Morning Star Post Acute

During a review of Resident 57's admission Record (AR- a document containing resident profile information) dated 12/9/25, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses which included right hip effusion (abnormal accumulation of excess fluid within the hip joint capsule), spinal stenosis (narrowing of spinal canal squeezing the nerves and causing pain, numbness, tingling, or weakness), muscle weakness and abnormalities of gait and mobility.

During a review of Resident 57's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 57's Brief Interview for Mental Status (BIMS-screening tool sed to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit)assessment score was 13 out of 15 which indicated Resident 57 had no cognitive deficit.

During an interview on 2/19/26 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was working the day Resident 57 signed herself out AMA and assisted Resident 57's nurse with the process. LVN 1 stated Resident 57 was not happy and wanted to leave.

LVN 1 stated he explained what AMA meant and the potential consequences, and Resident 57 signed the AMA form. LVN 1 stated he did not remember notifying or calling the MD and the ADM regarding of Resident 57's decision to leave AMA.

During a concurrent interview and record review on 2/19/26 at 3:18 p.m. with Registered Nurse (RN)2, RN 2 stated she was Resident 57's nurse when Resident 57 signed herself AMA on 2/6/26. RN 2 reviewed Resident 57's progress notes and stated she sent a message to the Director of Nursing (DON) but did not notify Resident 57's MD or the ADM. RN 2 stated she assumed the DON notified the ADM. RN 2 stated, I am new in the facility and did not know what to do.

During a concurrent interview and record review on 2/20/26 at 10:49 a.m. with Social Service Designee (SSD), Resident 57's SSD notes were reviewed.

The SSD stated she did not find any documentation indicating she had spoken with Resident 57 about wanting to go home or requesting a room change.

The SSD stated Resident 57 was not happy with her roommate and had been shown different room where she could have moved.

The SSD stated she should have notified the ombudsman (an official advocate for resident's rights), but she did not, and did not call Resident 57 to follow-up after leaving AMA.

During an interview on 2/20/26 at 12:20 p.m. with the DON, the DON stated, She (Resident 57) threatened to leave so many times and we talked to her but there are no documentations.

The DON stated she was not sure about the facility policy on AMA, but we can not keep them against their will.

The DON stated she reviewed the nurse documentation when Resident 57 signed herself out AMA.

The DON stated the nurse progress note did not indicate the MD and ADM were notified or made aware of Resident 57's decision to leave AMA.

During a review of facility's policy and procedure (P&P) titled, Transfer and Discharge (Including AMA), dated 12/19/22, the P&P indicated, . b.

The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. c.

Documentation of this notification should be entered in the nurses' notes by the nursing department.

The social service designee should document any discussions held with the resident/family in the social service progress notes .

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

periodically update written policies and procedures that govern the development, use, and

appropriate, qualified health professional will correctly document the resident's medical, functional,

functional abilities, and psychosocial status .

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During a review of the facility's policy and procedures (P&P) titled, Care Plans Comprehensive Person-Centered, dated 2/2022, the P&P indicated, .person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being.reflects currently recognized standards of practice for problem areas and conditions.

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During an interview with the Director of Nursing (DON) on [DATE] at 12:22 p.m., the DON stated oxygen was a medication and required a physician's order to be administered.

The DON stated if oxygen therapy was administered in an emergent situation an order was expected to be placed to reflect the use and continuing use of oxygen therapy.

The DON stated Resident 12 was at risk of being over oxygenated when she was administered oxygen therapy with no physician order or oversight.

The DON stated professional standards or practice, and facility policy and procedure were not followed when Resident 12 was administered 2.5 LPM of oxygen therapy with no physician order.

During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated [DATE], the P&P indicated, .oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable.

During a review of the facility's P&P titled, Physician Orders, dated [DATE], the P&P indicated, .medications should be administered only upon the signed order of a person lawfully authorized to prescribe.

During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, .

Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse .

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During an interview on 2/19/26 at 3:15 p.m. with LVN 1, LVN 1 stated the facility does not allow

are not allowed to keep medications at bedside either because other confused residents could access medications and potentially may cause allergic reactions. LVN 1 stated nursing staff had to document all medications administered to residents.

During an interview on 2/20/26 at 11:44 a.m. with the DON, the DON stated the facility does not allow medications to be kept at bedside.

The DON stated Resident 32 was alert and oriented, her partner visits daily and brought the medications and did not let the nurse know.

The DON stated, We can not go through their belongings to check for medications.

The DON stated if Resident 32 wanted to take the medication they could discuss it with her medical doctor (MD) and get an order.

The DON stated keeping medications at bedside could potentially put other residents in danger because they could take the medication and develop adverse interaction with other medications leading to more serious health conditions.

During a review of facility's policy and procedure (P&P) titled, Medication Storage Policy, date reviewed/revised 2/17/26, the P&P indicated, .All drugs and biologicals are stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control.

During a review of facility's P&P titled, Medications Brought to the Facility by the Resident/Family/Physician/Prescriber, Revision Date: 09/15/24, the P&P indicated, .Facility staff should not administer medications including over-the-counter medications. brought to facility by a resident, a resident's responsible party, or a resident's physician/prescriber without physician/prescriber's order.When medications from the resident's personal inventory are not ordered by the physician/prescriber, Facility staff should return the medications to the resident's family.

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During a concurrent observation and interview on 2/17/26 at 8:22 a.m. during initial tour in the kitchen with Dietary Service Manager (DSM), in the refrigerator there was a bag of chicken with prep date of 2/14/26 and used by date of 2/16/26.

The DSM stated, It [chicken] was supposed to be used yesterday [2/16/26].

The DSM stated the dietary staff defrosted the chicken more than was needed

During an interview on 2/19/26 at 8:28 a.m. with the DSM, the DSM stated the cook was responsible in pulling out food to thaw for use.

The DSM stated refrigerators and freezers are monitored daily and checking food for the expiration dates ensuring food past the used by date are not left inside the refrigerator.

The DSM stated the bag of expired chicken should have been remove from the refrigerator to avoid use.

The CDM stated staff might accidentally use the expired chicken and serve to residents and somebody might get sick and we do not want that.

During an interview on 2/20/26 at 8:10 a.m. with the Registered Dietitian (RD), the RD stated she was in the facility once a week and spot check refrigerators and freezers.

The RD stated once meat was thawed, it was required to be served, and any portions not used was to be discarded.

The RD stated it was the responsibility of all dietary staff to check daily for expired food and discard as needed.

The RD stated serving food passed its used by date could cause bad taste and food borne bacteria.

During a review of facility's policy and procedure (P&P) titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, the P&P indicated, .All food items will be labeled.

The label must include the name of the food and the date .

Rotate products so the oldest are used first.

Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date.

Discard food that has passed the expiration date .

Follow and adhere to the guidelines regarding proper storage temperatures and maximum length of storage .

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During a concurrent observation and interview on 2/18/26 at 8:15 a.m. with Dietary Service Manager (DSM), the facility's dumpster located behind the building was observed with two of the lids in the open position.

One dumpster contained overflowing garbage in a plastic bag, which prevented the lid from closing securely.

The DSM stated, They should have made sure to throw garbage bag in the back first for the lid to close.

During an interview on 2/19/26 at 8:35 a.m. with DSM, the DSD stated the facility's dumpster was everybody's responsibility.

The DSM stated leaving the dumpster open attracts vermins and causes odor.

The DSM stated it was the reason why the dumpster lids should be kept shut to avoid vermins going in and contain the odor.

During an interview on 2/19/26 at 9:15 a.m. with the Environmental Supervisor (EVS), the EVS stated it was his responsibility to ensure dumpster lids to remain closed at all times.

The EVS stated the facility's dumpsters contained dirty briefs, foods, and other garbage which could attract pests.

The EVS stated keeping garbage lids properly closed at all times help contained odors and prevent the attraction of unwanted pests.

During a review of facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, Revised date 10/17, the P&P indicated, .All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered .

Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests .

Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter .

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During a record review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, undated, the P&P indicated, .enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multidrug-resistant organisms that are resistant to many antibiotics] as well as those at increased risk of MDRO acquisition (e.g., residents with.indwelling medical devices.).signage will be posted on the door or wall outside the resident room indicating the type of precaution, required personal protective equipment (PPE) , and the high-contact resident care activities that require the use of gown and gloves.make gown and gloves available prior to performing tasks.

056338 02/20/2026

Morning Star Post Acute 111 Barstow Ave.

Clovis, CA 93612

During the initial tour on 2/20/26 at 10:53 a.m., the following rooms had more than four residents in each bedroom.

Although the bedrooms accommodated more than four residents, each room met the particular needs of each resident.

There was adequate closet and storage space.

Wheelchair and toilet facilities were accessible.

There was sufficient room for nursing care and for residents to ambulate.

Bedside stands were available for each resident.

The health and safety of residents would not be adversely affected by the continuance of this waiver.

Room Number Number of Beds11 812 714 8 Recommend waiver continue in effect. _____________________________________HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature Date