Sunflower Park Health Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's care plan included updated interventions for falls after a fall on 06/24/2026. This failure could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 3 of 5 residents (Resident #3, Resident #8, and Resident #12) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #12's GDR dated 10/08/25 for citalopram (antidepressant) was completed after being approved by the physician on 11/26/25. 2. The facility failed to ensure Resident #3's duloxetine (psychotropic medication used for depression) was decreased after the PMHNP-BC agreed to the pharmacy recommendation to reduce the duloxetine to 40 mg on 11/26/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that had an appetizing temperature on 01/04/2026. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

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 in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure regular texture corn, pureed corn, and pureed chicken strips were held at the proper temperature on 01/04/2025. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 3 (Resident #11, Resident #29, Resident #52) of 8 residents reviewed, in that: The facility failed to ensure the thermometers inside Resident #11's, Resident #29's and Resident #52's personal refrigerators were present and functioning properly and the staff recorded the accurate temperatures of the refrigerator for two months. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident #6, and Resident #26) reviewed for infection control. 1. The facility failed to ensure CNA K performed proper glove changes while providing incontinent care to Resident #6 on 01/05/2026. 2. The facility failed to ensure the Treatment nurse and the DON used PPE while providing wound care for Resident #1 on 01/05/26. 3. The facility failed to ensure Resident #1 and Resident #26 had enhanced barrier precaution signage and PPE available in a cart for the staff to be aware of EBP (enhanced barrier precautions). 4. [...]

Inspectors wroteBased on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 3 residents (Resident #44 and Resident #47) reviewed for resident rights. The facility failed to ensure Resident #44 and Resident #47 were treated respectfully by CNA E. This failure could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of treatment and treatment alternatives for 1 of 5 residents (Resident #3) reviewed for psychoactive medications. The facility failed to ensure written consent on HHSC Form 3713 was obtained from Resident #3 prior to the administration of Invega Sustenna, an antipsychotic medication, used to treat schizophrenia. This failure could place residents at risk for receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 8 resident rooms (Rooms 24a and 30B) whose environments were reviewed, in that: 1. The privacy curtain rod in room [ROOM NUMBER] was not secure to the ceiling.2. An electrical extension cord was in use in room [ROOM NUMBER]a. These deficient practices could place residents at-risk for injury and poor quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 27 residents (Resident #6 and Resident #44) reviewed for MDS assessment accuracy. The facility did not ensure Resident #6's Comprehensive MDS assessment dated [DATE] was accurately coded to reflect her level II PASRR status. The facility did not ensure Resident #44's Quarterly MDS assessment dated [DATE] accurately reflected he received hospice services. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessment for 1 of 8 residents (Resident #38) reviewed for PASRR services. Resident #38 had a diagnosis of bipolar disorder but did not have a Level II evaluation. This deficient practice could place residents at risk of not receiving appropriate services to meet their individual needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 8 residents (Resident #48) reviewed for PASRR Level I screenings and services. The facility failed to ensure the residents who were identified as PASRR positive on admission were assessed for appropriate services and care coordination in that Resident #48 was never evaluated for PASRR services that she was eligible for. This failure could place residents who had a mental illness at risk of not receiving individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 16 (Resident #5, Resident #59) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #5 and Resident #59. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Residents #7 and #59) reviewed for activities, in that:1. Resident #7 was not taken to activities after she expressed an interest in them or provided in-room activities.2. Resident #38 was not provided with 1-on-1 activities. This deficient practice could affect residents who received in-room and out-of-room activities, and place them at-risk for lack of stimulation, boredom, and depression.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The facility failed to ensure the Treatment Nurse documented accurate skin assessments for Resident #1.2. The facility failed to ensure Resident #1 had was provided treatment for his wound to his great right toe. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Resident environment remained as free of accident hazards as is possible for 2 of 16 residents (Resident #16, Resident #41) reviewed for accidents and hazards, in that: Resident #16 had an unsecured oxygen cylinder in his room. Resident #41 was utilizing a wheelchair with an unsecured seat backrest resulting in a fall. These deficient practices placed residents at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care (Residents #26). The facility failed to ensure Resident #26's suction machine yankauer was bagged. The facility failed to ensure Resident #26 had a physician order for the use of the suction machine. The facility failed to ensure Resident #26 had the use of the suction machine included on her care plan. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. An unnecessary medication is any medication used: In excessive doses; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 8 residents (Resident #41) reviewed for unnecessary medication. The facility failed to ensure Resident #41's protein pump inhibitor (PPI) Omeprazole had been decreased according to pharmacy recommendations and physician's approval. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medication) and providing medication without physician's knowledge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 27 residents (Resident #26) observed for medication storage. 1. The facility failed to ensure Resident #26 did not have a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of zinc oxide silicone cream (medications used for wound care and barrier cream used for wound prevention) in a mauve basin on top of her personal refrigerator in her room. These failures could place residents at risk for obtaining injury or harm from misuse.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #44) reviewed for hospice services. The facility failed to obtain Resident #44's most current Form 3071 Texas Medicaid Hospice Program Individual Election/Cancellation/Update, Form 3074, Physician Certification of Terminal Illness, Hospice Nurses' Notes, and Hospice Physician Orders. [...]

Inspectors wroteBased interviews and record review, the facility failed to ensure each resident was free from abuse, neglect, exploitation, and misappropriation of resident property for 1 of 3 residents (Resident #1), reviewed for drug diversion . The facility failed to prevent the misappropriation of Resident #1's Ondansetron. (Ondansetron is commonly used to prevent nausea and vomiting). This failure could place residents at risk for not receiving their prescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 4 residents (Resident #30) reviewed for abuse. The facility failed to keep Resident #30 free from abuse and neglect, when CNA K, CNA EE, Student NA FF, and Student NA O held her down and provided incontinent care while she was screaming and yelling stop, leave me alone on 10/05/2024. An Immediate Jeopardy (IJ) was identified on 10/29/2024 11:10 AM. The IJ template was provided to the facility on [DATE] at 11:13 AM. While the IJ was removed on 10/30/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse policies, behavior management policies, and restraint policies. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 3 of 4 residents' (Resident's #2, #4, and #30) reviewed for trauma-informed care. 1. The facility failed to ensure Resident #30 was not held down and provided incontinent care while she was screaming and yelling stop, leave me alone on [DATE] by CNA K, CNA EE, Student NA FF, and Student NA O. 2. The facility failed to ensure Resident #30's history of being kidnapped, raped, and almost murdered was included on the care plan. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 of 20 residents (Resident #5) reviewed for accidents and hazards related to coffee burns. The facility failed to follow the policy and procedure for preparing and temping coffee. On 10/02/24, Resident #5 spilt coffee on herself, which caused a second-degree burn (tissue damage to the outer layer of your skin and the second layer of your skin) to Resident #5's right upper thigh and lower abdomen. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/02/2024 and ended on 10/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at an increased risk for serious burn injuries while drinking hot liquids.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. Food items were labeled and dated. 2. Hair restraints were worn correctly. 3. The juice machine spigot was free from a red/orange gooey substance where the juice was dispersed. 4. Ice scoops were stored in a container. 5. Can opener blade was free from debris. 5. Dietary Manager TT washed her hands after touching her nose. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 5 of 7 (Resident's #49, #1, #2, #209 and Resident #42) residents and 1 of 1 linen carts reviewed for infection control. 1. The facility failed to ensure CNA C provided proper incontinent care to Resident #49. 2. The facility failed to ensure CNA C wore PPE prior to entering Resident #1's room. 3. The facility failed to ensure LVN A performed hand hygiene after checking blood sugar on Resident #2. 4. The facility failed to ensure CNA K provided proper incontinent care to Resident #209. 5. The facility did not ensure the DON and NA QQ don (on) their PPE prior to entering Resident #42's room. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 4 residents (Resident's #28, #32, #37) reviewed for dignity. 1. The facility failed to ensure Resident #32 was treated with dignity and respect when the Administrator called her big girl on 10/22/24. 2. The facility failed to ensure Resident #32 was treated with dignity and respect when CNA GG and MA HH told her washing her hair was too time consuming on 10/30/24. 3. The facility failed to ensure Resident #37 was treated with dignity and respect when CNA MM told her to shut up. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 16 of 16 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 05/22/2024, 06/26/2024, 07/25/2024, 08/29/2024, 09/26/2024, and 10/15/2024. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 4 of 23 residents (Resident #9, Resident #30, Resident #42, and Resident #47) reviewed for care plans. 1. The facility failed to ensure a care plan was developed and implemented for Resident #47's in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed). 2. The facility failed to ensure Resident #30's care plan reflected her history of trauma. 3. The facility did not ensure that Resident #42's care plan included treatment for a wound on the right medial (toward the middle or center) thigh, which required wound care three times per week. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of the receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 5 medication carts (Treatment Cart and Hall C Nurse Cart) and 1 of 1 medication room refrigerator reviewed for drugs and biologicals. 1. The facility failed to ensure the Treatment Nurse secured the facilities only treatment cart. 2. The facility failed to ensure Resident #12's Humalog (fast-acting insulin to control high blood sugar) insulin was dated when opened on Hall C's nurse cart. 3. The facility failed to ensure Resident #4's Lantus (Long-acting insulin that regulates blood sugar levels at a stable rate throughout the day) was dated when opened on Hall C's nurse cart. 4. [...]

Inspectors wroteBased on observations, and interviews the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 16 of 16 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 10/29/24. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 23 residents (Resident # 47) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 47's in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed) was coded accurately on the Quarterly MDS Assessment with an ARD of 08/01/2024. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 23 residents (Resident #42 and Resident #51) reviewed for quality of care. 1. The facility did not ensure that LVN A and LVN OO followed physician orders for wound care on Resident #42's right distal (away from the center of the body) medial (toward the middle or center) calf. 2. The facility failed to ensure CNA N and Student NA Z reported to the charge nurse after Resident #51 had an unwitnessed fall on 10/16/24. This failure could place residents at risk for decreased quality of care and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 2 residents (Resident #47) reviewed for urinary catheters. The facility failed to ensure Resident #47 was provided proper supplies to perform in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed). This failure could place residents at risk of urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 5 staff (CNA K) reviewed for competencies. The facility failed to ensure CNA K was competent in infection control and providing incontinent care on 10/29/2024. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 5.26 %, based on 2 errors out of 38 opportunities, which involved 2 of 4 residents (Resident #12 and #2) reviewed for medication administration. 1. The facility failed to ensure LVN B administered insulin correctly for Resident #12. 2. The facility failed to ensure LVN A administered insulin correctly for Resident #2. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 8 residents (Resident #9 and Resident #49) reviewed for laboratory services. 1. The facility did not obtain a physician's ordered A1C (used to measure average blood sugar over the past three months) for Resident #9. 2. The facility failed to ensure Resident #49's potassium level (Potassium is a mineral and electrolyte that helps maintain the body's water and electrolyte balance. It is also important for nerve and muscle function) was drawn on 07/23/24. These failures could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent with the resident's needs, for 2 of 3 (Resident #49 and Resident #44) residents reviewed for liquid inconsistency, in that: 1. The facility failed to ensure staff served Resident #49 nectar-thickened tea during her lunch meal on 10/28/24. 2. The facility failed to ensure LVN D checked the lunch tray appropriately for Resident #44 who required nectar thick liquids. This failure could place residents who have dysphagia at risk for aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 3 residents (Resident #49) reviewed for therapeutic diets. The facility did not ensure Resident #49 was given fortified food as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #1) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #1 had a call button. This failure could place resident at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their own established smoking policy for the facility's only smoking area and 1 of 7 residents (Resident #37) reviewed for smoking policies. 1. The facility failed to ensure Resident #37 wore a smoking apron during a supervised smoking break on 10/28/24. 2. The facility failed to ensure the smoking area was free of combustible materials on 10/28/24. These failures could place residents at risk of an unsafe smoking environment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents formulated an advance directive for 1 of 15 residents (Resident #16) reviewed for advanced directives. The facility did not ensure Resident #16's chart reflected the hospice OOH-DNR that was dated[DATE]. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews, and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents (Residents #16) reviewed for MDS assessment accuracy. The facility failed to accurately code the ostomy status on Resident #16. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was updated and revised to reflect she was on PASRR services. This failure could cause the resident to not receive the correct care impacting the patient's health and/or serious illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 15 (Resident #26) residents reviewed for accidents hazards and supervision. The facility failed to properly store wound cleanser leaving it on Resident #26's bedside table. The facility failed to properly store wound cleanser leaving it in Resident #'26's dresser. This failure could place residents at an increased risk for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #9) of 15 residents reviewed for urinary incontinence. The facility failed to provide timely treatment of Resident #9's Urinary Tract Infection. This failure could place residents with Urinary Tract Infections at increased risk of not receiving appropriate treatment, which could result in severe illness or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 33 opportunities, resulting in an 12% percent medication error involving 2 of 4 residents reviewed for medication administration (Residents #11and #36). MA A failed to verify the dose of eye drops to be administered and administered an inaccurate dose of 2 (two) drops instead of the ordered 1 (one) drop of Dorzolamide/Timolol eye drop solution (used to treat glaucoma by reducing pressure in the eye) to Resident # 36's right eye. MA A failed to administer 3 (three) scheduled medications including Isosorbide (used to prevent chest pain in patients with heart disease), Metformin (used to treat and manage high blood sugar levels), and Latuda (used to treat depression (a mental illness) to Resident #11 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents (Resident #11) reviewed for significant medication errors, in that: MA A failed to administer 2 scheduled medication, isosorbide mononitrate (to high blood pressure and metformin (to treat high blood sugar). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. for a lower than desired blood pressure and/or pulse.

Inspectors wroteBased on interview and record review facility failed to promptly notify the physician of laboratory results 1 of 15 residents reviewed for laboratory services (Resident #9). The facility did not notify Resident #9's physician about the results of her urinalysis. This failure could place residents with infections at risk of a delay in medical evaluation and treatment.

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 safety in the facility's only kitchen. The facility failed to ensure food items were dated and labeled. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #16 and Resident #28) reviewed for hospice services. The facility did not ensure Resident #16's hospice records were a part of their records in the facility. The facility did not ensure Resident #28's hospice records were a part of their records in the facility. The facility did not ensure Resident #16 had a physician order for hospice. [...]