Every finding on record at Centro Medico Wilma N Vazquez SNF

Based on observation, record review, staff interview, and facility documentation review, the facility failed to ensure food was stored, handled, and maintained under sanitary conditions by failing to maintain the dietary department walk-in freezer in operational condition. The deficient practice resulted in unsafe food storage temperatures and unsanitary environmental conditions within the dietary department, creating a likelihood that residents would be exposed to contaminated or temperature-abused food products. This failure placed residents at risk for serious adverse outcomes, including foodborne illness, infection, hospitalization, or death. The deficient practice constituted Immediate Jeopardy and had the potential to affect all residents receiving food services from the facility.Findings include: The facility failed to ensure food was stored, handled, and maintained under sanitary conditions by failing to maintain the dietary department walk-in freezer in operational condition. The deficient practice resulted in unsafe food storage conditions and unsanitary environmental conditions that created a reasonable expectation of serious adverse outcomes for residents.On May 20, 2026, at approximately 8:00 AM, surveyors observed that the dietary department walk-in freezer was not operational. During the investigation, surveyors identified food items being stored under conditions that did not ensure safe temperature control and observed unsanitary environmental conditions within the dietary department. The failure to maintain proper food storage temperatures and sanitary conditions placed residents at risk for foodborne illness, contamination of food products, and other serious health consequences.Surveyors conducted additional investigation and reviewed the circumstances surrounding the freezer failure, food storage practices, and potential resident impact. At approximately 11:30 AM, following survey team discussion and evaluation of the findings, it was determined that the deficient practice constituted Immediate Jeopardy.The facility's failure to ensure safe food storage and sanitary conditions in the dietary department created a situation in which residents were exposed, or were likely to be exposed, to contaminated or temperature-abused food products. The deficient practice had the potential to result in serious injury, harm, impairment, or death due to foodborne illness, infection, or other adverse health outcomes, particularly among the facility's elderly and medically vulnerable resident population.At approximately 12:30 PM on May 20, 2026, the facility Chief Executive Officer (CEO) was notified of the Immediate Jeopardy determination and provided the IJ template.At approximately 6:15 PM, the facility submitted an initial Plan of Correction (POC). Surveyors reviewed the submitted plan and determined that it did not contain the necessary corrective actions required to remove the Immediate Jeopardy and therefore was not accepted.At approximately 7:20 PM, the facility submitted a second Plan of Correction. Surveyors again reviewed the proposed corrective actions and determined that the plan remained insufficient to adequately address the Immediate Jeopardy condition and therefore was not accepted.At approximately 7:56 PM, the facility submitted a third Plan of Correction. Surveyors reviewed and evaluated the revised POC and determined that the facility's corrective actions adequately addressed the deficient practice and met the requirements necessary to remove the Immediate Jeopardy condition.Immediate Jeopardy was identified on May 20, 2026, at approximately 11:30 AM when surveyors determined that unsafe food storage and unsanitary conditions created a likelihood of serious harm to residents.The Immediate Jeopardy was removed on May 20, 2026, at approximately 7:56 PM after surveyors verified that the facility had implemented corrective measures sufficient to protect residents from the risk of unsafe food storage, food contamination, and foodborne illness.

Based on interviews and document review performed on 5/20/2026 from 8:30 AM through 8:00 PM, it was determined that the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 11 out of 11 residents. Findings include: The Facility policy and procedure, Section 6.1- Evaluación y seguimiento nutricional -Nutritional evaluation and follow up - February 2023 revision, was reviewed on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist during 24 hours after admission following nutritional risk criteria. 1. Resident #21 is a[AGE] years old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis, Right knee cleanser. On 05/20/2025 at 8:30 am. Resident stated that she did not eat breakfast this morning because she does not like the scrambled eggs, the bread, many cream, the milk. The surveyor asks if she was evaluated by the nutritionist and if she notified nurse personnel about her tastes and preferences, she states that was not evaluated by the nutritionist and that she notified the nurse personnel what she liked. During the record review no evidence was found that the nutritionist evaluates the resident nutritional needs since the admission until 05/20/2026. The Operational Director employee #3 stated on 5/20/2026 at 11:30 am that the nutritionist resigns 2 weeks ago on April 13/ 2026. On 05/07/2026 the physician ordered low salt diet, Lactose free milk, with dietary supplement Juven twice daily. The diet department card indicates the resident has a Low Sodium Diet with 87 milliequivalents (mEq) of Sodium, Lactose Free, no Jam, no turkey jam only lettuce but no dietitian or nutritionist evaluate nutritional need of the resident. On 5/20/2026 Initial Nutritionist evaluation recommended Low salt diet 1,500 kilo calories with 60 grams of protein and Juven twice daily. 2. Resident #35 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, during interview on 05/20/2026 at 9:50 am the resident state that food have good teste and temperature, but the menu was the same all days shredded chicken with rice and that the nutritionist has not evaluate her. The resident state that she eats it due to nobody gave her another alternative or preference. During the record review it was found that the nutritionist did not evaluate the resident nutritional needs until 05/20/2026. The resident has history of Lipidemia, Anemia post-surgery. The Operational Director employee #3 states on 5/20/2026 at 11:30 am the nutritionist resigns 2 weeks ago on April 13/ 2026. On 05/18/2026 the physician ordered No milk, No beet, corn green bean, high fiber irritant free. The diet department card indicates the resident has an Irritant free diet, but no dietitian or nutritionist evaluates nutritional need of the resident until 5/20/2026 at 21:18 that nutritionist performed the initial evaluation and recommended Regular diet, highs fiber 1,600 kilo calories and 1,600 milliliter per days. 3. Resident #36 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, during interview on 05/20/2026 at 9:50 am the resident state that food have good teste and temperature, but the menu was the same all days shredded chicken with rice and that the nutritionist evaluates her. The resident state I eat due to nobody gave me another alternative or preference, I told my daughter that when I get home, I do not want any more chicken. During the record review it was found that the nutritionist evaluates the resident nutritional needs on 5/14/2026. Residents have history of High Blood Pressure. The Operational Director employee #3 state on 5/20/2026 at 11:30 am the nutritionist resigns 2 weeks ago on April 13/ 2026. The diet department card indicates the resident has a Low Salt diet 87 milliequivalent (mEq)of Sodium, Lactose Free no red beef, no yellow cheese accordance with nutritionist recommendation. 4. Resident #26 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Left Knee Replacement. a. During the record review performed on 05/20/2026 at 4:00 PM, it was identified that nutritionist assessment was not performed. b. Facility policy and procedure Evaluación y seguimiento nutricional (Nutritional evaluation and follow up - February 2023 revision) was reviewed on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist at least 24 hours after admission. c. A second record review was performed on 5/21/2026 at 10:30 AM. Nutritional assessment was documented on 05/20/2026 at 7:11PM. 5. Resident # 28 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. a. During the record review performed on 05/20/2026 at 4:00 PM, it was identified that nutritionist assessment was performed on 5/16/26 at 9:33 AM. b. Facility policy and procedure Evaluación y seguimiento nutricional (Nutritional evaluation and follow up - February 2023 revision) was revised on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist at least 24 hours after admission. c. During interview performed with the Director of Operations (employee # 3) on 5/20/2026 at 11:30 AM, she states that: The clinical nutritionist submitted her resignation letter on 04/13/2026 with an effective date of 4/24/26. In the latest day, the resigning employee and the facility manager signed a professional services agreement and contract in which the clinical dietitian agreed to provide services as a clinical dietitian on Tuesdays, Thursdays, and Saturdays. During the dates of 4/24/26 through 5/12/26, clinical dietary services were provided only for emergencies. On May 12, 2026, a meeting was held by the Director of Operations with the clinical dietitian that resigned to clarify expectations of services to be provided, including the residents' nutritional assessments as per facility policy (at least 24 hours after admission). Even with the latest clarification of contractual agreement, nutritional assessment was not performed with mentioned residents as per facility policy. The facility failed to employ sufficient and competent staff to carry out the functions of the food and nutrition service. 6. Resident #29, a [AGE] year-old female admitted on [DATE] with diagnosis of right hip replacement, was reviewed on 05/21/2026 at 11:08 AM and revealed that the initial nutritional assessment was completed by the dietitian 05/16/2026, three days after admission. 7. Resident #30, a [AGE] year-old female admitted on [DATE] with diagnosis of left hip replacement, stated during an interview conducted 05/20/2026 at 11:25 AM that the dietitian had seen her but could not recall the specific date. Clinical record review conducted on 05/21/2026 at 10:20 AM revealed that the initial nutritional assessment was completed on 05/16/2026, three days after admission. 8. Resident #31, a [AGE] year-old female admitted on [DATE] with diagnosis of right knee replacement, stated during an interview conducted 05/20/2026 at 11:45 AM that the dietitian had seen her on either Monday or Tuesday of that week. Clinical record review conducted on 05/21/2026 at 11:23 AM revealed that the initial nutritional assessment was completed on 05/16/2026, three days after admission. 9. Resident #32, a [AGE] year-old male admitted on [DATE] with diagnosis of left knee replacement, stated during an interview conducted 05/20/2026 at 11:25 AM that the dietitian had seen him upon admission and later discussed food preferences with him by telephone. Clinical record review conducted on 05/21/2026 at 1:10 PM revealed that the initial nutritional assessment was completed on 05/14/2026, three days after admission. The facility failed to ensure that residents received a timely nutritional assessment in accordance with facility policy requiring completion within 24 hours of admission.

Based on observations and interviews performed on 05/20/2026 from 8:00 AM thru 4:00 PM, it was determined that the facility failed to employ a qualified dietitian to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service.Findings include:During interview performed with the Director of Operations (employee # 3) on 5/20/2026 at 11:00 AM the following was identified:The clinical nutritionist submitted resignation letter on 04/13/2026 with an effective date of 4/24/26. The resigning the clinical nutritionist signed a professional services agreement and contract in which the clinical dietitian agreed to provide services as a clinical dietitian on Tuesdays, Thursdays, and Saturdays.

Based on interviews and document review performed on 5/20/2026 at 3:30 PM, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents during operations and emergencies.Findings include:During entrance conference and interview with the Director of Operations (employee # 3), the facility assessment document was requested to be submitted within 4 hours after the entrance conference took place (05/20/2026 at 8:00 AM). The document was provided on 05/21/2026 at 3:30 PM.

Based on observation and interview, it was determined that the facility failed to implement and maintain an effective infection prevention and control program that develop and implement written policies and procedures for appropriate transmission-based precautions. These deficient practices had the potential to increase the risk of cross-contamination and transmission of infectious organisms among residents. Findings include: 1. Resident #21 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis Right knee cleanser, resident was evaluated by the infection control preventionist employee #2 on 05/07/2026 and resident refuse influenza and pneumococcus vaccine and indicate that has 3 Covid 19 vaccine. The residents had wound cultured on 05/05/2026 and the result on 05/07/2026 was negative. The resident was observed with Right subclavian Central Line. On 05/20/2026 at 1:10 pm, it was observed nurse personnel employee #4, performing Central line Care only with glove, Protective Personal Equipment (PPE) was not placed, and the resident did not have a face mask placed and resident was talking. Resident room entrance door was without any announcement of the Transmission Base Precaution (TBP) and no protective equipment place in the anteroom. During interview with the infection control preventionist employee #2, it he stated that do not have a policy and procedure for TBP, and there is no employee training related to TBP. 2. Resident #28 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Knee Replacement, the infection preventionist had not evaluated this residence still. 3. Resident #31 is a [AGE] year-old female admitted [DATE] with a diagnosis Right total knee replacement that was not evaluated by the infection control preventionist employee #2, due to the patient no available to perform the immunization Influenza and pneumococcus assessment. No evidence was found that the assessment was performed later.

Based on observations and interviews performed on 05/20/2026 from 8:00 AM thru 4:00 PM, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Findings include:During the survey of resident's rooms, the following electrical hazards were observed:In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection. The cord was pinched at the connection point, creating stress on the electrical wiring.In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection, and the cord was similarly pinched at the connection point.In room [ROOM NUMBER], Bed B, a modified power plug was observed with no strain relief at the cable-to-plug connection.In room [ROOM NUMBER], Bed A, a modified power plug was observed with no strain relief at the cable-to-plug connection.In room [ROOM NUMBER], Bed B, a modified power plug was observed with no strain relief at the cable-to-plug connection.

Based on observations, resident interviews, records reviewed (RR), and review of facility policy, it was determined that the facility failed to maintain resident rooms within acceptable temperature ( 69.8 grade ( ) Fahrenheit (F) and 75.2 F) and humidity parameters between 30 percent (%) and 60 % to provide a comfortable environment for 9 out of 11 residents interviewed (R.R #21, # 28, #29, #30, #31, #32, #34, #35 and #36).Findings include: During resident interviews and environmental observations conducted on 05/20/2026 between 9:00 AM to 12:00 PM, it was identified concerns related to the facility's ability to provide a comfortable environment. The following was observed: Review of the policy Temperature and Relative Humidity of Skilled Nursing Facility Rooms on 05/20/2026 at 3:10 PM, section 5.3.3 revealed that the environmental parameters established for resident rooms were temperatures between 69.8 degrees F and 75.2 degrees F and humidity between 30 % and 60 %. 1.R.R #29 is a [AGE] year-old female admitted on [DATE] with a diagnosis of right total knee replacement. During an interview and observation conducted on 05/20/2026 at 11:25 AM, the resident room temperature was noted at 68.6º F with humidity level of 84%. The resident stated that the room was cold and was observed covered up to the neck with two a blanket. 2. R.R #30 is a 69-year- old female admitted on [DATE] with a diagnosis of left total knee replacement. During an interview and observation conducted on 05/20/2026 at 11:08 AM, the resident room temperature was noted at 67.6º F with a humidity level of 84%. The resident stated that the feet felt cold. The resident was observed covered up to the neck with a blanket. 3. R.R #31 is a [AGE] year-old female admitted on [DATE] with a diagnosis of right total knee replacement. During an interview and observation conducted on 05/20/2026 at 10:41 AM, the resident room temperature was noted at 65.7º F with humidity level of 78%. The resident stated that the room temperature felt somewhat cold. The resident was observed wearing a jacket and covered with two blankets. 4. R.R #32 is a 65 -[AGE] year-old female admitted on [DATE] with a diagnosis of left total knee replacement. During an interview and observation conducted on 05/20/2026 at 10:54 AM, the resident stated that the room temperature felt comfortable. Observation revealed the room temperature was 66.7º F with a humidity level of 81%. 5. Resident #21 is a year-old female admitted to the facility on [DATE] with a diagnosis of Right Knee Septic Arthritis and S/P Right Knee cleanser. During the interview with the resident on 05/20/2026 at 8:45 am she states that she will stay here to complete 45 days of antibiotic, that room temperature was cold. The resident was observed with a jacket with hooded place on and a [NAME] blanket, at 9:47 am room temperature 65.6º F. At 1:04 pm the rooms temperature was 65.87ºF. On 05/21/2026 at 3:00 pm, the room temperature was 69.3ºF and resident state that yesterday the facility regulated the room temperature. 6. Resident #34 is a [AGE] year-old female admitted to the facility on 05/152026 with a diagnosis Left Knee Replacement, during observation of resident room, on 05/20/2026 at 9:48 AM, it was observed room temperature was at 67.3ºF. At 1:10 pm the room temperature was 65.7ºF and resident was observed sleeping with two [NAME] blanket and state that is very cold. 7. Resident #35 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, on 05/20/2026 at 9:50 am, during the initial tour rooms temperature was cold measure 68.7ºF. At 3:00 pm 63.4ºF and was observed with blanket. 8. Resident #36 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, on 05/20/2026 at 9:50 am during the initial tour rooms temperature was cold, measure 68.7ºF. At 3:00 pm 63.4ºF and was observed with 2 blankets. Facility failed to ensure comfortable room temperature and maintain a temperature range of 71 to 81 degrees F under the regulation, however the facilitys' policy establish temperatures of 69.8ºF to 75.2ºF . 9. Resident # 28 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During an interview and room observation conducted on 05/20/2026 at 1:49 PM, it was observed that the thermometer at the room entrance registered a temperature of 70º F and humidity in 90%. After touching the walls, they felt wet. The facility failed to maintain residents' rooms within acceptable temperature and humidity parameters to provide a comfortable environment.

Based on records reviewed (RR) and interview, it was determined that the facility failed to ensure that menu was adequacy, meet the nutritional needs of residents and be updated periodically for 3 out of 11 residents (R. R.# 21, #35 and #36.)Findings include: The Facility policy and procedure, Section 6.1- Evaluacion y seguimiento nutricional -Nutritional evaluation and follow up - February 2023 revision, was reviewed on 5/20/2026 at 7:02 PM. The policy states that the nutritional assessment must be performed by the clinical nutritionist during 24 hours after admission following nutritional risk criteria. 1. Resident #21 is a[AGE] years old female admitted to the facility on [DATE] with a diagnosis of Septic arthritis, Right knee cleanser. On 05/20/2025 at 8:30 am Resident stated that she did not eat breakfast this morning because she does not like the scrambled eggs, the bread, many cream, the milk. The surveyor asks if she was evaluated by the nutritionist and if she notified nurse personnel about her tastes and preferences, she states that was not evaluated by the nutritionist and that she notified the nurse personnel what she liked. During the record review no evidence was found that the nutritionist evaluates the resident nutritional needs since the admission until 05/20/2026. The Operational Director employee #3 state on 5/20/2026 at 11:30 am the nutritionist resigns 2 weeks ago on April 13/ 2026. On 05/07/2026 the physician ordered low salt diet, Lactose free milk, with dietary supplement Juven twice daily. The diet department card indicates the resident has a Low Sodium Diet with 87 milliequivalents (mEq) of Sodium, Lactose Free, no Jam, no turkey jam only lettuce but no dietitian or nutritionist evaluated nutritional need of the resident. On 5/20/2026 Initial Nutritionist evaluation recommended Low salt diet 1,500 kilo calories with 60 grams of protein and Juven twice daily. 2. Resident #35 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, during interview on 05/20/2026 at 9:50 am the resident state that food have good teste and temperature, but the menu was the same all days shredded chicken with rice and that the nutritionist does not evaluate her. The resident stated that she eats due to nobody gave her another alternative or preference. During the record review it was found that the nutritionist did not evaluate the resident nutritional needs until 05/20/2026. Residents have history of Lipidemia, Anemia post-surgery. The Operational Director employee #3 state on 5/20/2026 at 11:30 am the nutritionist resigns 2 weeks ago on April 13/ 2026. On 05/18/2026 the physician ordered No milk No beet, corn green bean, high fiber irritant free. The diet department card indicates the resident has an Irritant free diet, but no dietitian or nutritionist evaluates nutritional need of the resident until 5/20/2026 at 21:18 that nutritionist performed the initial evaluation and recommended Regular diet, highs fiber 1,600 kilo calories and 1,600 milliliter per days. 3. Resident #36 is [AGE] years old female admitted on [DATE] with a diagnosis of Right Total Knee Replacement, during interview on 05/20/2026 at 9:50 am the resident state that food have good teste and temperature, but the menu was the same all days shredded chicken with rice and that the nutritionist evaluates her. The resident state that she eats due to nobody gives me another alternative or preference, I told my daughter that when I get home, I do not want any more chicken. During the record review it was found that the nutritionist evaluates the resident nutritional needs on 5/14/2026. Residents have history of High Blood Pressure. The Operational Director employee #3 state on 5/20/2026 at 11:30 am the nutritionist resigns 2 weeks ago on April 13/ 2026. The diet department card indicates the resident has an Low Salt diet 87 milliequivalent (mEq)of sodium, Lactose Free no red beef no yellow cheese accordance with nutritionist recommendation.

Based on observation and staff interview, it was determined that the facility failed to ensure medications were stored and secured to prevent unauthorized access when a medication cart was left unattended and in locked in a resident care area.Findings include: On 05/21/2026 at 8:54 AM, during medication administration observations, a Registered Nurse (employee #7) was observed leaving the medication cart unattended in the hallway without securing or locking it while going to the medication storage room. The medication cart remained accessible to residents, visitors and other unauthorized individuals during the nurse's absence. This practice had the potential to allow unauthorized access to medications and failed to ensure the safe storage and security of drugs and biologicals in accordance with facility policy and accepted standard of practice.

Based on observation during the drug pass, it was determined that the facility failed to ensure establish and maintain an infection prevention to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections and hand hygiene procedures be followed by staff involved in direct resident contact for 6 out of 6 observations Findings include: 1. During the drug pass performed on 12/05/2024 from 08:25 AM till 8:39 AM, it was observed that the registered nurse Registered Nurse (RN) #2 initiate with the drug pass without washing her hand and disinfecting the medication cart. 2. During the medication preparation for resident #106 the nurse put her glove without washing her hand, the resident request to RN #2 to provide a jar of gum in the floor, the RN procced to take the gum jar of the floor placed it over the dinner table, and do not remove her glove and continue administrating the resident medication without removing her gloves and washing her hand. 3. When finish with the RN #2 discard the trash, remove her glove and without washing her hand put on another glove and continue to serve medication of the other residents. 4. The RN #2 failed to wash her hand on 5 out of 5 opportunities to wash her hands. 51629 5. During the medication pass performed on 12/05/2024 from 8:40 AM through 9:30 AM, the following was identified: a. Register nurse (employee # 2) did not perform handwashing in 19 opportunities while administering medications to five patients under her care. 6. During review of the crash cart on 12/05/2024 at 9:30 AM, with the register nurse (employee # 2), the following was identified: a. Three Vacuproo safety blood collections had expiration date of June 2024. b. One blood gas [NAME] had expiration date of May 2023.

Based on initial tour observation, resident interview, observations done during the assembly of the food trays, staff interviews and policies reviewed (Line assembly and delivery of meals or special foods), it was determined that the facility failed to ensure that food and drink is palatable, attractive, and at a safe and appetizing temperature. This deficient practice was identified in 1 out of 8 residents receiving services (sample resident #106). Findings include: 1. Resident #106 is an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Hip Fracture, on 12/04/2024 at 8:30 AM during resident interview he state that the food came on disposable Styrofoam every time and that when he eats was cold. 2. During the test trays performed on 12/04/2024 at 11:46 AM was observed that all the food came in a Styrofoam tray inside came a match sweat potatoes with chicken thigh that was an open tray, over them came a plastic glass with carrot, a plastic bowl with Stew with rice, plastic cup of milk, and plastic cup of apple sauce. During the temperature test the following was found: a. Mach sweat potatoes: 140 grade( ) Fahrenheit (F) b. Chicken Thigh: 109 F c. Carrots: 80 F d. Stew with rice: 137.7 F e. Apple sauce: 65.4 F d. Milk: 63.5 F. 51629 3. During the assembly of the food trays carried out on December 4, 2024, at 11:20 AM, the food had the following temperatures: vegetable mash (146 Degrees ( ) Fahrenheit (F)), meat (162 F), soup (168 F), milk (52 F). 4. Tray was performed on December 4, 2024, at 11:40 AM, the food had the following temperatures: vegetable mash (130 F), meat (109 F), soup (137.7 F), milk (63.5 F), fruit dessert (65.4 F). 5. Except for soup, hot foods were not covered. All components/food (hot and cold ones) were placed on a Styrofoam disposable tray. Clinical Nutritionist (employee #1) stated in the interview on 12/04/2024 at 11:20 AM that the temperature parameters for food are 140 F for hot foods and 40 F for cold foods.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 from 8:00 AM through 3:30 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1. During the visual inspection of the kitchen area it was observed that the High Temperature Sanitizing Door-type Dishwasher was inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated Sanitizing Dishwasher has been broken since September 2024. 2. During the visual inspection of the kitchen area it was observed that the Dish washing detergent and Arrex dispenser were inoperable at the time of the survey. This was confirmed by the Nutritional Services Manager (employee #1) who stated that the automatic dispenser has been broken since October 2024. 3. Food remains were observed on the floor below the food line.

Based on observations of the physical environment, on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located. Findings include: 1. Commodes on bathrooms of rooms [ROOM NUMBERS] were observed with rust in component parts. 2. 3 out of 3 four contact points walkers were observed with rust in the base. 3. 1 out of 4 crutches was observed with medical tape on the grab cushion.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the residents right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 8 out of 8 residents receiving services at areas where the deficient environment and items (equipment) is located. Findings include: 1. Residents on rooms [ROOM NUMBERS] complained about room temperatures being too cold, when the surveyor took temperature measurement it was noted that room temperatures exceeded the temperature stated in the facility's temperature policy Temperatura y Humedad relativa de las Habitaciones [NAME] Skilled Nursing Facility Temperature and Relative Humidity of the rooms of the Skilled Nursing Facility, which states that room temperature should be between 71- and 80-degrees ( ) Fahrenheit (F). a. 101 - 66 F b. 104 - 64 F 2. Grab bars in the bathroom on rooms 111, 113 and 117 were observed loose. 3. Headlights cord behind beds were observed tied with ribbons or no cord (rooms 111, 121).

Based on review of policies, procedures and facility staff interview performed on 12/06/24 to from 8:00 AM through 4:30 PM, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Findings include: Review on 12/06/2024 at 10:00 AM of facility's policy and procedure Almacenaje, Limpieza y Mantenimiento de Neveras Departamentales, Storage, Cleaning and Maintenance of Departmental Refrigerators stated that all food in the refrigerator must be identified with the resident's initials, room number and date. Approximately at 9:30 AM some snacks (birthday cake and snacks) were observed with no date or labeled in the residents' refrigerator.

Based on observations made during the initial pool process, records reviwed (RR) and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that there is documentation of resident capacity and plan of care to have medications at bedside self-administer these medications. This deficient practice was identified in 1 out of 8 residents receiving services (RR#3). Findings include: The facility's Policy & Procedures, WNV-FARM-028 Self Administration of Medications last updated March 2023 is reviewed with pharmacist on 12/06/2024 at 9:00 AM. 51637 1.RR # 3 is an [AGE] year-old female resident with Dx of Pneumonia, Muscle Decondition, S/P hip arthroplasty, depression and anxiety disorder, was admitted on [DATE], due to status post left hip fracture, resident is chronically bedridden. The resident was visited on 12/04/2024 at 8:53 AM and observed several albuterol pumps (Brand name Proventil - is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) on the side of the bed. The resident says that she needs to see them when she wakes up because if she does not see them, she has a panic attack. Several interviews and investigations were conducted and show the following: a. There was a total of 6 albuterol pumps (Proventil), 4 empty and 2 in use, all with expiration dates between March and May 2026. b. On 12/04/2024 at 9:35 AM during interview with the MDS coordinator (employee #7) to request self-administration policy and patient entitlement. Employee #7 provides a policy used in the hospital indicating that patients should not self-administer medications during their stay, except for some cases. The Interdisciplinary group care plan to address resident conditions and needs to self-administer this respiratory treatment was requested by the surveyor but was not available. 2. On 12/04/2026 at 9:50 AM clinical record is reviewed, and residents have order for Albuterol inhale (Proventil) 2 pumps every 4 hours PRN. There is no medical order to have the medication at the bedside or self-administration. 3. On 12/05/2024 at 10:30 AM Medical director (employee #15) is interviewed regarding what was identified on this resident medical record. The medical director (employee #15) stated that they have tried several times to remove the pumps from bedside and try another treatment, but the resident refused. She explains that they opted to leave the pump next to the bed so she can see them. She also says that the resident does everything with the help of the nursing staff except for the self-administration of the medication albuterol (Proventil). 4. On 12/06/2024 at 9:10 AM an interview was conducted with the facility pharmacist (employee #14). This to evaluate why the medication regimen review did not include the Albuterol pump (Proventil) as a medication that resident had at bedside, to self-administer it. The facility pharmacist (employee #14) stated on 12/06/2024 at 9:30 AM that the resident had ordered to use Albuterol in pump as part of her drug regimen, but no to have the medication at bedside to self-administer. She stated that the facility plans to hold a meeting with the interdisciplinary group to discuss resident cases and determine if is appropriate and safe that this resident self-administer this medication.

Based on observations made during the initial pool process and facility staff interview performed on 12/04/2024 through 12/06/2024 to from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the right of each resident to have personal privacy. This deficient practice had the potential to affect 8 out of 8 residents receiving services. Findings include: 1. During the initial pool process on 12/04/2024 at 8:55 AM it was observed that the resident located in room [ROOM NUMBER]-B (resident #58) participating in Occupational Therapy treatment. 2. The resident was observed sitting on the edge of the bed. 3. The resident was observed with only clothing from the waist down than the disposable diaper. 4. The curtain was drawn, however personnel failed to provide visual personal privacy before beginning the treatment. The Nursing supervisor (employee #6) was asked by the surveyor on 12/04/2024 at 9:00 AM if residents had available pajama pants. The Nursing supervisor stated in an interview on 12/04/2024 that the resident had pajama pants available and that rehabilitation personnel must ensure the resident is dressed before beginning treatment. The Director of Nursing DON (employee #10) was asked by the surveyor on 12/04/2024 at 10:55 AM in relation to facility policy and procedure to promote personal privacy to residents. 5.The DON stated that the facility does not have a personal privacy policy.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services for 24 out of 24 residents admitted . Findings include: After review of the personnel roster with Kitchen Supervisor ( employee #17), it was determined that facility does not have an Administrative Dietitian or to that effect a Kitchen Manager.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/08/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to provide each resident with a nourishing, palatable,special dietary needs. Findings include: During observation of the food service it was noted that food was served in Styro foam containers, these containers do not assure that food will get to residents in correct temperatures.

Based interview with the Director of nursing on 04/07/2024 through 04/09/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence of resident's categorization of dependence needs to be used to determine numbers each type of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 21 out of 21 residents. Findings include: 1.Director of Nursing (DON) (employee #2) was interviewed on 04/07/2024 at 8:00 AM and was asked for the categorization of residents admitted to the facility. DON stated that they did not have it available. DON explained that the person in charge of patient categorization is the facility supervisor, and this person has been suspended from duty since 04/05/2024. DON is trying to perform resident categorization; however, she was unsure whether to categorize residents daily or weekly and also does not know the exact procedure performed by nursing supervisor to perform the categorization. On 04/07/2024 at 10:00 AM during the interview with the DON referred when there is no staff in the same area, they look for resources in other hospital departments to cover the needs of the residents. The DON knows they are not complying with Payroll Based Journal, but the priority is to meet the needs of the residents. During survey procedures on 04/07/24 through 04/09/24 facility DON was unable to provide the categorization of residents admitted to the facility.

Based on a recertification survey, observations, review of staffing pattern, documents and interviews from 05/16/2022 through 05/19/2022 from 8:00 AM through 3:30 PM, it was determined that facility failed to ensure to have sufficient and competent nursing staff personnel to provide nursing and related services to residents. This deficient practice has the potential to affect 17 out of 17 admitted residents. Findings include: During the investigation process it was identified that the facility has a total of 5 License Practical Nurses-(LPN's) and 11 Registered Nurses- (RNs) for the seven days a week and the 3 shifts. All RN and LPN are working [NAME] shift. The facility staff are not in accordance with the Resident Census evidence by the Resident #111 is a male admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3 days ago, during the night shift I spent the night calling because I need help to change my diapers, and no one came. I do not recommend this place to anyone. The date of the incident the facility had 1 LPN and 2 RNs with 26 residents in the night shift.

Based on recertification survey, interviews, and initial tour from 05/16/2022 to 05/19/2022 from 8:00 AM to 3:30 PM, it was identified that the facility does not ensure that the resident receives the necessary services to maintain good personal hygiene. This deficient practice affects 1 out of every 17 residents (R) at the center. (R #111) Findings include: Resident #111 is a male admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/16/22 at 11:17 AM Resident #111 refer I have trouble changing my disposable diaper. 3 days ago, during the night shift I spent the night calling because I need help to change my diapers and no one came. I do not recommend this place to anyone. On 05/18/22 at 10:53 AM during the interview with resident # 111 he stated, I no longer have the problem, I call, and they responded quickly.

Based on review of policies and procedures, review of medical records with the director of nursing (employee #5 ) and the quality assurance officer (employee #2 ) , it was determined that the facility failed to provide supervision and implement interventions to reduce the risk of falls for 1out of 10 residents (R) in the sample (R #1 ) Findings include: 1. A mechanism to ensure that facility perform assessment and implement interventions for residents who had a recent history of falls and/or who are at risk of falls was not performed accordingly with these findings identified during survey procedures on 6/16/15 through 6/18/15: a. Resident #1 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 6/16/15 from 8:48 am till 10:00 am the resident refer that several days on 6/12/15 during 7-3 shift she got up from bed to use the bathroom and she lost her balance when using her walker and fell to the floor. The record was reviewed on 6/16/15 at 1:00 pm and provided evidence that the resident was found on the floor at 12:30 am was send immediately to emergency room when X rays were taken of the left elbow, left hip and left knee, resident was also evaluated by a physician. After the fall incident plan of care was not review in order to establish preventive measures to avoid that resident felt down to the floor again. The record review provided evidence that the fall protocol was activated for this resident when admitted to the facility and the resident was instructed to call for assistance when needing to use the bathroom and staff were to perform frequent round. However a complete assessment who include risk factors, to develop a fall incident, behavior, equipment and devices, environment medication side effects and medical status were not performed, not evidence on the medical record. During interview on 6/17/15 at 11:34 am quality assurance officer (employee #2) stated that facility policies and procedures for fall prevention and protocols establish that to every resident admitted to the facility risk assessment must be performed in order to identify fall risk factors that resident could have in order to prepare a plan of care for fall prevention. That if a resident felt down while receiving care at the facility interdisciplinary group must re-assess fall risk factors that resident could be developed after admission in order to identify causes and circumstances related with the fall incident and took measures to prevent felt down incident reoccurrence.

Based on observation during the extended survey and interview it was determined that the facility fail to prevent residents from harm which constitute an Immediate Jeopardy to all residents 19 out of 19 admitted at the SNF, staff and visitors. Finding Includes: During the extended survey on 9/10/14 at 8:15 am surveyors observed the cafeteria was closed. The surveyors were informed by the kitchen personnel that the kitchen was closed due to a Propane gas leak at the cafeteria. It was identified that the facility ' s maintenance personnel was trying to fix the gas leak. The facility did not call the gas company to fix and certified the function of the gas line. The kitchen manager informed that they planned to open the gas lines again when the facility maintenance personnel finish the work. The facility knows since 2012 that the gas line system located at the kitchen and cafeteria has to be change. The facility failed to promote a safety environment related to a potential gas explosion and poisoning which constitute and Immediate Jeopardy. The State Agency coordinator was inform of the situation 11:45 am and at 12:10 md the facility Director employee # 21 was informed of the IJ and the statement of deficiency for the IJ was given. During the investigation the following was found: At 8:40 am the administrative dietitian (employee # 11) confirms that there is a gas escape at the cafeteria floor. The gas wrench is closed. At 8:50 am two employees from the physical environment maintenance repairing the pipes that has a hole. They were to cover the hole with 5 minutes quick fix Epoxy putty 700psi At 9:00 am the menu cycle is requested to the administrative dietitian (employee #11) , which was change due to the situation. The administrative dietitian (employee #11) stated on interview that all lunch is ready. That she was called at 7:40 am to inform her of the leak. The surveyor informs the administrative dietitian (employee # 11) and the physical plant manager (employee #7) that they wanted to be present when the gas company " Empresas " arrive to evaluate and certify the job and approve to open the wrench. They stated that the owner of the company will come. At 9:10 am an alternate plan for this situation is requested to the physical plant manager (employee # 7). He stated he did not have one, " I will sit to prepare one. I am conscious that what is happening if dangerous what is going on " . At 9:15 am it was observed that the food, breakfast was ready in the refrigerator. Two employees were interviewed from the kitchen and they stated the " malangas " were ready on top of the stove. The rice is being cook at the steamer. The pumpkin will be cook in the steamer too. Atum is ready in the refrigerator without been identified just cover with plastic. At 9:20am the kitchen supervisor (employee # 22) states that if the employee from Empresas Gas delays they will buy an electric stove to maintain the food hot. At 9:30 am the employee from "Empresas Gas" (employee #18) stated they can not certify their work done by the physical plan employees. He stated that he called the company and they need a separate line to be able to certify. He indicated he will write the list of materials necessary for the provisional line. At 9:45 am the administrative dietitian (employee # 11) stated they will install a new electrical line 220 voltage that comes from the electrical panel located in front of the kitchen door. This line will go up to the fryer because it belongs to the cafeteria and there is no priority for this. " They are going to purchase an electric stove. The job will be done by one of the physical plan employees of the hospital that is an Experience Electrician and is going to certify the job and the stove." At 10:00am a contingency plan is requested to the security officer (employee # 14) of the gas escape, she stated she will provide all three in one report. At 10:45 am the physical plant supervisor (employee # 7) stated that the air-condition system is all connected to the hospital. At 1:45 pm the employee from (employee #18) "Empresas Gas" company is interview and he stated they will throw a [MEDICATION NAME] line on the roof and will connect it on the main valve. "I want to inform you that all this is temporary." At 2:05 pm (the employee # 15) from the cafeteria is interview, a [AGE] year old female that is admitted to the emergency room at 8:15 am and is evaluated by the physician who [DIAGNOSES REDACTED]. The employees record was evaluated from 2:25 pm to 2:45 pm and revealed the following: the triage done to the employee at 8:17 am states that the chief complaint of the patient is: headache, nausea, dizziness, nasal congestion and heaviness. Vital signs BP: 137/80, P 88, R: 18. The treatment order by the physician is [MEDICATION NAME] 125 mgs IV/100 at 12:10 pm, [MEDICATION NAME] 1 gr IV/100 at 12:40 pm and [MEDICATION NAME] 0.2mg/3cc q 20 minutes per 3. The employee is interview from 2:05 till 2:20 pm and she states " since Monday I have being feeling nausea, irritation of the eyes, headache, dizziness and confusion. I start to work at 6: 30 am at the cafeteria and the gas odor was very strong. I immediately inform the supervisor and she told me not to say anything because she does not smell anything. I return to the cafeteria and people stated they smell gas. I started to get confuse and dizzy. Immediately I informed to the supervisor employee #22 and told me that do not say anything because she does not smell gas in here. She said if I kept saying things about the gas smell she would make me a report. After that she came at the cafeteria area and opens the two doors. Everyone that was there said it smell like gas. She came with a bottle of water and soap threw it on the line to see where the escape was. Since Monday employees and doctor were saying there was an odor like fulminant. At 3:15 pm the surveyor visits the kitchen to verify the plan of correction POC. The (employee # 18) from " Empresas " Gas stated that he requested the certification from the company for the use of the gas lines connected. The personnel present at the inspection of the installation of the lines were, employee #11, employee # 7, employee #14, employee #18 and employee #1 and #2 from Empresas gas. Safety Officer (employee # 14) stated that in 30 days the new and permanent lines will be installed. At 4:20 pm the POC was given to the surveyors which evaluated it and accepted it. The IJ is abated however monitoring will take place also by local authorities and surveyors until fully install. The facility ' s POC states as follow: Situation Identified: 7:28 am a gas odor was detected in the cafeteria area by the cafeteria personnel. a. Approximately at 7:30 am Engineer dept. personnel closed main line Propane gas System located in the kitchen department. Department/Person responsible: Maintenance Department, Engineer Personnel, Nutritional Services. b. All personnel and visitors were evacuated from the area. Department/Person responsible: Nutritional Services personnel, Safety Officer c. Cafeteria area was closed to personnel visitors and general public. Department/Person responsible: Safety Officer d. Approximately. 7:35 am Maintenance personnel started assessing and evaluating the area where the gas leak was suspected. An assessment of the gas line in the cafeteria dept. was done by the maintenance personnel. No other areas with this problem at this moment. Department/Person responsible: Engineering personnel and maintenance e. Approximately 8:30 am "Empresas " de Gas " Company was notified of situation by the supervisor. Department/Person responsible: " Empresas de Gas " Company f. At 9:30 am " Empresas " de Gas " Company assessed and evaluated the situation; their recommendations was to install a provisional gas line above ground to supply the equipment in cafeteria area and dietary department. Comments: An alternate Plan of Correction was develop by the Dietary and Engineer Department. This one installing two electric stoves in the Dietary department. Purchase Order for acquiring these electrical stoves was given by the Administration department. (9-10-14) 240 volts electrical outlet was installed by a licensed electrician (see certification included) (9-10-14). Expected Date of Completion: 9-10-14 g. At 2:30 pm " Empresas " de Gas started working with the above ground provisional gas line mention. (see certification included) h. In 30 days the permanent above ground gas line will be installed, and the temporary above ground gas line will be removed. Expected Date of Completion: 10-10-14 A contingency dietary plan was developed by the Nutritional Director for all patients including Acute Care and SNF residents. This was developed regarding special nutritional needs and regular diets for 3 days plan. Expected Date of Completion: Daily for 30 days An ongoing monitoring will be performed by the maintenance department, overseeing with the safety officer and License Nutritional Director on a daily basis for the next 30 days and weekly once the permanent lines are installed. Expected Date of Completion: Weakly starting permanent lines installed Department/Person responsible: License Nutritional Director (LND) Comments: See contingency plan included Expected Date of Completion: 9-10-14 The POC was signed by employee # 7 Manager Maintenance and Engineer, employee # 14 Safety officer and employee # 11 LND.

Based on observations from 8/18/14 thru 8/19/14, interviews to nursing staff and record review (RR), it was determined that the facility failed to establish preventive measures to avoid the development of pressure ulcer for 1 out of 8 residents in the sample selection (R# 3) . Findings include: 1. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the SNF for rehabilitation of her left leg. She is bedridden since February 2014. Most of the time the resident is in bed and moves in a wheelchair for the physical therapies. 2.During RR performed on 8/19/14 from 8:30 a.m. thru 3:00 p.m. it was found that on the Nursing Initial Assessment that the Registered Nurse (RN) in charge of performing the admission of the resident on 8/11/14 at 11:30 a.m., identified on the section called as "Sistema Intergumentario" (Integumentary System) that the resident has normal skin. On this nursing assessment, the RN did not identify on section called as "Educacion a ofrecer" (Orientation to Offer) education related to pressure sores prevention. An ulcer protocol was found in the record. The criteria that were indicated are: Wash hands before and after each procedure, Use of gloves and / or protective equipment, Keep resident dry and clean, Place mattress geomatts 3. On 8/19/14 at 11:00 am when the resident ' s was visited, the daughter tells the surveyor that at 8:00 am she reported to the nurse that her mother is developing an ulcer in the area of the sacrum. The surveyor asks her how she found this. She stated that her mother told her that it hurt quite in the back. When she checked the resident sacrum area it was red. 4. On 8/19/14 at 11:05 am the Registered Nurses (RN) (employee # 23) in charge the resident was ask by the surveyor about what is happening with resident #3. She stated that her daughter told her that her mother has an ulcer in her back. The surveyor asked if she went to make an access to the resident skin and she indicated that she sent the LPN and she said that the sacrum area was red but the skin is not opened. The RN called the physician and she ordered Zinc oxide ointment daily in the affect area. 5. On 8/19/14 at 11:20 am the surveyor requested for a RN to look at the affected area of the resident. The RN indicated that she was waiting for the prescribe medication to apply it. At 11:30 am it was observed that the License Practical Nurse (LPN) employee # 20, did not wash her hands prior to using a pair of non-sterile gloves to assist the resident and change the diaper. Redness in the buttock and intergluteal was observed. After removing the dirty diaper and dispose in the biohazard waste disposal, with the same gloves, the LPN applied Zinc oxide ointment in the sacral area in which the pressure sore is developing. (Cross reference Tag: F-281) 6. On 8/19/14 at 1:30 pm in the record was found the RN " Evaluacion y Re-evaluacion de las ulceras dermales " (dermal ulcer evaluation and re-evaluation). The pressure sore was identified stage 1 located at intergluteal and buttocks. The sore measure is 4 cm length and 6 cm width no depth and [MEDICAL CONDITION] phase. The sheet only has the date 8/19/14, no evidence or signature of who performed the resident evaluation. 7. During interview with the Quality administer officer (employee #3) and Nurse supervisor (employee #1) on 8/19/14 at 2:00 pm the surveyor asked if they were conscious about the skin condition of resident #3. They indicate that they did not know anything about it. The surveyor explained to them the situation and (employee #1) and (employee 3) informed that they are going to work with the situation. 8. The facility failed to ensure an accurate initial assessment to implement a protocol for risk of pressure ulcer development.

Based on observations, records reviewed (RR) and interviews with the nursing staff responsible for resident care and a family member, it was determined that the facility failed to provide necessary care, monitor, document and implement pain and pressure sore protocols to ensure that resident's reach their highest practicable well-being for 1 out of 8 residents (R) in the sample selection (R #3). Findings include: 1. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the SNF for rehabilitation of her left leg. She is bedridden since February 2014. Most of the time the resident is in bed and moves in a wheelchair for the physical therapies. 2. During RR performed from 8/19 and 8/22/14 from 8:30 a.m. thru 3:00 p.m. it was found that an initial comprehensive assessment for pain management was performed on 8/11/14 at 10:30 am and revealed that the resident at that moment did not have pain. The evaluation performed indicated that the resident pain is acute and intermittent related to a surgery. Reviewing the physician progress notes [REDACTED]. The resident on February 2014 suffered a fracture in her left tibia and it was corrected with a cast. The lack of performing a pain comprehensive assessment based in the resident condition cannot allow developing an objective plan of care showing the real needs that the resident has. 3. During the RR performed on 8/19 and 8/22/14 from 8:30 a.m. thru 3:00 p.m. it was found that the resident was admitted with no pain. The nursing progress notes do not show accurate pain assessment and alternate interventions to keep resident in comfort zone. According to interviews with the resident, she was feeling pain in her right leg since 8/12/14 and sacral area since 8/17/14 thru 8/19/14. 4. The physician ordered medications on 8/11/14 [MEDICATION NAME] 800 mg by mouth twice a day. On 8/12/14 at 11:00 a.m. the physician [MEDICATION NAME] by mouth before bed time per 7 days. On 8/12/14 at 9:00 am the physician discontinued [MEDICATION NAME] order [MEDICATION NAME] 30 mg by mouth before bed time per 7 days. On 8/13/14 at 5:30 pm the physician ordered [MEDICATION NAME] 75 mg intramuscular every 6 hours as needed for pain per 48 hours and [MEDICATION NAME] 5/325 mg two tablets by mouth every 4 hours per 48 hours. On 8/15/14 at 6:00 pm physician ordered to discontinued the [MEDICATION NAME] and no narcotics. During interview of the resident and family indicated that they spoke with the nurses because the resident could not sleep. The resident stated that she could not sleep because of the pain in the right leg. The daughter indicates that the 8/14/14 at night the resident got disoriented and wanted to remove her clothes. The nurse told us that the doctor gave the order to remove all narcotic for pain because it is not good for her mentally. On 8/18/14 the physician ordered to discontinue the Tylenol and ordered [MEDICATION NAME] two tabs by mouth immediately and then every four hours per 48 hours for the pain. During interview with the physician (employee # 2) on 8/18/14 at 1:00 pm stated that the resident has problems with narcotics and because of this, she was being administered Tylenol for pain. The surveyor asked the doctor if she assess her right leg. The physician stated that the resident came to SNF to rehabilitate her left leg which was where she suffered the tibia fracture. It was observed an involuntary movements and shrinking of the right leg from the resident on 8/19 until 8/22/14. Progress notes of the physician and physiatrist did not indicate anything about this situation. The physician on 8/18/14 at 1:00 pm, in presence of the surveyor, asks the resident what medication her primary physician gave her for pain relieved. The resident indicated [MEDICATION NAME]. The doctor indicates that [MEDICATION NAME] is a narcotic and therefore it will order for 48 hours. 5. On 8/19/14 at 11:00 am the resident ' s daughter tells the surveyor that at 8:00 am she reported to the nurse that her mother is developing an ulcer in the area of the sacrum. The surveyor asks her how she found this. She stated that her mother told her that it hurt quite in the back. When she checked the resident sacrum area it was red. 6. During the RR it revealed there were no nurses notes indicating a pain assess of the resident in the right leg and sacral area 8/16 thru 8/17/14. (Cross Reference Tag F-314) 7. The facility failed to perform the interventions for pain management.