Sunflower Park Health Care
SUNFLOWER PARK HEALTH CARE in KAUFMAN, TX — inspection on January 7, 2026.
Found 19 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 01/05/2026 at 5:30 PM, CNA G said Resident #44 and Resident #47 reported to her that CNA E was rude to them. CNA G said management was aware of the residents reporting that CNA E was rude to them. CNA G said the residents were saying it's the way CNA E talks to them and the tone she uses.
During an interview on 01/07/2026 at 12:53 PM, the Administrator said he was told Resident #44 dropped his coffee on the floor the morning of 01/04/2026, and Resident #44 requested CNA E give him another cup of coffee. CNA E refused to do so, and he was really upset because he said she should have given him another one.
The Administrator said RN C gave him another cup of coffee.
The Administrator said CNA E told him she did not give Resident #44 coffee because she was waiting until he was in his chair because he was shaking.
The Administrator said none of the staff or residents reported to him CNA E was rude to them.
The Administrator said he expected all the residents to be treated with dignity and respect.
The Administrator said he and the DON were responsible for ensuring the staff was treating residents with dignity and respect.
The Administrator said the residents not being treated with dignity and respect could affect the residents' outcome and could make them feel unhappy.
During an interview on 01/07/2025 at 2:29 PM, the DON said CNA E reported to her that Resident #44 threw his coffee and spilled it everywhere.
The DON said CNA E told her she was going to get Resident #44 up, and she told him to let her get him up in his chair and then she would get him the coffee. CNA E said he became upset and knocked the coffee over, and she left and got another nurse.
The DON said Resident #44 told her he just wanted his coffee.
The DON said Resident #44 did not report to her that CNA E was rude to him, but RN C told her Resident #44 reported CNA E was rude to him.
The DON said prior to this incident she did not receive any complaints about CNA E being rude from the staff or the residents.
The DON said she had received complaints from the residents and staff saying CNA E was too loud and talked too much.
The DON said she expected the staff not to be rude to the residents, to have empathy and be caring towards them.
The DON said treating the residents rudely could make them feel like the staff do not care about them and make them not feel safe.
Record review of the facility's undated policy titled, Resident Rights, indicated, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.
The facility must protect and promote the rights of the resident.Respect and dignity - The resident has a right to be treated with respect and dignity.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
did not have a consent or a Form 3713 for Invega Sustenna.
The DON said it was important to obtain
02/12/2025, indicated, Residents have the right to be informed of and participate in their treatment.
representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.
The resident has the right to accept or decline the initiation or increase of a psychotropic medication.
The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also acceptable.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
Rounds and stated that the Administrator monitors the room rounds that were completed daily by
this case an electrical fire.
Record review of the facility admission Packet, p. 24 titled Items Not
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/2026 at 2:19 PM, the DON said the ADON and she were responsible for
Resident #12's citalopram be decreased to 20 mg.
The DON said she was not aware the pharmacy recommended for Resident #3's duloxetine to be decreased to 40 mg.
The DON said when they receive the pharmacy recommendations, they go through them and put them in the providers folder for them to sign, and once it is signed off, they put the order in.
The DON said she did not know if GDRs were done for Resident #8's olanzapine and Invega Sustenna.
The DON said the ADON and she kept track of the GDRs with the pharmacy recommendation binder.
The DON said GDRs should be attempted because of the side effects associated with the medications.
Record review of the facility's policy titled, Psychotropic Medication, revised 02/12/2025, indicated, The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.
Also, residents will only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior.
These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic. b.
Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs.
Residents who use psychotropic drugs will receive gradual dose reductions (GDRs), unless clinically contraindicated, to discontinue these drugs.
For any resident who is receiving a psychotropic medication, the facility will show evidence that a GDR has been attempted unless clinically contraindicated.
Medical record documentation should reflect the date of the GDR attempt, the outcome of the dose reduction attempt, and the plan regarding future GDR attempts.
Physician documentation should contain the rationale for why GDR attempts are clinically contraindicated for the resident.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/2026 at 11:56 AM, the MDS Coordinator said she completed Resident #6's and Resident #44's MDS assessments.
The MDS Coordinator said Resident #44 went on hospice in September 2025, so his MDS should have reflected he was on hospice.
The MDS Coordinator said it was not coded accurately because it was a data entry error.
The MDS Coordinator said Resident #6's MDS assessment should have reflected she was PASRR positive.
The MDS Coordinator said she was aware Resident #6 was PASRR positive, and it was an oversight that she coded her MDS assessment incorrectly.
The MDS Coordinator said regional provided oversight by doing spot checks, but not every MDS assessment was reviewed.
The MDS Coordinator said it was important for PASRR status to be coded accurately to ensure the residents received the needed services.
The MDS Coordinator said the hospice not coded accurately would affect the residents' care plan.
During an interview on 01/07/2026 at 12:36 PM, the Administrator said he expected the MDS assessments to be completed accurately.
The Administrator said the MDS Coordinator was responsible and the corporate MDS nurse completed audits to ensure she completed them accurately.
The Administrator said not coding the MDS assessments correctly could affect the residents' function and diagnoses.
During an interview on 01/07/2026 at 2:31 PM, the Regional Compliance Nurse said they did not have a policy for MDS accuracy that they followed the RAI.
Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11 dated October 2023 indicated, .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/2026 at 2:30 p.m., the DON stated she has a general understanding of
and submitting the PASRR Evaluations to determine eligibility.
The DON stated that failure to ensure PASRR Evaluations were submitted could cause the eligible resident not to receive the care they may need and the care services they are eligible for.
The DON stated that she was responsible for the accuracy of the PASRR program in the facility.
Review of a facility policy, titled, PASRR Level 1 Screen Policy and Procedure, dated 03/06/19, indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PASRR Level 1 screening form from the RE (referring entity) prior to admission to the NF.
The PASRR Level1 will be submitted via Simple Long-Term Care timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age.
The PASRR Program is important because it provides options for individuals to choose where they live, who they live with, and the training and therapy they need to live as independently as possible.PASRR Program has 3 Goals:1. To identify individuals with MI, ID, or DD/RC (this includes adults and children).2. To ensure appropriate placement, whether in a community or in a Nursing Facility.3. To ensure individuals receive the required services for their MI, ID, or DD.Procedure:1.
The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of admission or prior to admission. A PL1 is obtained for every individual, regardless of payment type. 2.
The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1 Screening Form. 3.
The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations.
Procedures: 1.
The facility's designated staff will review all potential admissions for possible positive PASARR conditions and ensure that Centers for Medicare Services Preadmission guidelines are followed Review the PL1 Form for completion and correctness before admission.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
correctness prior to admission and submit the PASRR level 1 form per regulations.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/26 at 12:33 PM the ADON said the MDS Nurse was responsible for completing the baseline care plan when residents were admitted to the facility.
The ADON said the DON was responsible for providing the baseline care plan to the family of residents.
The ADON said the failure of the baseline care plan not being completed placed Resident #59 at risk for staff not knowing Resident #59's limitations or any other care Resident #59 needed.
During an interview on 01/07/26 at 1:24 PM the Administrator said the baseline care plan should have been completed within 72 hours of Resident #59's admission date.
The Administrator said the nursing department was responsible.
The Administrator said the failure of the baseline care plan not being completed placed a risk of staff not providing the care that Resident #59 needed.
During an interview on 01/07/26 at 2:35 PM the DON said the charge nurse was responsible for the baseline care plan when the resident admits to the facility.
The DON said she was not aware that the baseline care plan for Resident #59 was not completed.
The DON said she thought she completed her comprehensive care plan, but it was only started.
The DON said all of Resident #59's information should have been included in the care plan and not just the surgical wound and medication monitoring.
The DON said the failure of the baseline care plan not being completed placed a risk for no staff knowing how to care for the Resident #59.
Record review of facility's policy titled Baseline Care Plan, undated, read This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. and The baseline care plan will be developed within 48 hours of a resident's admission.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
cannot participate in group settings are provided individual programming.
Inability to participate could
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/26 at 12:42 PM the ADON said when a nurse completed a skin assessment anything new should be in the skin assessment, including what it looks like, drainage, and treatment.
The ADON said the previous DON taught them that.
The ADON said she understood a skin assessment to be an assessment of the entire body, and it should have been documented according to what was seen.
The ADON said the failure of not completing an accurate skin assessment could have placed a risk for skin areas being missed and worsened skin problems.
During an interview on 01/07/26 at 1:33 PM The the Administrator said he expected the skin assessments to include all skin issues correctly and the size each week.
The Administrator said the failure placed a risk for the skin assessments not being accurate and could have caused skin issues to worsen.
During an interview on 01/07/26 at 2:54 PM The the DON said she and the ADON had discussed the issues with the skin assessments, and she expected the nurses to assess and document all findings.
The [NAME] said the failure placed a risk for skin assessments not being completed accurately and could cause worsening of wounds.
Record review of thee facility policy Skin Assessment revised 12/24 indicated:It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner.
Procedure:1.
All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed If the facility Treatment Nurse/designee is available he/she should complete the assessment within four (4) hours of the resident's arrival at the facility. If the Treatment Nurse/designee isn't available then the charge nurse should complete the assessment within four (4) hours of the resident's arrival at the facility.
The charge nurse will then notify the Treatment Nurse/designee of any skin problems noted.
Complete the appropriate attachments/assessments.
The DON or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations.
Any pressure ulcer should also be care planned.
Any alterations in skin integrity will be treated according to physician orders.
Notify DON and responsible family member.
Documentation will then be entered into the resident's chart with the following information. 2.
All residents should have a skin assessment on a weekly basis completed in PCC3. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview on 01/07/2025 at 9:15 a.m., CNA H stated that she does utilize the scan code for maintenance work order requests, and the last one she submitted what a while back. CNA H stated she was not aware that Resident #41 had a fall related to wheelchair malfunction.
During an interview on 01/07/2025 at 8:52 a.m., the Director of Rehabilitation Services (DOR) stated that all wheelchairs were checked at the time of the incident with Resident #41 and that his team completes monthly wheelchair safety audit on all residents who go to the therapy gym.
The DOR stated that approximately 80% of the residents are on therapy caseload so chairs are seen regularly.
The DOR was unable to provide documentation that wheelchair safety checks were on-going and stated that he tends to repair as concerns arise and if it is outside of his capability, he will notify maintenance or the specialty wheelchair company.
During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated the facility had a system in place called Champion Rounds to help monitor the rooms and equipment for maintenance repairs.
The Administrator stated he follows up with the maintenance director to ensure the work orders are completed timely.
The Administrator stated he expected the Department Heads assigned to participate in Champion Rounds to complete a thorough review of the room and medical equipment to include wheelchairs and walkers to ensure proper functioning.
The Administrator stated he was not employed at the facility at the time the self-report regarding Resident #41's wheelchair malfunction and that he would review with the DOR and the Maintenance Director to ensure monthly wheelchair safety rounds are completed and logged.
The Administrator stated he received the weekday Champion Round logs and monitors daily to ensure repairs are completed.
During an interview on 07/07/2026 at 2:30 p.m., the DON stated that all staff were responsible for reporting maintenance concerns for resident's' rooms and equipment.
The DON stated that each room has a Department Head assigned to monitor equipment repair needs and she expected the person assigned to report concerns timely.
The DON stated that failure to identify equipment repair needs could result in harm or injury to the resident as in this incident with Resident #41.
Requested facility policy for wheelchair maintenance on 01/05/2026 at 2:20 p.m.
The ADMIN and Maintenance Director stated they did not have a policy regarding equipment repair and maintenance.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
the nose, pharynx, and trachea.
Assemble the sectioning materials with clean container, tubing, and
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
During an interview with the Regional Nursing Director on 01/07/2026 at 1:45 p.m., the Regional Nursing Director stated the facility follows HHSC standards and protocol for medication administration.
According to Guidance 483.45(d) Unnecessary Drugs and (c)(3) and (e) Psychotropic Drugs .Proper medication .without adequate monitoring-ma increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, hip fractures, and death.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
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.Findings include: Record review of Resident #26's face sheet dated [DATE] indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder (disease that causes extreme mood swings from high manic to depressive lows).
Record review of Resident #26's admission MDS assessment dated [DATE] indicated she understood others and usually made herself understood.
The MDS also indicated she had a BIMS score of 11 which meant she had moderate cognitive impairment.
The MDS also indicated she was dependent on staff for toileting, bathing, and transfers, and required setup assistance from staff for eating.
Record review of Resident #26's care plan dated [DATE] indicated she had impaired vision and impaired cognitive function with interventions in place to provide medications as ordered.
Record review of Resident #26's order summary report dated as of [DATE] indicated she had orders for:Clean wound with wound cleanser or normal saline and cover with abdominal pad or gauze.
Change/clean daily and when soiled as needed for wound care with a start date of [DATE] and no end date.May apply barrier cream to Bilateral buttocks as needed every shift with a start date of [DATE] and no end date.
During an observation on [DATE] at 9:45 AM Resident #26 had a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of silicone cream in the mauve basin on top of Resident #26's personal refrigerator in her room.
During an observation on [DATE] at 8:35 AM Resident #26 continued to have a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of silicone cream in the mauve basin on top of fridge in her room.
During an interview on [DATE] at 1:18 PM RN C said none of the medications should have been left in Resident #26's room. RN C said all staff were responsible for ensuring no medications were in residents' rooms. RN C said the failure placed a risk for Resident #26, family, or other residents getting the medication and misusing or harming themselves.
During an interview on [DATE] at 1:33 PM the Administrator said all medications should be stored in medication carts.
The Administrator said the failure of leaving the medications in the room placed a risk for Resident #26 using and not knowing how to use the medications correctly and the failure also placed a risk for wandering residents getting the medications and misusing them.
During an interview on [DATE] at 2:50 PM the DON said none of the medications should have been left in Resident #26's room.
The DON said the wound care medications should have been kept in the medication cart with Resident #26's name and date they were opened on them.
The DON said the failure placed a risk for Resident #26 or any other residents getting the medications and using, or the medications could have expired, and no one would have known.
Record review of the facility policy Medication storage in the facility dated 3-2025 indicated: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.
The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
The facility failed to ensure dietary staff provided food that had an
kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.
Findings included:
During an interview on 01/04/2026 at 10:24 AM, Resident #4 said the food was cold when she received it.
During an interview on 01/04/2026 at 10:55 AM, Resident #30 said sometimes the food was cold when he received it.
During an observation and interview on 01/04/2026 at 12:53 PM, the lunch tray was sampled by the Dietary Manager and three surveyors.
The lunch tray sampled consisted of chicken fried chicken, corn, and mashed potatoes.
The chicken fried chicken was lukewarm, and the mashed potatoes and corn were cold.
The Dietary Manager said some people may have wanted the chicken fried chicken to be hotter.
The Dietary Manager said the corn needed to be a little warmer because it was not hot.
The Dietary Manager said the mashed potatoes needed to be warmer, as they had cooled down a little bit.
During an interview on 01/04/2026 at 2:38 PM, Resident #23 said sometimes when she received her food it was cold.
During an interview on 01/04/2026 at 3:46 PM, Resident #13 said the food was cold because it took so long to pass out the food to the halls from the time the food was in the kitchen.
During an interview on 01/05/2026 at 6:02 PM, [NAME] A said she had not received any complaints from the residents about the food being cold. [NAME] A said the residents were supposed to be served a hot meal. [NAME] A said she was not sure how the residents receiving a cold meal could affect them.
During an interview on 01/07/2025 at 11:30 AM, the Dietary Manager said she received cold food complaints from the residents.
The Dietary Manager said the food was hot when it left the kitchen, but sometimes the food was not passed out in a timely manner by the staff.
The Dietary Manager said she had reported the cold food complaints and the food not being passed out in a timely manner to the Administrator, DON, and previous Administrators.
The Dietary Manager said she had suggested closed carts to keep the meals warmer but did not receive any resolution.
The Dietary Manager said the food being cold could make the residents sick or the residents would not eat it.
During an interview on 01/07/2025 at 12:30 PM, the Administrator said he expected the food to be served hot to the residents.
The Administrator said the Dietary Manager was responsible for ensuring this happened.
When asked if the Dietary Manager had told him about the cold food complaints and the trays not being passed out in a timely manner, the Administrator said when the food came out of the kitchen, the nursing department needed to be involved to make sure the food was taken to the residents in a timely manner, so the residents could receive their meals at the appropriate temperatures.
The Administrator said if the food was cold, it was not going to taste good.
Record review of the facility's policy titled, Preparation of Foods, from the Dietary Services Policy & Procedure Manual 2012, indicated, We will establish safe and nutritional preparation of food.
Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value.2.
All food will be prepared by methods that preserve nutritive value, flavor, and appearance with a variety of color, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
Findings included: During an observation on 01/04/2026 at 11:53 AM, temperatures were taken of the food on the steam table by [NAME] A.
The regular texture corn was 130 F, the pureed corn was 130 F, the pureed chicken strips were 132 F.
During an interview on 01/05/2026 at 6:02 PM, [NAME] A said food should be held at least at 140 F. [NAME] A said if the food was not at 140 F, the food should be reheated. [NAME] A said she did not think about reheating the food before serving it because she was just trying to start serving the trays. [NAME] A said not holding food at the correct temperatures could cause the food to be bad.
During an interview on 01/07/2026 at 11:35 AM, the Dietary Manager said food should be held at or above 140 F.
The Dietary Manager said she liked for it to be at 165 F.
The Dietary Manager said if the food temperature was not correct the food should be pulled off, and it should have been reheated to ensure it reached the appropriate temperature.
The Dietary Manager said she had not observed the food temperatures to be incorrect.
The Dietary Manager said the food not being held at the proper temperature could make the residents sick.
During an interview on 01/07/2026 at 12:33 PM, the Administrator said he expected the food to be held above the recommended level.
The Administrator said the Dietary Manager and the dietary staff should ensure they were holding the food at the proper temperatures.
The Administrator said the food not held at the proper temperature could affect the quality of the food the residents received.
Record review of the facility's policy titled, Daily Food Temperature Control, revised 04/09/2025 indicated, We will assure that food is served at a safe temperature.
Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.
This is done to help ensure that food is safe and is served within acceptable ranges.4.
All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above. 5.
Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds.
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Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
Observation revealed refrigerator contained undated food
personal needs shopping. Resident #52 stated he does not know who checks the refrigerator temperature and could not recall the last time he saw a thermometer.
Record review of temperature log for Resident #11's refrigerator from 01/01/26-01/06/26 revealed 45 degrees Fahrenheit each day.
Record review of temperature log for Resident #29's refrigerator from 01/01/26-01/06/26 revealed 33 degrees Fahrenheit each day.
Record review of temperature log for Resident #52's refrigerator from 01/01/26-01/06/26 revealed 32 degrees Fahrenheit each day.
Surveyor notes no thermometer was visible in all three refrigerators from 01/04/2026-01/06/2026.
During an interview on 01/05/2026 at 8:24 a.m., LVN B stated that she does not check the personal refrigerators, and she was not sure who checks them.
During an interview on 01/07/2026 at 8:35 a.m., MA D stated that the maintenance department was responsible for checking the resident's' personal refrigerators and noted that she never opens them.
During an interview on 01/07/2026 at 8:42 a.m., Housekeeper F stated that she does not check their refrigerators for the residents for cleanliness or temperature.
Housekeeper F stated she believed her supervisor was responsible for the refrigerators.
During an interview on 01/07/2026 at 9:15 a.m., CNA H stated she believed the housekeeping staff were responsible for checking the refrigerator temperatures and cleaning the refrigerators.
During an interview on 01/07/26 at 9:50 a.m., the Housekeeping Supervisor stated that the families were responsible for maintaining the refrigerators, but she checked them when she cleans the rooms.
The Housekeeping Supervisor stated she keeps a log of the temperatures and will try to clean them out but stated that a lot of times, the residents do not let me.
The Housekeeping Supervisor stated that it was important to take out old food items because they could make the residents sick and that she would notify the Administrator of any residents who do not allow her to clean their refrigerator.
During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that the facility does allow long term residents to have a personal refrigerator in their rooms.
The Administrator stated that he expects the administrative staff who complete Champion Rounds (daily room checks) to monitor the refrigerator for proper functioning, temperature and ensure no spoiled food items are present.
The Administrator stated he will assist with any residents who refuse to let staff check or clean their refrigerators.
The Administrator stated adverse effects of not having refrigerator temperatures monitored could result in resident eating spoiled food items causing him/her to become ill.
During an interview on 01/07/2026 at 2;30 p.m., the DON stated that she was aware the residents were allowed to have a personal refrigerator and that she believed housekeeping was responsible for monitoring temperatures and cleanliness.
The DOM stated this was a concern she had when she was hired when she learned that not all of the refrigerators had a thermometer and accurate temperatures.
The DON stated that failure to monitor the temperature could result in the residents consuming spoiled food items that would cause them to become sick.
Record review of facility Food and Nutrition Services policy, revised 04/13/2022 revealed resident and/or family members are responsible for monitoring the interior temperature of personal refrigerators to ensure all foods are stored at a safe temperature of 40 degrees Fahrenheit or less.
Additionally, perishable foods should be discarded within 7 days after preparation for food safety.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142
will include:The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form
does not have Medicare Part AHospice Plan of CareCurrent interdisciplinary notes to include nurses
the hospice certification period.
During an interview on 01/07/26 at 2:51 PM The DON said EBP should have been used with foley catheter care, intravenous line care, and when residents have wounds.
The DON said Resident #1 and Resident #26 should have EBP signage and PPE carts outside of their rooms.
The DON said the failure placed a risk for infection.
The DON said the DON and ADON were responsible for ensuring the EBP signage and the carts were in place.
The DON said she asked the Administrator for carts for PPE, but she thought it fell by the side, and she forgot about it.
Record review of the facility policy Enhanced Barrier Precautions undated indicated: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities.
Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs.
Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
Communication to Staff the facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP.
Record review of the facility's policy titled, Perineal Care, effective 05/11/2022 indicated, 10) Perform hand hygiene 11) [NAME] gloves and all other PPE per standard precautions.17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area – CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening.20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27) Clean and store reusable items 28) If visibly soiled or contaminated during the procedure, disinfect or discard the barrier towel on the table 29) Return resident items on the table 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene 32) Thank you: thank the resident for assisting in self-care.
675390 01/07/2026
Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142