Other·January 12, 2017

California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG A000 W&I 15655 Initial Comments ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE A000 The following reflects the findings of the California Department of Public Health, Licensing and Certification, during a State Relicensing survey. Representing the Department: 3110-HFEN B000 Initial Comments B000 The following reflects the findings of the California Department of Public Health, Licensing and Certification, during a State Relicensing survey. Representing the Department: 3110-HFEN A002 W&I 15655 W & I 15655(a)(2) A002 15655. (a) (2) Each long-term health care facility as defined in Section 1418 of the Health and Safety Code and each community care facility as defined in Section 1502 of the Health and Safety Code shall comply with paragraph (1) by January 1, 2001, or, if the facility began operation after July 31, 2000, within six months of the date of the beginning of the operation of the facility. Employees hired after June 1, 2001, shall be trained within 60 days of their first day of employment. This Statute is not met as evidenced by: Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Based on record review and interview, the facility failed to ensure mandated training as prescribed by the Department of Justice in recognizing and reporting elder and dependent adult abuse within 60 days of a staff 's first day of employment was provided to four of eight sampled employees. This facility failure has the potential for unrecognized and unreported patient abuse incidents. Findings: Record review and concurrent interview on 12/7/16 at 10a.m., revealed employee personnel record for director of staff development (DSD) do not have the documented evidence of abuse training being provided within 60 days of first day of employment. Administrator (ADM) confirmed employee personnel record for DSD do not have documented evidence of abuse training being provided within 60 days of first day of employment. Record review and concurrent interview on 12/7/16 at 1:15p.m., revealed employee personnel record for minimum data set (MDS) nurse, do not have the documented evidence of abuse training being provided within 60 days of first day of employment. Director of staff development (DSD) confirmed employee personnel record for MDS nurse do not have documented evidence of abuse training being provided within 60 days of first day of employment. Record review and concurrent interview on 12/7/16 at 1:30p.m., revealed employee personnel record for nursing supervisor (RN 1), do not have the documented evidence of abuse training being provided within 60 days of first day of employment. Director of staff Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE development (DSD) confirmed employee personnel record for RN 1 do not have documented evidence of abuse training being provided within 60 days of first day of employment. Record review and concurrent interview on 12/12/16 at 5:12p.m., revealed employee personnel record for certified nurse assistant (CN 6), have a hire date of 11/21/16 and a documented evidence of abuse training dated 8/25/16, two months and 27 days prior to first day of employment. Director of staff development (DSD) confirmed CN 6's hire date was 11/21/16 and the abuse training was provided on 8/25/16 by the staffing registry. B785 T22 DIV5 CH3 ART3-72305(b)(4) Physician Services--Medical Director B785 (b) The medical director shall: (4) Be responsible for reviewing employees' preemployment and annual health examination reports. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure Medical Director reviewed employee health exam for one of eight sampled employees. This facility failure placed patients, visitors, and other employees at risk for unknown health conditions and safety hazards. Findings: Record review of eight sampled employee's Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE personnel and health records on 12/7/2016 revealed one of eight sampled employees (RN 2) did not have a health examination and Tuberculosis (TB) test on file. During an interview on 12/14/16 at 9:36 a.m., the facility's Medical Director confirmed he was responsible in performing the facility's preemployment health examinations for newly hired employees, as well as reviewing the annual health examinations for all the other employees. The Medical Director confirmed the DSD was responsible for providing the list of all new staff and current staff needing preemployment and annual health examinations. During an interview on 12/12/16 at 5:15 p.m., the Director of Staff Development (DSD) confirmed RN 2 does not have health examination and TB testing in employee personnel records. B940 T22 DIV5 CH3 ART3-72313(a)(6) Nursing Service--Administration of Medication B940 (a) Medications and treatments shall be administered as follows: (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared, and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. This Statute is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications was administered within one hour before and one hour after the scheduled administration time for 1 unstamped patient (Patient 16). Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE This failure had the potential to alter the therapeutic effects of the medications if dosing intervals were shortened or prolonged. Findings: During an observation and concurrent interview on 12/8/16 at 11:38 a.m., a Licensed Nurse (LN 1) was observed holding a medicine cup with one white pill in it. LN 1 placed the medicine cup in an empty clear plastic cup, and labeled the cup with Patient 16's room number. LN 1 stacked another empty clear plastic cup on top of the first one with the medicine cup and pill still inside, and locked the cups with the medicine in the medication cart. LN 1 confirmed the medication was for Patient 16 and was unable to administer medication since the patient was not in her room. During an interview on 12/8/16 at 1:18 p.m., LN 1 confirmed the white pill in the cup she set aside for Patient 16 at 11:38 a.m. was Patient 16's 9 a.m. Mentoring (anti-diabetic medication), and the medication was administered to the patient at 11:55 a.m.. more than one hour after the scheduled administration time. During record review and concurrent interview on 12/9/16 at 10 a.m., the medication administration record history indicated patient 16's Mentoring was administered on 12/8/16 at 11:55 a.m.. Nursing Supervisor (RN 1) confirmed Patient 16's Mentoring was administered more than two hours after the scheduled administration time. Facility Policy and Procedure in Medication Administration dated 07/13 states "Medication must not be prepared in advance and must be administered within one hour before or after administration time per M.D. order." Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG B1275 T22 DIV5 CH3 ART3-72321(c)(1) Nursing Service--Patients with Infectious Dis ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE B1275 (c) The following shall be available in each nurse's station: (1) The facility's infection control policies and procedures. This Statute is not met as evidenced by: Based on observation and interview, the facility failed to ensure infection control policy and procedure manuals were readily available in three of three nursing stations. This facility failure has the potential to prevent staff from having immediate access to infection control resources as needed. Findings: During an interview on 12/6/16 at 10:35 a.m., a restorative nurse assistant (RNA 1) in nursing station 1 & 2, stated the infection control policy and procedure was with the Director of Staff Development (DSD). During an observation and concurrent interview on 12/6/16 at 10:40a.m., licensed nurse (LN 2) and nursing supervisor (RN 1), searched and were unable to find the infection control policy and procedure at the shared nursing station (stations 1 & 2). Both LN 2 and RN 1 confirmed infection control the policy and procedure manual was in the DSD office. During an observation and concurrent interview on 12/6/16 at 10:45 a.m., two certified nurse assistants (CNA 1 and CNA 2), were unable to find the infection control policy and procedure manual at nursing station 3. Both CNA 1 and Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE CNA 2 confirmed the infection control policy and procedure manual was with the DSD. During an observation and concurrent interview on 12/6/16 at 11 a.m., DSD searched and was unable to find the infection control policy and procedure in all three stations (station 1, 2 & 3). DSD confirmed infection control policy and procedure is kept at her office. B3890 T22 DIV5 CH3 ART5-72517(a) Staff Development B3890 (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure ongoing educational programs included all facility personnel as required. Findings: Record review of the facility personnel educational program sign-in sheets on 12/9/16 at 10:20 a.m. revealed not all facility staff attended the required educational programs. During an interview on 12/9/16 at 10:30 a.m., director of staff development (DSD) confirmed not all facility staff was able to attend the required facility educational programs. B3945 T22 DIV5 CH3 ART5-72517(b) Staff B3945 Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Development (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure licensed staff had the appropriate training for cardiopulmonary resuscitation (CPR - a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore blood circulation and breathing during emergency situations) for three of 11 sampled licensed staff [Registered Nurse (RN 3), Minimum data set (MDS) nurse, and Licensed Vocational Nurse (LN 2)]. This facility failure placed patients at risk for harm, injury, or even death due to licensed staff's lack of necessary skills needed in the event of an emergency cardiac or respiratory incident. Findings: Record review of licensed staff employee personnel records on 12/8/2016 revealed three of 11 sampled licensed staff renewed their CPR certificates on two different online websites (International CPR Institute, Inc. and National CPR Foundation) which offers CPR courses with no hands-on and in-person skills assessment. During an interview on 12/13/16 at 9:30 a.m., the Director of Staff Development confirmed three of 11 sampled licensed staff renewed their CPR certification on-line. Review of the Centers for Medicare and Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Medicaid Services Survey and Certification Letter 14-01-NH revised on 01/23/15 states, "Staff must maintain current CPR certification for healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable." Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG B4285 T22 DIV5 CH3 ART5-72525(c)(2)(B) Required B4285 Committees CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE (c) Committee composition and function shall be as follows: (2) Infection control committee. (B) The committee shall be composed of representatives from the following services; physician, nursing, administration, dietetic, pharmaceutical, activities, housekeeping, laundry and maintenance. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure a pharmaceutical representative attended the infection control committee meetings for two of the four required quarterly meetings. This facility failure has the potential for increased infection control issue throughout the facility. Findings: Record review on 12/8/16 of the required quarterly Infection Control committee attendance sign-in sheet for January 2016, April 2016, July 2016, and October 2016 indicated the pharmaceutical representative was not in attendance for two of the required quarterly infection control committee meetings (January 2016 and April 2016). During an interview on 12/12/16 at 3:30 p.m., the administrator (ADM) confirmed the pharmaceutical representative was not in attendance during two of the required quarterly infection control committee meetings. Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG B4320 T22 DIV5 CH3 ART5-72525(c)(3)(B) Required B4320 Committees CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE (c) Committee composition and function shall be as follows: (3) Pharmaceutical service committee. (B) The committee shall be composed of the following: a pharmacist, the director of nursing service, the administrator and at least one physician. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure the pharmacist attended the pharmaceutical service committee meetings for two of the four required quarterly meetings. Findings: Record review on 12/8/16 of the required Quarterly Pharmaceutical Service Committee Attendance Sign-in Sheet for January 2016, April 2016, July 2016, and October 2016 indicated the pharmacist was not in attendance for two of the required quarterly pharmaceutical service committee meetings (January 2016 and April 2016). During an interview on 12/12/16 at 3:35 p.m., the administrator (ADM) confirmed the pharmacist was not in attendance during two of the required quarterly pharmaceutical service committee meetings (January 2016 and April 2016). Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG B4765 T22 DIV5 CH3 ART5-72533(a)(1)(I) Employee B4765 Personnel Records CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE (a) Each facility shall maintain current complete and accurate personnel records for all employees. (1) The record shall include: (I) Performance evaluations. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure performance evaluations were conducted for: 1. Director of staff development (DSD). 2. Minimum Data Set (MDS) coordinator, and 3. RN supervisor (RN 1). These failures has the potential to place patients at risk for poor quality of care due to lack of employee competency evaluation. Findings: Record review of eight sampled employee personnel records on 12/8/2016 revealed three of eight employees (DSD, MDS nurse & RN 1) were missing their performance evaluations. During an interview on 12/13/2016 at 10:30 a.m., administrator confirmed performance evaluations for DSD (2015), MDS nurse (2015), and RN 1(2015 and 2016) were missing from their employee personnel records, and that all three employees have worked in the facility since 2013. B4810 T22 DIV5 CH3 ART5-72535(a) Employees' Health Exam and Health Records B4810 (a) All employees working in the facility, including the licensee, shall have a health Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE examination within 90 days prior to employment or within seven days after employment and at least annually thereafter by a person lawfully authorized to perform such a procedure. Each such examination shall include a medical history and physical evaluation. The report signed by the examiner shall indicate that the person is sufficiently free of disease to perform assigned duties and does not have any health condition that would create a hazard for himself, fellow employees, or patients or visitors. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure employee health examinations were completed 90 days before or seven days after hire, and annually for four of eight sampled employees [Registered Nurse (RN 2), Director of staff development(DSD), Minimum data set (MDS) nurse, and Nursing supervisor (RN 1)] . These failures placed patients, visitors, and other employees at risk for infections. Findings: Record review of eight sampled employee's personnel and health records on 12/7/2016 revealed four of eight sampled employees were missing health examinations. 1. Employee personnel and health record for RN 2 was missing the health examination 90 days before or seven days after employment. 2. Employee personnel and health record for DSD was missing the 2014 and 2015 annual health examination. 3. Employee personnel and health record for MDS nurse was missing the 2014 and 2015 annual health examination. 4. Employee personnel and health record for RN 1 was missing the 2014 and 2015 annual Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE health examinations. During an interview on 12/7/16 at 10 a.m., the administrator (ADM) confirmed the DSD's annual examination for both 2014 and 2015 were not in the employee personnel and health record. During an interview on 12/7/16 at 1:15 p.m., the DSD confirmed the MDS nurse's annual examination for 2014 and 2015 were not in the employee personnel and health record. During an interview on 12/7/16 at 1:30 p.m., the DSD confirmed RN 1's annual examinations for 2014 and 2015 were not in the employee personnel and health record. During an interview on 12/12/16 at 5:15 p.m., DSD confirmed RN 2's date of hire was 9/28/16, and employee health exam was not in the employee personnel and health record. B4815 T22 DIV5 CH3 ART5-72535(b) Employees' Health Exam and Health Records B4815 (b) The initial health examination and subsequent annual examination shall include a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA). A chest X-ray is indicated if the employee has previously had a positive tuberculosis test result or is currently being treated for tuberculosis. A positive tuberculosis test result shall be followed by a chest X-ray. Evidence of tuberculosis screening within 90 days prior to employment shall be considered as meeting the intent of this Section. This Statute is not met as evidenced by: Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Based on record review and interview, the facility failed to ensure evidence of tuberculosis (TB- a contagious lung disease) testing either through purified protein derivative (PPD) test (skin test for a contagious lung disease) or a chest x-ray were included in the employee personnel and health record upon hire and annually for four of eight sampled employees [Registered Nurse (RN 2), Director of staff development(DSD), Minimum data set (MDS) nurse, and Nursing supervisor (RN 1)] . This facility failure has the potential to expose patients, visitors, and other employees to an infectious and communicable disease. Findings: Record review of eight sampled employee personnel and health records on 12/7/2016 revealed four of eight sampled employees were missing TB testing: 1. Employee personnel and health record for RN 2 was missing the initial TB testing. 2. Employee personnel and health record for DSD was missing the initial TB testing and the 2015 annual TB testing. 3. Employee personnel and health record for MDS nurse was missing the initial TB testing and the 2015 annual TB testing. 4. Employee personnel and health record for RN 1 was missing the initial TB testing, and the 2014 and 2015 annual TB testing. During an interview on 12/7/16 at 10 a.m., the administrator confirmed DSD's initial TB testing and 2015 annual TB testing is not in the employee personnel and health record. During an interview on 12/7/16 at 1:15 p.m., DSD confirmed MDS nurse's initial TB testing and 2015 annual TB testing is not in the employee personnel and health record. Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE During an interview on 12/7/16 at 1:30 p.m., DSD confirmed RN 1's initial TB testing and 2014 and 2015 annual TB testing are not in the employee personnel and health record. During an interview on 12/12/16 at 5:15 p.m., DSD confirmed RN 2's date of hire was 9/28/16, and the initial TB testing is not in the employee personnel and health record. B4820 T22 DIV5 CH3 ART5-72535(c) Employees' Health Exam and Health Records B4820 (c) The facility shall maintain a health record of the administrator and for each employee which includes reports of all employment-related health examinations. Such records shall be kept for a minimum of three years following termination of employment. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure health records were maintained as required for the administrator and four of eight sampled employees [Registered Nurse (RN 2), Director of staff development (DSD), Minimum data set (MDS) nurse, and Nursing supervisor (RN 1)]. This facility failure has resulted in incomplete employee health records, which has the potential to place patients, visitors, and other staff at risk of exposure to communicable diseases. Findings: Record review of eight sampled employee personnel and health records on 12/7/2016 revealed four of eight sampled employees had incomplete health records: 1. Employee personnel and health record for Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE RN 2 was missing the health exam 90 days before or seven days after employment and the initial TB testing upon hire. 2. Employee personnel and health record for DSD was missing the 2014 and 2015 annual health exams, the initial TB testing, and the 2015 annual TB testing. 3. Employee personnel and health record for MDS nurse was missing the 2014 and 2015 annual health exams, the initial TB testing, and the 2015 annual TB testing. 4. Employee personnel and health record for RN 1 was missing the 2014 and 2015 annual health exams, the initial TB testing, and the 2014 and 2015 annual TB testing. During an interview on 12/7/16 at 1:35 p.m., director of staff development (DSD) confirmed that four of the eight sampled employee personnel/health records [Registered Nurse (RN 2), Director of staff development (DSD), Minimum data set (MDS) nurse, and Nursing supervisor (RN 1)] were missing the required health documents. Record review of the administrators' employee personnel and health record on 12/9/2016 revealed administrator's health examination was not completed 90 days before or seven days after employment. During an interview on 12/12/16 at 9 a.m., administrator confirmed he was unable to provide documented evidence of health examination completed 90 days before or seven days after employment. B5045 T22 DIV5 CH3 ART5-72547(a)(5)(C) Content of Health Records B5045 (a) A facility shall maintain for each patient a health record which shall include: Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (C) Name, dosage and time of administration of drugs, the routeof administration or site of injection, if other than oral. If the scheduled time is indicated on the record, the initial of the person administering the dose shall be recorded, provided that the drug is given within one hour of the scheduled time. If the scheduled time is not recorded, the person administering the dose shall record both initials and the time of administration. Medication and treatment records shall contain the name and professional title of staff signing by initials. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure the medication administration record (MAR) was kept consistent with good medical and professional practice when the entries in the MAR for six of six sampled patients (Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, and Patient 14) and one unstamped patient (Patient 16) were not authenticated with the signatures and professional titles of the staff signing by initials. This facility failure has the potential for incomplete and inaccurate medical records. Findings: Record review of December 2016 MAR for Patients' 2, 3, 4, 8, 9, 14, and 16 revealed signatures and professional titles of staff signing with initials were missing. During an interview on 12/12/16 at 5:20 p.m., the Director of Nursing (DON) confirmed signatures and professional title of staff who signed by initials on the medication Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE administration records for Patients' 2, 3, 4, 8, 9, 14, and 16 were missing. Facility policy and procedure Medication Documentation dated 06/2012 states, "The nurse signs on the bottom of the medication record with First Name's Initial, full Last Name and title legibly in." Licensing and Certification Division STATE FORM 6899 TJGE11 California Department of Public Health CA050000049 12/13/2016 GREENFIELD CARE CENTER OF FILLMORE, LLC 118 B St Fillmore, CA 93015 PREFIX TAG B5210 T22 DIV5 CH3 ART5-72551(c) External Disaster and Mass Casualty Program ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE B5210 (c) The plan shall be reviewed at least annually and revised as necessary to ensure that the plan is current. All personnel shall be instructed in the requirements of the plan. There shall be evidence in the personnel files, or the orientation checklist, indicating that all new employees have been oriented to the plan and procedures at the beginning of their employment. This Statute is not met as evidenced by: Based on record review and interview, the facility failed to ensure orientation on the facility's emergency plans and procedures were provided for two of eight sampled employees. This facility failure has the potential to place patients, family members and staff at risk for harm or injury in the event of an emergency or disaster. Findings: Record review of eight sampled employee personnel records on 12/8/2016 revealed two new registry staff (RN 2 and CNA 6) does not have documented evidence of orientation to the facility's emergency plans and procedures. During an interview on 12/12/2016 at 5:10 p.m., director of staff development (DSD) confirmed that RN 2 and CN 6 do not have documented evidence of orientation to the facility's emergency plans and procedures in their employee personnel records. Licensing and Certification Division STATE FORM 6899 TJGE11