for every medication pass. The AP addressed failures identified with the timely ordering of medications and timely delivery of medications from the pharmacy. The AP addressed the identified failures related to accurate MAR documentation and the accurate transcription of physician orders onto the MAR. The survey team conducted monitoring of care at the facility on each day following the calling of the IJ on 1/25/18. Serious findings related to unsafe medication administration were observed and validated on 1/26/18, 1/27/18, 1/28/18, 1/29/18, 1/30/18, 1/31/18, 2/1/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18 and 2/7/18. Because of the failure to effectively implement the Action Plan meant to address the IJ situation and additional validated serious findings (cross referenced at F 684, F 725 and

F 726), CMS RO authorized an exit from the investigation. An exit conference was conducted via teleconference on 2/8/18 at 8:50 a.m. without removing the IJ situation. The Administrator, DON and Vice President of Operations for Corporate attended the exit conference and were informed of the exit without removing the IJ situation. The following findings represent examples of observed serious medication administration errors for the days following the IJ from 1/26/18 through 2/7/18. During a medication pass observation and concurrent interview with LN 5 assigned to medication cart 1, on 1/26/18 at 6 a.m., there was one medication not administered as ordered by the physician for Resident 14. LN 5 stated Resident 14 had orders for 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Levothyroxine Sodium (a thyroid hormone) 25 mcg once daily. LN 5 stated the medication was not in the medication cart 1. LN 5 stated, the medication had not been delivered from the pharmacy. Review of Resident 14's clinical record "February 2018 Physician Order" indicated, "Levothyroxine Sodium 25 mcg 1 tablet before meals. Order date: 8/27/17. Schedule: every day at 6 a.m." During an interview with LN 8, on 1/26/18 at 3 p.m., LN 8 stated Resident 7 did not receive her Brimonidine Tartrate medication for glaucoma on 1/26/18 at 8 a.m., because it had not yet been delivered from the pharmacy. LN 8 stated, "We are not following orders and her glaucoma is not being treated as it should." LN 8 stated she had not yet called the physician or the pharmacy because she did not have time to do so. During an interview with LN 8, on 1/26/18 at 3:05 p.m., LN 8 stated Resident 3's Jardiance was ordered to treat Resident 3's diabetes, had not been delivered from the pharmacy. LN 8 stated she had not called the physician to inform him about the medication unavailability because she did not have time to do so. LN 8 stated Resident 3 was due to have a fingerstick to check her blood sugar level at 11 a.m., but did not do so because Resident 3 did not want to come out of the dining room. LN 8 stated Resident 3 was not yet eating when the request was made for her to come out of the dining room. LN 8 stated, "We were told blood sugars could not be taken in the dining room." LN 8 stated she had just finished her afternoon medication pass and had no time to make the calls to the physician. During an interview with Resident 3, on 1/26/18 at 3:55 p.m., Resident 3 stated she had not 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE been asked to come out of the dining room earlier in the day. Resident 3 stated, "No one said anything to me about coming out of the dining room. My blood sugar checks are important to me." Resident 3 stated her blood sugar was checked by the LN after 3 p.m., with blood sugar result over 400. Resident 3 stated, "I get worried when my blood sugar is that high." During an interview with LN 8, on 1/26/18 at 4:05 p.m., LN 8 stated Resident 3's blood sugar was taken at 3:30 p.m., with a blood sugar level of 438. During review of Resident 3's clinical record titled, "Clinical Notes Report" dated 1/26/18 at 4:39 p.m., indicated, "Resident missed diabetic meds and MD informed ...Resident did not want finger stick done due to she was already in dining room ..." During a medication pass observation and concurrent interview with LN 6 assigned to medication cart 1, on 1/27/18 at 7:12 a.m., LN 6 stated Resident 40's medication, Pantoprazole Sodium (medication to treat gastroesophageal reflux disease) 40 mg, was not available in the cart and was not administered. LN 6 stated Resident 40 did not receive the medication on 1/26/18 and 1/27/18. LN 6 stated "I need to look into the medication for the resident." During a medication pass observation and concurrent record review with LN 6 and medication cart 1, on 1/27/18 at 9:50 a.m. six medications were administered late to Resident 52. LN 4 stated Resident 52 received his 8 a.m., dose of Baclofen 10 mg , Aspirin 81 mg, Lisinopril 20 mg, Fexofenadine HCL 180 mg, Gabapentin 600 mg, Fluoxetine 20 mg at 9:50 a.m. LN 4 stated the medications were being 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE administered late (1 hour and 50 minutes past the scheduled time of 8 a.m.). During a medication pass observation of LN 12, on 1/27/18 at 7:45 a.m., LN 12 stated Resident 22 received her 6 a.m., doses of Pantoprazole 40 mg, Levothyroxine 112 mcg, and Sucralfate 10 ml at 7:45 a.m. LN 12 stated the medications were administered late. During review of Resident 22's clinical record titled, "January 2018 Physician Order Sheet" indicated, "PANTOPRAZOLE SODIUM 40 mg (1 TABLET)" for Acid Reflux scheduled to be administered at 6 a.m. "LEVOTHRYROXINE SODIUM 112 mcg (1 TAB)" for Hypothyroidism scheduled to be administered at 6 a.m., "SUCRALFATE 100 mg /ml SUSPENSION" scheduled to be administered four times a day at 12 a.m., 6 a.m., 12 p.m., and 6 p.m. During a medication pass observation of LN 12, on 1/27/18 at 7:55 a.m., LN 12 stated Resident 14 received her 6 a.m. dose of Levothyroxine 25 mcg at 7:55 a.m. LN 12 stated the medications were being administered late. Resident 14 stated, "I have not gotten my [Levothyroxine] for two days, this is a serious problem." During review of Resident 14's clinical record titled, "January 2018 Physician Order Sheet" indicated, "LEVOTHYROXINE SODIUM 25 MCG ORAL One Day ...before breakfast" for Hypothyroidism scheduled to be administered at 6 a.m. During review of Resident 14's MAR titled "JANUARY 2018 MEDICATIONS" indicated, "LEVOTHYROXINE SODIUM 25 MCG ORAL One Day" scheduled dose for 6 a.m. had circled initials as not given on 1/25 and 1/26 with no documented reason why medication 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was circled as not administered. During a medication pass observation of LN 12, on 1/27/18 at 8:02 a.m., LN 12 stated Resident 50 received his 6 a.m., dose of Glipizide 10 mg at 8:02 a.m. LN 12 stated the medication was being administered late. During review of Resident 50's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated, "GLIPIZIDE 10 mg" for diabetes scheduled for 6:30 a.m., and 4 p.m. During a medication pass observation of LN 12, on 1/27/18 at 8:15 a.m., LN 12 performed a fingerstick to check blood sugar value on Resident 3. LN 12 stated Resident 3's fingerstick was due at 7 a.m., before breakfast. Resident 3 was eating breakfast at the time LN 12 checked her blood sugar. Resident 3's blood sugar was 225. During review of Resident 3's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated blood sugar check four times daily at 7 a.m., 11 a.m., 4 p.m., and 8 p.m. During a medication pass observation of LN 12, on 1/27/18 at 8:20 a.m., LN 12 performed a fingerstick to check blood sugar value on Resident 80 at the time Resident 80 was eating breakfast. Resident 80's blood sugar was 164. LN 12 stated Resident 80's fingerstick was due at 7 a.m., before breakfast. During review of Resident 80's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated blood sugar check four times daily at 6 a.m., 11:30 a.m., 4:30 p.m., and 8 p.m. During a medication pass observation of LN 12, on 1/27/18 at 8:35 a.m., LN 12 performed a fingerstick to check blood sugar value on 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 18. At the time Resident 18 was eating breakfast and stated, "My blood sugar is usually taken before breakfast." Resident 18's blood sugars was 393. During review of Resident 18's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated, "LISPRO INSULIN (35 units) Subcutaneous Notes: Per Dr. [name of doctor] via telephone order increase Lispro from 25 units to 35 units to start immediately to try to control Blood sugar levels continually above 450." Blood sugar check was to be checked prior to receiving the insulin before meals (breakfast, lunch and dinner) During review of Resident 18's clinical record titled, "Minimum Data Set (MDS) (an assessment used to identify resident level of care which drives care planning decision) assessment, dated 2/5/18, indicated Resident 18 had no cognitive (pertaining to short and long term memory) impairment. During a medication pass observation of LN 12, on 1/27/18 at 8:45 a.m., LN 12 performed a fingerstick to check blood sugar value on Resident 30. Resident 30 was lying in bed with an empty breakfast tray. Resident 30 stated, "I already ate." LN 12 performed the fingerstick with results of 572. LN 12 stated, "I will have to call his doctor, he is a brittle diabetic" (meaning Resident 30 was a hard to control diabetic). During review of Resident 30's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated blood sugar check four times daily at 6 a.m., 11:30 a.m., 4:30 p.m., and 8 p.m. During a medication pass observation and concurrent interview with LN 6 assigned to medication cart 1, on 1/27/18 at 7:12 a.m. during a medication pass observation and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE concurrent interview, LN 6 stated Resident 40's medication was due at 6 a.m., Pantoprazole Sodium, (medication to treat gastroesophageal reflux disease) 40 mg tab DR daily, was not available in the cart and was not administered. LN 6 stated Resident 40 did not receive the medication on 1/26/18 and 1/27/18. LN 6 stated, "I need to look into the medication for the resident". During review of Resident 40's clinical record titled, "JANUARY 2018 Physician Order Sheet" indicated Pantoprazole Sodium 40 mg tablet Delayed Release Enteric coated, 1 tablet oral daily at 6 a.m. During a medication pass observation and concurrent interview with LN 4 assigned to medication cart 1, on 1/27/18 at 9:50 a.m., LN 4 stated Resident 52 received his 8 a.m., dose of Baclofen (used to treat muscle spasm) 10 mg, Aspirin 81 mg, Lisinopril (blood pressure medication) 20 mg, Fexofenadine (treat or prevent symptoms of allergies) HCL 180 mg, Gabapentin (used for nerve pain) 600 mg, Fluoxetine (antidepressant) 20 mg at 9:50 a.m. and were administered late. During a medication pass observation and concurrent interview with LN 4, on 1/27/18 at 10:05 a.m., LN 4 stated Resident 40 received his 7 a.m. dose of Calcium-Vitamin D 600 mg, 8 a.m. doses of Eliquis (used to prevent strokes) 5 mg, Carvedilol (treat heart failure and high blood pressure) 3.125 mg, Cyancobalamin ( treatment of pernicious anemia) 500 mcg, Docusate Sodium (prevent constipation) 100 mg Finasteride (treat male pattern baldness and enlarged prostate) 5 mg, Isosorbide Dinitrate (treat and prevent chest pain )10 mg, Probiotic ( dietary supplement (1 cap), Folic Acid (vitamin B complex) 0.4 mg, Lisinopril (blood pressure medication) 10 mg, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Hydrocortisone (treat inflammation) 20 mg, at 10:05 a.m. LN 4 stated the medications were administered late. During an interview with Registered Nurse (RN)/Pharmacy Consultant (PC) 1 on 1/27/18 at 8:19 p.m., RN/PC 1 stated, on 1/27/18 at 5:28 p.m., LN 2 did not administer Resident 3's Novolog (a rapid-acting insulin [hormone that controls the level of the sugar glucose in the blood]) as ordered. The RN/PC 1 stated LVN 2 could not find Resident 3's Novolog in the medication cart, medication refrigerator, or anywhere in the nurses' station. The RN/PC 1 stated he immediately contacted the Pharmacist and requested Novolog to be delivered to the facility. When asked if the Novolog had been delivered and/or given to Resident 3, the RN/PC stated, "I don't know." During an interview with LN 2 on 1/27/18 at 8:48 p.m. LN 2 stated on 1/27/18 at 5:28 p.m., he could not find Resident 3's Novolog in the medication cart. LN 2 stated all of the resident's insulin were routinely kept inside the medication cart. He stated he looked in the refrigerator shelves and the "baskets" with other insulin and "did not see" Resident 3's Novolog. He stated he told one of the "corporate" Nurse Consultants (NC) and RN/PC 1, then continued to check blood sugars and administer insulins to six (6) other residents. When asked if Resident 3's blood sugar had been rechecked, LN 2 stated he did not know. LN 2 stated Resident 3's Novolog was later found by LN 11 inside the refrigerator at 8:30 p.m., and was administered to Resident 3 at 8:40 p.m. (3 hours and 12 minutes later). During a concurrent interview and record review on 1/27/18 at 9:35 p.m. conducted with Nurse Consultant (NC) 1, NC 1 stated, on 1/27/18, she was one of the three "proctors" 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE who followed LN 2 with the afternoon medication pass. She stated LN 2 had checked Resident 3's blood sugar level at 5:28 p.m. (1 hour and 27 minutes late). The physician's order was to check at 4:00 pm. Resident 3's blood sugar level at 5:28 p.m. was 219 ug/ml (unit [conversion] per gram per milliliter). Resident 3 ate her dinner at 5:45 p.m. The NC stated the physician was called and he instructed LN 2 to "Give Humulin R based on the sliding scale (a progressive increase in the pre-meal or night time insulin dose, based on pre-defined blood glucose ranges) and give the Novolog later." The NC stated Resident 1 received 4 units of Humulin R at 5:32 p.m., and the Novolog was administered at 8:40 p.m. (three hours and 12 minutes later). During a review of Resident 3's MAR dated 1/18 listed Resident 3 's insulin and sliding scale orders as follows: Humulin R 100 unit/ml four times a day (7:00 am, 11:00 am, 4:00 pm, and 8:00 pm), subcutaneous (injected under the skin), for Type 2 Diabetes. Sliding Scale: Blood Sugar is <60 or >500 Notify MD; Blood Sugar is 61 - 150, 0 Units; Blood Sugar is 151 200, 2 Units; Blood Sugar is 201 - 250, 4 Units; Blood Sugar is 251 - 300, 6 Units; Blood Sugar is 301 - 350, 8 Units; Blood Sugar is 351 - 400, 10 Units; Blood Sugar is 401 - 450, 12 Units; Blood Sugar is 451 - 650, 14 Units; Novolog mix 70-30 100 unit/ml - (70-30) (5 units) vial (ml) subcutaneous, two times daily at 7:00 am and 4:00 pm. During an interview with NC 2 on 1/28/18 at 4:40 p.m., NC stated all blood sugar checks and insulin administration must be done timely as ordered. During an observation and concurrent interview and record review on 1/28/18 at 6:30 a.m. at 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medication cart 2 outside of Resident 23's room, LN 5 was preparing medications for administration to Resident 23 under the supervision of Proctor (P) 1. LN 5 poured a Hydralazine (medication to treat high blood pressure) 100 mg tablet, a Synthroid (a thyroid hormone) 75 mcg tablet, a Finestride (a medication to treat an enlarged prostate gland, a gland that is located below the bladder and when enlarged can interfere with the ability to pass urine) 5 mg tablet and a Renvela (a medication given to treat high blood phosphorus level, the medication binds to phosphorus in food when eaten, the phosphorus is then excreted in the stool) 800 mg tablet into a plastic medication cup to administer to Resident 23. P 1 interrupted LN 5's medication administration and informed LN 5 the MAR indicated the Renvela should be administered with meals. P 1 stated the morning meal was served at 7:30 a.m. and the medication schedule needed to be changed. P 1 pointed out the Renvela schedule on the MAR which indicated scheduled times of 6:30 a.m., 11:30 a.m. and 4 p.m. and stated the 6:30 a.m. dose was too early for breakfast and the 4 p.m. dose was too early for the evening meal. Review of Resident 23's January 2018 MAR indicated Resident 23 had received Renvela at 6:30 a.m., 11:30 a.m. and 4 p.m. from January 1, 2018 to January 28, 2018. P 1 stated Renvela could cause stomach upset if given without food. LN 5 discarded the Renvela without administering the morning medication dose to Resident 23. Review of Resident 23's clinical document tiled, "January 2018 Physician's Orders" indicated, "Renvela 800 mg (1 tab) Tablet by mouth three times a day with meals." Review of Resident 23's clinical document tiled, "Face Sheet" indicated Resident 23 was 89 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE years old with diagnoses that included End Stage Renal Disease (kidney failure requiring treatment with an artificial kidney to maintain life). Professional reference "Davis's Drug Guide for Nurses" Eleventh Edition, Deglin Pharm D and Vallerand PhD, RN; F.A. Davis Company Philadelphia C. 2009; indicated, "sevelamer [generic name for Renvela] ...Indications: Reduction of serum (blood) phosphate levels in patients with hyperphosphatemia [high blood phosphorus levels] associated with end-stage renal disease. Implementation: Doses of concurrent medications, especially antiarrhythmics, should be spaced at least 1 hr [hour] before or 3 hr after sevelamer [Renvela] ...administer with meals ..." During an observation and concurrent interview on 1/28/18 at 12 p.m., LN 2 arrived at medication cart 1. LN 2 stated he was the nurse assigned to pass medications to Resident 50 at 8 a.m. LN 2 stated he did not administer all of Resident 50's 8 a.m. medications because he was called away from the medication cart to assist another resident. LN 2 stated when he returned to medication cart 1 Resident 50's medications were over an hour late so he did not t administer the 8 a.m. medications. LN 2 reviewed Resident 50's MAR and confirmed he had not administered Resident 50's 8 a.m. medications including clopidogrel (medication that inhibits the stickiness of blood platelets and is used to decrease the risk of stroke and heart attack) 75 mg, Humulin 70-30 (a mix of quick acting and intermediate acting insulin, a hormone that lowers blood sugar levels) 20 units subcutaneously (injected below the upper layer of the skin), metformin HCL (a medication used to control blood sugar) 500 mg, Senokot (a medication used to treat constipation) 8.6 mg, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Metoprolol Tartrate (a medication to treat high blood pressure) 25 mg, and Propafenone HCL (a medication to treat irregular heart rhythms) 300 mg. When asked if Resident 50 had been assessed for any problems related to not receiving the 8 a.m. medications, LN 2 responded that he had not assessed Resident 50 but planned to notify Resident 50's physician of the missed medications. Review of Resident 50's clinical record titled, "face sheet" (document containing resident personal information), indicated Resident 50 was a 77 year old with diagnoses that included Hemiplegia (paralysis on one side of the body), Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (lung disease resulting in difficulty in breathing and shortness of breath), Type 2 Diabetes Mellitus (disease resulting in high blood sugar levels), Gastroparesis (disorder that slows or stops the movement of food from the stomach to the small intestines), Angina Pectoris (chest pain that results from poor blood supply to the heart), Paroxysmal Atrial Fibrillation (irregular heart rhythm causing rapid heart rate), Supraventricular Tachycardia (irregular heart rhythm caused by the upper chambers of the heart beating rapidly and ineffectively), history of Myocardial Infarction (heart attack), Diverticulosis of the large intestine (pouches in the wall of the intestines which can become inflamed and infected) and mild cognitive (pertaining to memory and reasoning ability) impairment. Review of Resident 50's clinical record titled, "January 2018 Physician Order Sheet" indicated, " clopidogrel 75 mg [milligram, a dose measurement] 1 tab[tablet] tablet oral, frequency - every day, schedule - 8 a.m.; Humulin 70-30 100 unit/ml [units per millimeter, a liquid measurement] 20 units 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE subcutaneously, frequency - two times daily, schedule - 8 a.m., 8 p.m.; metformin HCL 500 mg (2 tab), frequency - two times daily, schedule - 8 a.m., 8 p.m.; Senokot 8.6 mg (2 tab) oral, frequency - two times daily, schedule - 8 a.m., 5 p.m.; Metoprolol Tartrate 25 mg (1 tab), frequency - two times daily, schedule - 8 a.m. and 8 p.m.; and Propafenone HCL 300 mg (0.5 tab), frequency - every eight hours, schedule - 12 a.m., 8 a.m., 4 p.m." During an interview and concurrent record review with Nurse Consultant (NC) 2 on 1/28/18 at 1p.m, NC 2 stated the nurse that proctored LN 2's 8 a.m. medication pass should have intervened to help LN 2 complete the medication pass for Resident 50 when LN 2 was called to help another resident. NC 2 stated, "Someone could have assessed the other resident and asked for help to finish passing meds [to Resident 50]. We need to find out if there are any problems due to missing the meds [Resident 50's 8 a.m. medications] check the blood pressure etc. I will follow up on that." NC 2 stated she would provide a written plan of care for Resident 50 to assess for adverse effects from the missing medications. Review of Resident 50's clinical record titled, "Resident Care Plan, Short Term, Missed Medications" dated 1/28/18 indicated, "Problem : Resident missed the medication due at 8 a.m. ...Name of medication: clopidogrel, Humulin 7030 insulin, Metformin, Metaprolol, Propafenone ...At risk for adverse effect. Goal: Resident will not have any adverse effect from the missed medication. Goal Date: 1/31/18. Approach: Check resident for any adverse reaction from the missed. Notify the physician of the missed medication. Notify RP (responsible party), Notify Pharmacy if indicated. Monitor for symptoms of hypoglycemia/hyperglycemia, monitor for chest pain, dizziness and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE arrhythmia (irregular heart beat), bleeding or bruising. Start Date: 1/28/18. Discipline: Nursing." During an interview with the Pharmacy Consultant (PC 2), on 1/30/18 at 4:10 p.m. The PC 2 stated he was hired by the facility to help them out through the immediate jeopardy. The PC 2 stated the facility did not have standardized medication administration times, and were having problems with the stock medications. The PC 2 stated, "What they have available does not necessarily match what the doctor has ordered. The PC 2 stated if there is an order for Famotidine 20 mg 1 tab, the facility has Famotidine 10 mg and the nurse is now administering 2 tablets. The PC 2 stated the nurse would be required to clarify the order with the doctor. The PC 2 stated he proctored a morning medication pass on 1/30/18 and identified Resident 12 had a discrepancy with the Lovenox (injectable blood thinner). PC 2 stated, "Her order was ordered last night and the med was still not delivered until late today. She got the medication but it was given significantly late. This is a pharmacy problem." During an interview and concurrent record review with LN 11, on 2/1/17 at 2:30 p.m., LN 11 stated Resident 12 had an order for Lovenox 80 mg two times per day since 1/12/18. LN 11 stated the medication was clarified on 1/29/18 to include, "When INR (International Normalized Ratio) (a way of reporting the prothrombin time, which is a measure of the blood's ability to clot) is equal to 2 or greater than 2, then discontinue Lovenox." LN 11 reviewed Resident 12's MAR and stated the Lovenox ordered to be given at 8 a.m., on 1/30/18 and 8 p.m., on 1/30/18 was initialed as not given. LN 11 turned to the back of the MAR and stated, "Looking at the MAR it looks like the Lovenox dose due on 1/30/18 at 8 a.m., 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was administered at 4 p.m. it says the medication was given from the Cubex." During an interview and concurrent record review with LN 14 on 2/1/17 at 2:45 p.m., LN 14 stated she was the assigned nurse for Resident 12 on 1/30/18 during the evening shift. LN 14 stated Resident 12 did not receive the 8 p.m., dose of Lovenox. LN 14 stated she did not call the physician to inform him the medication was unavailable and she did not call the pharmacy to follow up. During a medication pass observation and concurrent interview with LN 8 assigned to medication cart 3, on 1/31/18 at 12:23 p.m., LN 8 performed the fingerstick after Resident 30 finished eating lunch. Resident 30's blood sugar was 558, LN 8 proceeded to the nursing station and called the physician to inform him of the elevated blood sugar results. During a medication pass observation of LN 8, on 1/31/18 at 12:37 p.m., LN 8 prepared medications for Resident 30. LN 8 administered Sucralfate (medication used to treat acid reflux) 1 tab after Resident 30 had eaten his lunch meal and administered 20 units of Novolog Insulin. During review of Resident 30's clinical record titled "JANUARY 2018 MEDICATIONS" indicated, "SUCRALFATE 1 gram (1) TABLET Oral Four Times Daily ...Give 1 tab before meals ..." During a medication pass observation of LN 8, on 1/31/18 at 12:48 p.m., LN 8 prepared medication for Resident 23. LN 8 administered Renvela (phosphate binder to help prevent low levels of calcium in the body caused by elevated phosphorus) 1 tab with a glass of water. LN 8 stated Resident 23 did not like to 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE eat lunch and the tablet was given without food. During review of Resident 23's clinical record titled "JANUARY 2018 MEDICATIONS" indicated, "RENVELA F/C 800MG (1 TAB) TABLET ...Give 1 tab by mouth three times a day with meals." During a medication pass observation and concurrent interview of LN 8, on 1/31/18 at 1:07 p.m., LN 8 prepared medication for Resident 18. LN 8 stated Resident 18's antibiotic was due at 11 a.m. and was being administered late. During a medication pass observation and concurrent interview of LN 8, on 1/31/17 at 1:10 p.m., LN 8 prepared Resident 80's medication. LN 8 poured liquid Sucralfate into a measuring cup and stated there was not enough supply of the medication for Resident 80. LN 8 looked into the medication cart for another bottle of Sucralfate but could not find an additional supply of the medication for Resident 80. LN 8 stated, "I don't have it." During review of Resident 80's clinical record titled "JANUARY 2018 MEDICATIONS" indicated, "SUCRALFATE 100 mg/ml (10 ml) ...Four Times Daily ...BEFORE MEALS AND AT BEDTIME." During a medication pass observation and concurrent interview with LN 7 assigned to medication cart 1, on 1/31/18 at 10:45 a.m., LN 7 administered Pioglitazone-Metformin (diabetes medication) 15-500 mg at 10:45 a.m. LN 7 stated the medication was being administered late. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10:55 a.m., LN 7 prepared Resident 35's 8 a.m., medications. LN 7 stated Resident 35's medications were due at 7 a.m., 7:30 a.m., and 8 a.m. LN 7 stated Resident 35 was due to receive Aspirin 81(cerebrovascular disease) mg, Docusate Sodium(treat constipation) 250 mg , Folic Acid( vitamin of B complex) 1 mg, Coreg (treat heart failure and high blood pressure) 3.125 mg, Lisinopril (blood pressure medication) and Ferrous Sulfate (treatment of anemia) on time and not at 11:05 a.m. LN 7 stated the medications were administered late. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 11:55 a.m., LN 7 stated Resident 11 received her 8 a.m. dose of Fluticasone Propionate (treat the symptoms of asthma) 50 mcg/actuation nasal spray, her 8 a.m. dose via G-Tube of Eliquis (used to prevent strokes) 5 mg, Calcium 600 with Vitamin D 400 IU, Folic Acid ( family if vitamin B) 400 mcg, Oxybutynin Chloride ER(treat overactive bladder) 5 mg, Vesicare (treat an overactive bladder) 10 mg, Januvia ( diabetic medication) 50 mg, Juven (muscle-support supplement) 1 packet, and acetaminophen( pain reliever) 325 mg 2 tablets v and Lantus insulin (treat type 1 insulin dependent or type 2) 15 units SQ at 11:34 A.M. LN 7 the ordered multivitamin with iron was not administered because "it is not in the cart." LN 7 stated the medications were being administered late. LN 7 did not do fingerstick Blood Sugar as ordered for 11:30 a.m. LN 7 stated "it is too late to do the 8 a.m. blood sugar" During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 11:55 a.m., LN 7 stated Resident 84 received her 8 a.m. dose of Aspirin 8(cerebrovascular disease) 1 mg chewable, Senna (laxative) 17.2 mg, Calcium 600 mg with Vitamin D, and 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Lisinopril (blood pressure medication) 10 mg, with blood pressure and pulse parameters at 11:58 a.m. LN 7 stated the medication was being administered late. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 12:17 p.m., LN 7 stated Resident 37 received her 8 a.m. dose of Multivitamins with Minerals, and Remeron (antidepressant) 15 mg at 12:17 p.m. LN 7 stated the medication were administered late. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 12:40 p.m., LN 7 stated Resident 44 received her 8 a.m. dose of Calcium 600 mg with Vitamin D, Docusate Sodium (laxative) 100 mg, Aspirin (cerebrovascular disease) 81 mg. chewable, Losartan Potassium ( treat high blood pressure)100 mg, Carvedilol (treat heart failure and high blood pressure) 6.25, Metformin HCL( diabetic medication) 1,000 mg, Cholecalciferol SP/NF Vitamin D3 ( vitamin D) , Ferrous Sulfate (iron supplement) 325 mg, Magnesium Oxide 400 mg, Combigan ( treat open-angle glaucoma) 0.2-0.5% (1) DROPS, left eye at 12:40 p.m. LN 7 stated the medication was being administered late. Resident 44 received PRN dose of Acetaminophen 325 mg, 2 tablets at 12:40 p.m. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 12:50 p.m., LN 7 stated Resident 39 received her 8 a.m. dose of Metoprolol Succinate (treat hypertension and angina) 50 mg, with blood pressure and pulse parameters within normal limits, and Losartan Potassium (treat high blood pressure) 25 mg at 12:50 p.m. LN 7 stated the medication was being administered late. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 1:05 p.m., LN 7 stated Resident 85 received her 8 a.m. dose of Keppra (medication used to treat seizures) 1,000 mg, Memantine (medication for dementia) HCL 2mg/Ml (5ML) SOLUTION ORAL and Aspirin 81 mg chewable at 1:05 pm. LN 7 stated the medications were administered late. During a medication pass observation and concurrent interview with LN 7, on 1/31/18 at 1:30 p.m., during a medication pass observation and concurrent interview, LN 7 stated Resident 16 received her 8 a.m. dose of Lisinopril (high blood pressure) 20mg, and Aspirin (cerebrovascular disease) 81 mg chewable, at 1:10 p.m. LN 7 stated the medication was being administered late. During a medication pass observation and concurrent interview with LN 7 on 1/31/17 at 1:45 p.m., during a medication pass observation and concurrent interview, LN 7 stated Resident 49 received her 8 a.m. dose of Norvasc (treat high blood pressure and chest pain) 10 mg, Famotidine (treat stomach or intestinal ulcers) 20mg, and Metformin HCL (diabetic medication) 500 mg, at 1:47 p.m. LN 7 stated medications were administered late. During a medication pass observation and concurrent interview of LN 7, on 1/31/18 at 1:53 p.m., LN 7 administered Resident 83's 8 a.m. dose of Hydralazine HCL(treat blood pressure) 50 mg, Isosorbide Mononitrate ER (dilates (widens) blood vessels) 30 mg, Lasix(treat edema (tissue swelling) 40 mg , Docusate Sodium ( treat constipation)250 mg, Metoprolol Tartrate ( treat hypertension and angina) 50 mg, Aspirin 325 mg and Famotidine (treat stomach or intestinal ulcers) 20 mg. LN 7 stated medications were administered late. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a medication pass observation and concurrent interview of LN 7, on 1/31/18 at 3:05 p.m., LN 7 stated Resident 43 received her 10 a.m. dose of Carbamazepine (used as an anticonvulsant) 200mg at 3:05 p.m. LN 7 performed Resident 43's fingerstick at 11:30 a.m., with blood sugar results of 176 and Novolog (treat diabetes) insulin administration of 2 units at 3:15 p.m. LN 7 stated the medication were administered late. During a medication pass observation and concurrent interview of LN 7, on 1/31/18 at 3:25 p.m., LN 7 administered Resident 75's, 12 p.m. dose of Morphine Sulfate (treat pain) 20mg/ML. LN 7 stated the medication was due every four hours, and was administered late at 3:25 p.m. During a medication pass observation and concurrent interview of LN 7, on 1/31/18 at 3:45 p.m., during a medication pass observation and concurrent interview, LN 7 stated Resident 52 received her 12 p.m. dose of Gabapentin(an anticonvulsant drug) 600mg, at 3:45 p.m. LN 7 stated medication was administered late. During a medication pass observation and concurrent interview of LN 13 assigned to medication cart 3, on 2/1/18 at 5 a.m., LN 13 prepared medication for Resident 79 and administered Calcium Carbonate (antacid) 500 mg 1 tab. LN 13 reviewed Resident 79's MAR and stated, "I made a mistake, I gave her the Calcium Carbonate that was due at 8 a.m. ...I am tired. I worked since yesterday at 6 p.m." During review of Resident 79's clinical record titled "JANUARY 2018 MEDICATIONS" indicated, "CALCIUM CARBONATE 1 TAB Oral Three Times Daily" scheduled to be administered at 7 a.m., 10 a.m., and 4 p.m." 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an observation and a concurrent interview on 2/3/18 at 12:52 p.m., LN 13 obtained Resident 30's blood sugar (BS) by performing a fingerstick (One hour and 22 minutes after the scheduled time for fingerstick and insulin administration according to the results of the blood sugar was ordered). LN 13 stated Resident 30's BS was 420 mg/dl (milligrams per deciliter). LN 13 did not administer any insulin to Resident 30. On 2/3/18 at 1 p.m. Resident 30 was observed eating his lunch in his room. Review of Resident 30's "Physician Order Sheet" indicated "Novolog Latex-Free 100 unit/ml [units per milliliter], Sliding Scale [insulin is administered according to the resident's blood sugar levels] If above 400 call MD [physician]...order date: 1/28/18...schedule 6 a.m., 11:30 a.m., 4:30 a.m., 8 p.m...." During an interview and concurrent record review on 2/3/18 at 4:55 p.m., at medication cart 3, LN 13 stated she gave 15 units of insulin to Resident 30 at 3:30 p.m. for his blood sugar result of 420 at 12:52. The medication administration record (MAR) dated February 2018 indicated LN 13 received a physician's order for Humulin R, (onset -when the insulin starts working is about 30-45 minutes, Peak of action -when the insulin is at its strongest varies from 2-4 hours) and she gave 15 units of the insulin at 3:30 p.m. During an interview with LN 13, on 2/3/18, at 5:25 p.m., at medication cart 3, LN 13 stated Resident 30's BS was 335 mg/dl at 4:30 p.m. LN 13 stated she gave Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 8 units. LN 13 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated she gave Humulin R and Novolog within one hour from each administration. LN-13 stated she did not call the physician after she gave the Novolog one hour after she gave the Humulin R. The facility policy and procedure titled "Medication-Errors" dated 1/1/12, indicated, "Medication Error means the administration of medication: ... B. At the wrong time ..." During observation and concurrent interview and record review on 2/3/18, at 11:53 a.m., at the nurse's medication cart (3), LN 13 was observed starting the medication pass (med pass). At 1:32 p.m. LN 13 stated she was not going to give the 11 a.m. and 12 p.m. medication due to the time being passed 11 a.m. The med pass was completed at 2:27 p.m. LN 13 reviewed the MAR to identify the 11 a.m., 11:30 a.m. and 12 p.m. medications/monitoring not administered or not administered timely which included the following: Resident 30 - Blood Sugar (BS) ordered to be checked at 11:30 a.m., was checked at 12:52 p.m.; Resident 30, 80 Sucralfate (used for treating stomach ulcers) ordered to be given at 11 a.m., was not given; Resident 82 - Iron supplement ordered to be given at 12 p.m., was not given; Resident 19 Albuterol (Inhaler) ordered to be given at 12 p.m., was not given; Resident 71 - Stool softener ordered to be given at 12 p.m., was not given; Resident 69 - Depakote (seizure medication) ordered to be given at 12 p.m., was not given; Resident 7 - Prednisolone (eye drops for inflammation) ordered to be given at 11 a.m., were not given. During a medication pass observation on medication cart 2 with LN 6, on 2/3/18, at 11:41 a.m., LN 6 prepared the scheduled 8 a.m. medications for Resident 83. LN 6 dispensed 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE eleven medications into a medication cup and administering the scheduled 8 a.m. medications two hours and 41 minutes late to Resident 83. Resident 83 stated he was experiencing pain to LN 6. LN 6 stated resident requested pain medication (pain rating of 8/10) LN 6 stated she did not administer the pain medication because Resident 83 was complaining about his stomach. She stated to Resident 83, "so I didn't give it to you." Resident 83's 8 a.m. medication was not administered as ordered by the physician. During a concurrent record review and interview with LN 6, on 2/3/18, at 2:10 p.m., Resident 83's "Physician Order Sheet" and MAR, on 2/3/18, at 3:35 P.M., LN 6 stated the MS Contin 15 mg (medication used to relieve severe pain) was not administered as ordered. The MAR indicated LN 6 administered Norco (used to relieve moderate to severe pain) 5/325 mg (milligrams) one tablet for pain at 11 a.m. LN stated she did not administer the pain medication at the time she documented. LN 6 reviewed the MAR and stated the MAR did not accurately reflect that Norco 5/325 mg was not administered. She stated the Norco was signed as given but was not administered. LN 6 stated the risks for not administering the two pain medication as ordered by the physician could be unrelieved pain. During a medication observation on medication cart 2 with LN 10, on 2/3/18, at 12:36 p.m., the following types of medications were not admininstered for the scheduled 8 a.m. medication pass for15 residents (Resident 32, Resident 3, Resident 29, Resident 9, Resident 31, Resident 51, Resident 54, Resident 55, Resident 59, Resident 61, Resident 62, Resident 63, Resident 66, Resident 67, Resident 79): 1. Anti-hypertensive (blood pressure) 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medications 2. Anticoagulant (blood thinning) medications 3. Cardiac (heart) medications 4. Gastroesophageal (the backward flow of stomach contents into the esophagus due to malfunctioning of a sphincter at the lower end of the esophagus and results in heartburn) medication 5. anticoagulants (to treatment thrombosis [blood clots]) 6. Constipation medications Gout (disease in which defective metabolism of uric acid [breakdown of your body's cells. creating crystals to form in joints causing pain] ccauses arthritis, especially in the smaller bones of the feet, deposition of chalkstones, and episodes of acute pain 7. Seizure medication 8. Nerve pain medication 9. nonsteroidal aromatase inhibitor (used in the treatment and prevention of breast cancer) 10. Pain medications 11. Asthma medications 12. Diabetes medications 13. Antibiotics (medication to treat infections) 14. Hyperlipidemia (high cholesterol) medications 15. Hypotensive (low blood pressure) medications 16. Muscle spasm medications 17. Parkinson (a problem with certain nerve cells in the brain that affects movement) 18. Therapeutic nutrition drink mix to support wound healing 19. NMDA receptor antagonists (decreasing abnormal activity in the brain to treat Dementia) medications 20. Medication used to dissolve certain types of gallstones 21. Anti-depressant (a mood disorder causing severe symptoms that affect how feeling, thinking, and handle daily activities, such as sleeping, eating, or working.) 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 22. Antiarrhythmic drugs (to treat abnormal heart rhythms). During an interview with LN 10, on 2/3/18, at 2 p.m., LN stated she did not know why the 15 residents did not receive their 8 a.m. medications as ordered. She stated she took over the medication administration pass at 12:30 p.m. She stated "all I know is that we don't have enough nurses to finish the job." During an interview and concurrent record review with LN 6, on 2/6/18, at 8:20 a.m., LN 6 stated she was the nurse administering the 8 a.m. medication on 2/3/18. She stated she had worked the night before and was asked to stay over to start the 8 a.m. medication administration and did not finish administering the 8 a.m. medications to all assigned residents because she was running late. LN 6 stated she stopped the 8 a.m. medication pass at 12 p.m. and gave report and medication cart keys to LN 10 at 12:30 p.m. LN 6 stated she did not know why LN 10 did not finish the 8 a.m. medication pass after 12:30 p.m. for the 15 residents that did not receive their 8 a.m. medications. She stated the facility did not have enough nurses to meet the needs of the residents. LN 6 reviewed the MARs and was unable to find documentation on why the medications were not administered at 8 a.m. She stated the nurses have to document the reason for not administering a medication or administering it late. LN 6 confirmed findings and stated she did not document. During an observation and concurrent interview on 2/4/18 at 7:50 a.m., at medication cart 3, LN 1 prepared Resident 18's medications scheduled for 8 a.m. administration. LN 1 stated, "The resident's fenofibrate [a medication to help lower blood fats and cholesterol] is still not here. I don't know why it 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE has not been delivered since 2/1/18 so I am just going to encircle it [circle the LN's initials to indicate the medication was not administered]. No documentation was provided on the MAR to indicate why the medication was not administered and LN 1 did not notify Resident 18's physician of the omitted fenofibrate. Review of Resident 18's "Physician Orders" dated February 2018, indicated, "Fenofibrate 48 mg 1 tablet oral [by mouth] daily for hyperlipidemia [high concentration of fats in the blood). During an observation and concurrent interview on 2/4/18 at 8:03 a.m., at medication cart 3, LN 1 prepared Resident 7's medications scheduled for 8 a.m. administration. LN 1 stated, "I don't have the dorzolamide [an eye drop given to lower pressure in the eye] eye drops for the resident." LN 1 encircled his initials on the MAR indicating the dorzolamide eye drops were not administered. No documentation was provided on the MAR to indicate why the medication was not administered and LN 1 did not notify Resident 7's physician of the omitted eye drops. Review of Resident 7's "Physician Orders" dated February 2018, indicated, "DorzolamideTimolol 223.-6.8 mg/ml (1 drop) right eye for glaucoma [a condition that increases pressure in the eye that if untreated can lead to blindness] two times daily." During a concurrent interview with LN 1 and the Vice President of Clinical Operations (VPOCO) 2 on 2/4/18 at 10:20 a.m., LN 1 was asked about the medications not administered to Resident 18 and Resident 7. LN 1 stated, "I don't know why it's [the medication] not here; we just changed pharmacy. The VPOCO 2 stated "The process of following up with 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medications if it is not available is to call the physician and to document on the back of the MAR. If it is not documented, it is not done." During an observation of the 8 a.m., medication pass at Station 1 on 2/6/18 at 7:45 a.m., Proctor 2 and Proctor (P 3) accompanied LN 15 for the medication administration. During the medication pass, LN 15 and P 3 were unable to complete administration of the 8 a.m. medications in the scheduled time frame. LN 15 and P 3 were observed to continue administering medications scheduled for 8 a.m. at 10 a.m. During an interview with P 3, on 2/6/18 at 3:50 p.m., P 3 stated the 8 a.m. medication pass with LN 15 that morning was completed at 11:30 a.m., two and one half hours after the scheduled time frame allowed for medication administration. P 3 stated 35 of 37 residents received their medications more than an hour past the scheduled time. Late medication included: for Resident 11 an anticoagulant (a blood thinner) due twice daily and a medication for diabetes given once daily; for Resident 39, Resident 44 and Resident 83 medications for high blood pressure to be given once daily; for Resident 84 an anti-seizure medication to be given twice daily; for Resident 16 an antibiotic to be given twice daily; for Resident 85 a diuretic medication (given to increase urine production and elimination for multiple medical conditions including high blood pressure) to be given once daily; for Resident 46 a narcotic pain medication to be given every 6 hours. During an interview with LN 10, on 2/7/18 at 3:40 p.m., LN 10 stated she completed her 8 a.m. med pass at 11:30 a.m. She stated there were many interruptions during her morning med pass. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an observation and concurrent interview with LN 9 on 1/24/18 at 10:50 a.m. on Station Two's medication cart, LN 9 was standing in front of the medication cart writing on the Medication Administration Record (MAR) (record used to document medication administration). LN 9 initialed in the space dated 1/24/18 for Amlodipine Besylate (blood pressure lowering medication) 5 mg (milligram) to be administered at 8 a.m. for Resident 57. LN 9 stated, "I did not give the medication, "I am going to give it [medication] now."

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 02/27/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure resident meals were served to preserve palatability and proper temperature for two of 87 sampled residents, Resident 78 and Resident 45, when a hot lunch meal and a hot breakfast meal were served too cold for resident consumption and meals were not reheated according to facility dietary policy. This failure resulted in facility residents, including Resident 78 and Resident 45, 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE complaining of hot meals served cold and the potential for meals served to residents to lose palatability. Findings: During an observation in Dining Room A, on 1/11/18 at 12 p.m., Certified Nursing Assistant (CNA) 3 was distributing trays to the resident dining room. Resident 78 sat while she was assisted by her Family Member (FM) 4. Resident 78 told her daughter, "My food is cold and I do not want to eat it." FM 4 took Resident 78's plate and inserted the meal plate in the microwave available in Dining Room A. During an interview with FM 4, on 1/11/18 at 12:10 p.m., FM 4 stated Resident 78 did not like to eat cold food. During an observation in Dining Room A, on 1/11/18 at 12:15 p.m., Resident 45 entered the dining room and requested his lunch tray. CNA 3 opened the enclosed meal cart sitting in the dining room and obtained Resident 45's lunch tray. Resident 45 stated, "My food is cold, please warm it up." CNA 3 took Resident 45's lunch tray and inserted the tray inside the microwave to warm Resident 45's lunch tray. During an interview with CNA 3, on 1/11/18 at 12:20 p.m., CNA 3 stated, "We warm up their food in the microwave, we do this for them all of the time. CNA 3 stated he did not check the food temperature with a thermometer after he reheated the meal tray in the microwave. During an interview with the Registered Dietician (RD), on 1/22/18 at 12:20 p.m., the RD stated, "I have heard from residents that breakfast trays are too cold ...in my opinion it is because of the distributions of trays; it takes long and the meal cart doors are left open 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE during the distribution. They [CNAs] pass as quickly as they can but the residents require set up and areas to be prepped." The RD stated she had not communicated her observations regarding length of time required for staff to pass meal trays to anyone in the nursing department." During an interview with the Dietary Manager (DM), on 1/22/18 at 2:55 p.m., the DM stated CNA's were not allowed to reheat Resident meal trays inside the microwave. The DM stated, "If they want food to be reheated it needs to be taken to dietary, temps need to reach 165 degrees Fahrenheit." During an observation and concurrent interview with the DM and the morning cook (MC), on 1/26/18 at 8:30 a.m., two CNA staff members passed the breakfast trays to the Residents of Station 1. The meal trays were kept in an enclosed meal cart. Three meal trays were observed not to be in the meal cart, one tray sat on top of the meal cart and two trays were on an open coffee delivery cart. The DM stated the purpose of the enclosed meal cart was to carry trays and keep the food warm. The DM stated she did not have enough space in the meal cart and she had to deliver one meal tray on top of the enclosed cart and two meal trays in the opened coffee delivery cart. The DM stated there were 27 trays that needed to be delivered to Station 1 and there were only 24 available spaces in the enclosed meal cart. The DM stated the facility had a broken meal cart and had not been repaired for about 3 months. The DM stated the Maintenance Supervisor knew the meal cart needed to be repaired but had been too busy to do it. During an observation and concurrent interview with the DM, the RD and the MC on 1/26/18 at 9:10 a.m., the two CNAs distributed the last 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE breakfast tray. The DM, the RD and the MC tested the breakfast test tray for adequate temperature. The test tray contained one serving of pureed eggs, one serving of pureed sausage and one serving of pureed bread. The DM sated the food temperature should be at 135 degrees Fahrenheit. The RD stated, "We want our food to be at 130 degrees or above at this point." The DM measured the following food temperatures: pureed eggs at 90 degrees Fahrenheit, pureed sausage at 94 degrees Fahrenheit, and pureed bread at 102 degrees Fahrenheit. During an interview with the DM, the RD and the MC on 1/26/18 at 9:15 a.m. the RD and the MC ate from the test tray. The RD stated, "The eggs were warm and the sausage was lukewarm." The MC stated the eggs and sausage tested were cold. During an interview with the RD, on 1/26/18 at 9:20 a.m., the RD stated the facility had a broken enclosed meal cart for about one year. The RD stated the purpose of the enclosed meal cart was to keep the food warm. The RD did not respond when asked why the facility had not repaired the broken enclosed meal cart or why the facility had not purchased a new meal cart. The facility policy and procedure titled, "COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS" dated 3/13, indicated "...Methods of Reheating Food 1) Previously cooked, potentially hazardous foods that will be held hot should be rapidly reheated to an internal temperature of 165 degrees Fahrenheit within two hours. Internal temperature must then register 165 degrees Fahrenheit for fifteen seconds. Be sure the food reaches a full 165 degrees Fahrenheit." 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE The facility policy and procedure titled, "Food Temperatures" dated 4/1/14, indicated, "To provide the dietary department with guidelines for food preparation and service temperatures. Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety ...II. Acceptable Serving Temperatures Food Items ...Pureed foods ...Temperature Required [Fahrenheit]) > (greater than) 140 [degrees Fahrenheit]."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 02/27/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Based on observation, interview and record review, the facility failed to maintain a sanitary environment in the kitchen when: 1. A black organic substance covered portions of the wall next to the dish washer after an unfinished repair project. 2. The wall behind the ice machine had an open hole. 3. Four metal cabinet drawers used to store spoons and cookware were corroded. 4. The dry food storage area had dry scattered oatmeal and crumbs inside two large containers. 5. Four metal shelves used for storing pots and pans were corroded and peeling. These failures created an unsanitary environment in the kitchen and had the potential risk of causing food borne-illness to residents. Findings: 1. During an observation and concurrent interview with the Dietary Manager (DM), on 1/30/18 at 2 p.m., the bottom of the ice machine was inspected. There was a large hole on the bottom of the wall behind the ice machine. The ice machine PVC piping inserted into the wall leaving a large open hole around the wall where the polyvinyl chloride (PVC) piping went through. The DM stated she didn't know there was a hole in the wall. The DM stated the hole was a potential access for insects and pests to come into the kitchen. 2. During an observation and concurrent interview with the DM and the Maintenance Supervisor (MS), on 1/30/18 at 2:05 p.m., the wall next to the dishwasher was noted with a horizontal filler foam above the metal lining of the dishwasher. The filler foam was covered 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE with yellow colored stains and a black organic material that was visible throughout the foam and the wall. Parts of the wall had chipped, exposing peeling green paint. The MS stated, "I applied filler foam to fill out the holes. There was a window that was sealed off ...It looks like it is dirty. I cannot tell if it is mold but it is definitely dirty." The MS stated he made repairs to the wall in August of 2017. The MS stated, "My repair consisted of sealing the hole but I didn't know what else to do. I was told by the Administrator that the entire dishwasher had to be moved forward in order for the wall to be repaired. He was going to get a contractor to do the repairs. It never got done. [The following Administrator] said he thought it was cosmetic and for me to do work on other things instead. I am the only maintenance man in the facility and there is a lot to do. The repair job did not get completed." During a concurrent interview with the DM and the MS, on 1/30/18 at 2:10 p.m. the DM stated, "I have tried to keep it [the filler foam] clean with bleach. I spray it when the kitchen staff is not present." The DM and the MS stated they had been told not to spend money on costly repairs. The DM stated the biggest example was the broken dietary cart, the MS was to figure out how to fix the cart instead of purchasing a new one. The MS stated again, "We were told not spend." The DM stated the RD was aware of the soiled foam and had given instructions to remove the foam. During an interview, with the Registered Dietician (RD) on 1/31/18 at 10:55 a.m., the RD stated she was aware of the area in the kitchen repaired with filler foam. The RD stated it had been more than three months ago that she noticed the filler foam. The RD stated the area was exposed to water and with the elements the black organic material kept coming back despite it being cleaned with bleach. The RD 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated the black organic material located on the wall and filler foam looked like "mold" but could not say it was mold because she was not a mold specialist. The RD stated, "My understanding is that once you have mold you can clean it but it will come back if the same factors continue." The RD stated she was not sure if the area in the kitchen had ever been addressed by a professional cleaner or an environmental hygienist. The RD stated that she addressed this concern to each Administrator including the Vice President of Operations in her sanitation report. Review of the kitchen sanitation report dated 12/29/17, indicated, "Caulking in dish wash area had black organic matter. Foam fill near dish wash sink overfilled." Under Corrections the document indicated, "What: Clean/re-caulk if necessary, trim foam fill. Who: [DM]/Maintenance. When: 1/12/18." Review of the kitchen sanitation report dated 11/30/17, indicated, "Caulking in dish was area appears to have been re-done: however, there appears to be black organic matter in several places and an area of wall right of disposal is damaged ..." 3. During an observation in the kitchen and concurrent interview with the DM, on 1/30/18 at 1:50 p.m., the DM was asked to open all of the drawers used for storage. The DM opened two metal drawers from under the counter across the walk-in refrigerator. The DM removed spoons from the second drawer and identified an aluminum foil covering the bottom of the drawer. The DM then removed the aluminum foil and revealed the corroded drawer. The DM stated, "The drawer is metal and is rusted. We use aluminum to cover the rust ...It looks like the drawer needs to be replaced." The DM opened three additional drawers used for 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE storage of small cups and spoons, they were all noted with a corroded appearance. The DM stated, "They will all need to be replaced." 4. During an observation of the dry food storage area and concurrent interview with the DM, on 1/30/18 at 1:55 p.m., there was one large plastic container holding individual packets of jam. The container had a significant amount of scattered dry oatmeal. The RD stated, the scattered oatmeal should not have been there and needed to be washed out. The RD stated, "If it is not clean, there is a potential to draw in pests." A second container holding 16 oz. (ounce) bags of chips had dust particles and crumbs. The DM stated the container needed to be washed. 5. During an observation in the kitchen and concurrent interview with the DM, on 1/30/18 at 1:52 p.m. there were four metal counter tops with peeling shelves underneath. The shelves did not have a smooth finish and areas with peeling particles were visible. The shelves were used to store pots and pans used in the kitchen. The DM stated the shelves were peeling and needed to be looked at by the MS. 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG

F921 Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 SS=E DEFICIENCY) COMPLETE DATE 02/27/2018 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and administrative document review the facility failed to maintain a safe environment for residents, staff and the public when 12 of 14 outside lights that illuminated the facility outside entrance and the facility parking lot were not in working order. This failure placed residents, staff, and the public at risk for accident hazards. Findings: On 1/10/18 at 2:15 p.m., during a interview, the Maintenance Supervisor (MS) stated, he was aware of residents' family members complaints of the facility outside lights not working at night. The MS stated, "I have known about the outside lights not working for a week." On 1/11/18 at 1:05 p.m., during an observation and concurrent interview with the MS while touring the outside of the facility, seven recessed lights were observed above the main entrance to the building. The MS tested the lights and only two lights illuminated. The MS stated five lights needed new light bulbs.. On 1/11/18 at 1:10 p.m., during an observation and concurrent interview with the MS while touring the outside of the facility, seven flood lights set on top of the roof of the facility 131 555179 02/08/2018 NORTH POINT HEALTHCARE & WELLNESS CENTRE, LP 668 E Bullard Ave Fresno, CA 93710 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE pointing toward the parking lot and surrounding area including the main entrance were seen. The MS tested the flood lights and all seven flood lights did not work. The MS stated the flood lights were needed to illuminate the parking lot and the front of the building after dark. The MS stated "The flood lights not working is a safety issue for residents, family members, and employees." The MS stated the flood lights need to be fixed immediately. The facility policy and procedure titled, "Maintenance Service - Operational ManualPhysical Environment" dated January 01, 2012 indicated, "The Maintenance Department is responsible for maintaining the building grounds and equipment in a safe and operable manner at all times...Maintaining the building in good repair and free from hazards...to assure that the buildings and grounds...are maintained in a safe and operable manner... monitor the condition of various areas of the facility..." 131