Kingsburg Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the food service manager met state requirements when the Dietary Account Manager (DAM) hired for this role did not meet the qualifications required for food service managers. This failure had the potential to place residents at risk for compromised food safety and inadequate oversight of dietary operations for the 75 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program were incomplete for February 2026, March 2026, April 2026, and May 2026. These failures had the potential to place residents at risk for an adverse effect (bad reaction or unwanted result) of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) were completed and documentation was maintained demonstrating delivery of the notices to the resident and/or responsible party (RP) for one of three sampled residents (Resident 90). This failure had the potential to prevent Resident 90 and or RP from being fully informed of Medicare coverage termination, potential financial liability, and appeal rights.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the required bed hold notice at the time of transfer to the hospital for two of six sampled residents (Resident 1 and Resident 13), when:1. Resident 1 was transferred to the hospital on 3/8/26 due to low oxygen levels and was not given the required facility document titled, Bed Hold Notice of Policy & Authorization (BHNPA).2. Resident 13 was transferred to the hospital on 5/25/26 due to shortness of breath (SOB-the feeling that you cannot get enough air into your lungs) and was not given the required facility document BHNPA. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of six sampled residents (Resident 2 and Resident 84) when:1. Resident 2's surgical incision was not coded in the quarterly MDS assessment dated [DATE].2. Resident 84's use of oxygen was not coded in the annual MDS assessment dated [DATE]. These failures had the potential for Resident 1 and Resident 84's needs to not be met and changes in status not monitored which could lead to wound and respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Residents 27 and 84), when:1. Resident 27's physician order for daily dressing changes to the left breast wound were not followed. This failure had the potential to increase the risk of infection and result in inaccurate medical record documentation. 2. Resident 84's physician order for oxygen was not followed, and there was no documentation and monitoring of oxygen saturation (measures the percentage of oxygen in the blood). This failure placed Resident 84 at risk for receiving too much oxygen or too little oxygen without adequate monitoring which could cause damage to the lungs, brain, and eyes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information was consistently posted in a prominent location that was readily visible and accessible to residents, and visitors, in accordance with regulatory requirements. The facility census was eighty residents. This failure had the potential to prevent residents, visitors and family members from readily accessing required staffing information necessary to make informed decisions regarding resident care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (medicines or products made from living organisms) was labeled in accordance with current professional standards of practice and facility procedures for one of four sampled residents (Resident 84), when Resident 84's morphine sulfate (strong opioid pain medication) medication label directions did not match the medication order in the electronic medical administration record (EMAR-digital version of a patient's medication chart). This failure placed Resident 84 at risk of receiving too much or too little pain medication which could lead to more serious health conditions such as not experiencing pain relief or slow or shallow breathing or even unconsciousness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when:1. One of three dietary staff (Dietary Aid [DA]) did not have facial hair (mustache) properly restrained.2. A [Brand name] (a commercial-grade food processor machine) lid had left over residue of food and was stored on a standing rack that contained dry, clean, and ready-to-use equipment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when pipes on top of two of two washers in the laundry room were observed covered with thick white and green build up. This failure had the potential to affect the efficiency of the washers to clean the personal clothing of 80 residents and linens used in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that care and services were provided in accordance with the manufacturer's instructions for use for an air loss mattress (specialized medical mattress with internal air tubes and tiny holes that continuously circulate air to keep skin dry, cool, and reduce pressure, preventing bedsores (pressure ulcers) by shifting pressure points) and facility staff were trained and competent to use their air loss mattresses safely for one of two sampled residents (Resident (RES)) 2, when RES 2 who had a history of a recent fall (12/9/25) while on an air loss mattress at the facility. RES 2 weighed 124.4 pounds (lbs. -unit of weight measurement) and weight settings on the air loss mattress indicated weight was set at 245 -285 lbs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) received treatment and care in accordance with professional standards of practice when nurses assessed both of Resident 1's legs as discolored and one leg as swollen on [DATE], contacted the physician for orders and did not follow physician's orders to obtain a vascular consult ordered on [DATE]. A Change in Condition (CIC- documentation completed when nurse's identify a change from a resident's baseline condition) was not completed on [DATE] due to the changes in Resident 1's legs. The nurse assessed Resident 1's left leg as more swollen than the right leg on [DATE] and failed to complete a CIC. A weekly head-to-toe assessment was done on [DATE] and should have been repeated on [DATE] and was not. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) assessment done quarterly (every three months) as per their written policy and procedure, and failed to initiate elopement risk interventions for Resident 1 when she was assessed to have a significant increase in her elopement risk factors. These failures had the potential to result in Resident 1's elopement from the facility when she was found outside the facility briefly in a confused state early in the winter morning, potentially causing significant risks to Resident 1's health and safety, placing Resident 1 at risk of cold exposure, fear, dehydration and/or other medical complications, or being struck by a motor vehicle.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the results of the most recent survey document titled Statement Survey Binder in a place readily accessible for 83 of 83 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established State standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full-time; and 2. Ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the Food and Nutrition Services department. [...]

Inspectors wroteBased on observations, interview and review of facility documents, the facility failed to ensure the menu was followed: 1. For the lunch meal on October 8, 2024, when steamed spinach was served instead of creamed spinach for 79 of 81 residents eating spinach at the facility. 2. For the lunch meal on October 8, 2024, when an incorrect scoop size was used for the mechanical (diced) ham given to 24 residents (Resident 34, 185, 1, 16, 33, 51, 42, 22, 24, 43, 46, 26, 60, 2, 29, 186, 27, 40, 21, 30, 76, 184, 18, 35) on the dysphagia advanced (Dys Adv per the National Dysphagia Diet as Level 3-food should be: soft solid, easy-to-cut-meats, fruits and vegetables, requires some chewing ability, meats in soft, bite-size pieces) and the 9 residents (Resident 66, 62, 75, 7, 70, 183, 3, 54, 56) on the dysphagia mechanical (Dys Mech per the National Dysphagia Diet as Level 2-food should be: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 21 sampled residents (Residents' 48, 52, and 54) when: 1. Resident 52's oxygen nasal cannula (O2 NC- a tube that directs oxygen into the nose) tubing was observed on top of the oxygen concentrator (medical device that supplies oxygen-enriched air to help people breathe easier) was not stored in a plastic bag. This failure placed Resident 52 at an increased risk to develop respiratory and healthcare associated infections. 2. Resident 48's medication syringe was stored in a wet plastic bag and had some orange liquid substance at the tip of the syringe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for three of six sampled residents (Residents' 3, 13 and 64) when: 1. Resident 3 was administered escitalopram oxalate tablet (medication used to treat depression [serious mental illness affecting person's though, feelings, behavior, and sense of well-being] from 6/2/24-6/31/24, 7/1/24-7/31/24 and 81/24-8/27/24 and informed consent was not obtained prior to medication administration. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for two of eight sampled residents (Resident 75 and Resident 29) when: 1. Resident 75 did not have a care plan (a document that outlines how a resident's health care needs will be met, and is used by the resident and their care team to facilitate communication and collaboration) for the use of indwelling urinary catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine). This failure placed Resident 75 at risk for her indwelling urinary catheter needs to not be met. 2. Resident 29 did not have a care plan for urinary tract infection (UTI- common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of eight sampled residents (Resident 29 and Resident 55) when: 1. License nurses continued to sign the physician's order to monitor for side effects for Resident 29's anticoagulant medication which was discontinued on 9/5/24. This failure resulted in an inaccurate documentation and monitoring of Resident 29's medical symptoms related to the side effects if a medication that has been discontinued. 2. Licensed Vocational Nurse (LVN) 1 prepared and signed Resident 55's medications, and the Infection Preventionist (IP) administered the medication prepared by LVN 1. This failure had the potential for Resident 55 to not received the medication and could lead to medication error and or drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide personal hygiene for two of eight sampled residents (Resident 233 and 32) when Resident 233 and 32's fingernails were long and had black particles underneath. This failure had the potential to result in Resident 233 and 32 to develop skin infections or sustain skin injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled Residents (Resident 13 and Resident 33) received the necessary care and respiratory services, consistent with professional standards of practice when: 1. Resident 13's oxygen (a colorless, odorless, tasteless gas essential to living organisms) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order (an order given for specific patient/resident by a health care provider). This failure resulted in Resident 13 not obtaining the ordered amount of oxygen via the oxygen concentrator (a machine that pulls in the air around you), which could lead to breathing problems which includes shortness of breath, headache, and confusion. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 48 and 133) were assessed for the use of bed (side rails) when Residents 48 and 133 had no assessment for the risk of entrapment, a physician's order specifying reason for use was not obtained and a care plan was not created. Additionally Resident 133 did not have informed consent obtained (a form signed by the resident or family explaining the risks). This failure had the potential to place Resident 48 and 133 at risk for decreased freedom of movement, entrapment and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (6.9 % [percent]) when: 1. Licensed Vocational Nurse (LVN)1 did not administer Resident 48's metformin (brand name-medication used to control high blood sugar) medication during medication pass. This failure had the potential to result in a high blood sugar which could lead to serious medical condition. 2. Resident 23 had a lidocaine patch (transdermal[through the skin] skin patch- topical anesthetic that numbs pain by blocking the nerve signals in your skin) and in place for more than 12 hours. This failure resulted in Resident 23 receiving more than the recommended dose and had the potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards of practice for three of 14 sampled residents (Residents 18, 51, and 76) when: 1a. Resident 51's Fluticasone Propionate (medication sprayed into the nostrils in order to reduce swelling in the body) was not labeled with its expiration date. 1b. Resident 76's albuterol sulfate (medication used to help open up the airways making it easier to breathe) was not labeled with its expiration date. These failures placed Residents 51 and 76 at risk of being administered medications way past its expiration date which could result in less effective medications. 2. Resident 18's insulin pen (pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge) was missing a label on the pen. [...]

Inspectors wroteBased on observations, interview and review of facility documents, the facility failed to: 1. Ensure Resident food preferences were accommodated for three residents (Resident 44, 75, 184); and 2. Provide an alternate option when residents disliked a food group for two residents (Resident 31, 39). This failure had the potential to increase residents' refusal of food items due to the facility not following the resident's preferences and potential reduction of meeting the resident's nutritional needs. 3. Resident 52 's dislike of warm food and preference of cold food on his meal ticket (document used to write a resident ' s diet, likes, dislikes, and allergies) was not documented. This failure had the potential for Resident 52 to not receive the caloric intake needed to meet his nutritional needs.

Inspectors wroteBased on observations, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety when the sanitizer solution was not the appropriate concentration to sanitize food preparation areas and equipment. This failure had the potential to result in cross contamination and the growth of microorganisms which could lead to food borne illness for the 83 residents admitted to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of four sampled residents (Resident 39) when: 1. Licensed Vocational Nurse (LVN) 1 checked Resident 39's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. 2. LVN 1 administered medication to Resident 39 and did not provide privacy. These failures resulted in Resident 39 not being provided with respect and dignity while his B/P was checked and while taking his medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of one of five sampled residents (Resident 75) when Resident 75's diagnosis of indwelling urinary catheter was not coded on the MDS assessment. This failure had the potential to result in Resident 75's care needs to not be met.

Inspectors wroteBased on interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of 8 sampled resident (Resident 29) when the care plan was not updated to reflect the insulin (a hormone that regulates blood sugar levels by moving glucose from the bloodstream into cells throughout the body) medication was discontinued on 7/23/24. This failure had the potential for Resident 29's care needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet residents needs for one of four sampled residents (Resident 48) when Resident 48's metformin (brand name-medication used to control high blood sugar) medication was not available for administration for two days (10/9/24 and 10/10/24). This failure had the potential for Resident 48's blood sugar to increase which could result to serious medical condition.

Inspectors wroteBased on observations, interviews and review of facility documents, the facility failed to ensure support personnel was able to effectively carry out the functions of food and nutrition services when [NAME] 1 did not follow menus and recipes. This failure resulted in not accommodating resident preferences which could result in disinterest in meals and decreased meal intake which has a potential to result in weight loss which can compromise the medical condition. This also had the potential to result in increased residents' risk of choking for nine residents.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure pureed food was in the proper form when a whole green bean was served on a pureed diet test tray. This failure had the potential to increase the risk of choking for nine residents who had physician ordered pureed diets due to having severe chewing and/or swallowing problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician prescribed diets were followed for one of seven sampled residents (Resident 6) when Resident 6 did not receive his ordered double portion meal for lunch on 10/8/24. This failure placed Resident 6 at risk to not receive the full nutritional value of his meal which had the potential for Resident 6 to experience weight loss

Inspectors wroteBased on observations, interviews and review of facility documents, the facility failed to provide a comfortable environment in the kitchen for staff. This failure had the potential to increase staff risk of developing heat related illnesses such as heat cramps, heat exhaustion or heatstroke caused by exposure to heat.

Inspectors wroteBased on interview and record review, the facility failed to create a care plan for elopement (to run away secretively) risk for one of three sampled residents (Resident 1) when Resident 1 attempted to leave against medical advice (AMA) from an appointment at the dialysis center on 8/23/23 and was assessed to be a risk for elopement. This failure resulted in Resident 1 successfully leaving AMA from the dialysis center on 9/6/23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. There was no air gap (a fixture that provides back-flow prevention) underneath the food prep sink and the two-compartment sink. 2. Three silver-colored pitchers had grime and build up inside. 3. There were Saltine crackers and graham crackers past the use by date. 4. A package of hot dog buns and a package of sliced bread did not have labels identifying the open dates and use by dates. 5. A container of applesauce did not have the use by date. 6. The freezer temperature reading was 12 °F (degrees fahrenheit [scale of temperature]). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain kitchen equipment in safe operating condition when the steamer machine in the kitchen was leaking and dripping liquid onto towels placed under the equipment. This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner which could affect the residents health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for two of six sampled residents (Resident 11 and Resident 56) when: 1. Resident 11 was administered lorazepam (medication used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) without current and updated informed consent. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for 3 of 12 residents (Residents 2, 26 and 66) when: 1. Resident 66's care plan reflected active interventions for treatment to his right foot even after having a right below the knee amputation (surgical removal of limb). This failure placed Resident 66 at a potential risk of his right lower leg care needs not to be met. 2. Resident 12 no longer used a communication board (paper with words and pictures) to communicate with staff. This failure placed Resident 12 at a potential risk of not being able to communicate her needs due to not having a tool to help communicate. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for 4 of 12 sampled residents (Residents 22, 28, 47 and 22 ) when: 1. Licensed Vocational Nurse (LVN) 6 failed to follow the manufacturers direction to shake tube feeding formula prior to hanging and administering to Resident 22. This failure placed Resident 22 at a potential risk to not receiving the amount of nutrition ordered by the physician. 2. LVN 6 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 22's medications. This failure resulted in inaccurate charting and placed Resident 22 at a risk to not receive the medication ordered. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. One Fluticasone Prop 50mcg (microgram -a unit of measure) spray (medication used to treat allergy) was opened with no label of used-by date or open date and another bottle of Fluticasone was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 138 and Resident 69. 2. Resident 81's Ipratropium/Albuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath) medication was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 81. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly for three out of four dumpsters when the dumpster lids were not have securely closed lids. This failure had the potential to attract rodents, insects and flies and spread infection which placed residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete, accurately documented in accordance with accepted professional standards of practice for eight of 38 residents (Residents 22, 26, 29, 32, 55, 59, 66 and 73) when: Residents 22, 26, 29, 32, 55, 59, 66 and 73's Physician Order for Life Sustaining Treatment (POLST- a document indicating wishes for end-of-life care) were incomplete in the residents medical record. This failure had the potential risk for Residents' 22, 26, 29, 32, 55, 56, 59, 66 and 73's end-of-life care decisions to not be followed in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 12 sampled residents (Residents 4 and 22, and 33) when: 1. Resident 4's room entry did not have signage indicating he was on Enhanced Barrier Precautions (EBP- gown and glove use during high contact resident care activities, designed to reduce transmission MDROs [organisms resistant to multiple antibiotics]) or indicate what precautions and personal protective equipment (PPE-items worn to protect healthcare worker from body fluids and infectious diseases) were required. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 2) when Registered Nurse (RN) left her workstation computer open and unattended with resident information exposed to public view. This failure resulted in violation of Resident 2's rights to confidentiality and the potential for unauthorized access to Resident 2's personal information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 11) when Resident 11's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 11's care needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 56) when Resident 56 was on continuous oxygen (a life supporting component of air) therapy for her respiratory illness. This failure placed Resident 56 at a potential risk for her oxygen care needs not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper maintenance and care for residents with foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) for one of two sampled residents (Resident 65) when Resident 65's urinary catheter bag was touching the floor on three separate occasions. This failure resulted in compromised urine drainage and accumulation of a large amount of sediment in the urinary catheter tubing and placed Resident 65 at a potential risk for catheter contamination, urinary retention (unable to empty the bladder) and a urinary tract infection (UTI-an infection in any part of the urinary system [kidneys, ureters, bladder]).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of six sampled residents (Resident 35) when Resident 35's Benazepril (brand name [medication used to treat high blood pressure]) was not available for administration for 8 days (7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23 and 7/11/23). This failure had the potential for Resident 35's blood pressure to be uncontrolled and lead to serious medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (eight percent) when: 1. Registered Nurse (RN) did not administer Resident 35's benazepril (brand name [medication used to treat high blood pressure]) medication during medication pass. This failure had the potential for Resident 35's blood pressure to go higher and lead to serious medical condition. 2. RN administered diltiazem (medication used to treat high blood pressure) medication to Resident 68 with blood pressure of 157/71 and pulse rate of 51. This failure resulted in Resident 68 receiving her blood pressure medication not as prescribed by the physician and had the potential for Resident 68's blood pressure and pulse to go lower and lead to serious medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the planned menu was followed for one of 81 residents (Resident 83) when incorrect portion sizes of the spinach au gratin and baked sweet potatoes was served to Resident 83 during lunch on 7/11/23. This failure had the potential for Resident 83 to receive the wrong caloric intake and not meet his nutritional needs.

Inspectors wroteBased on interview and record review the facility failed ensure their policy and procedure was followed for one of five sampled residents (Resident 29) when there was no documentation of Resident 29's education of the risk and benefits and his refusal of the Influenza vaccine (a preparation used to stimulate body's immune response against infection by flu viruses). This failure had the potential for Resident 29 of not being informed on the risks and benefits of receiving the influenza vaccine and not being able to make an informed decision.