Health inspection·May 31, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based 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. FINDINGS: During an interview on 9/13/23 at 8:35 a.m. with Social Service Director (SSD), SSD stated she was aware Resident 1 had eloped from previous Skilled Nursing Facilities (SNF) but she had never eloped from current SNF. SSD stated she did not know if Resident 1 had a care plan for Elopement. During a concurrent interview and record review on 9/13/23 at 8:48 am with Licensed Vocational Nurse (LVN) 1, Patient 1's care plans, nurses notes dated 8/23/23, and elopement evaluations dated 8/10/23 and 8/23/24 were reviewed. LVN 1 stated Resident 1 often talked about how she wanted to get out of this place . LVN 1 read the nurses note from 8/23/23 by LVN 2 which indicated the facility had been made aware of Resident 1 attempting to elope from the dialysis center on 8/23/23. LVN 1 validated Resident 1 had an elopement evaluation completed on 8/10/23 that indicated Resident 1 was not a risk for elopement as she was not able to ambulate or self-propel in wheelchair independently, and an elopement evaluation completed on 8/23/23 which indicated Resident 1 could self-propel in wheelchair independently, had a history of actual elopement or attempted elopement, had a history of wandering that placed the patient at significant risk of getting to a potentially dangerous place outside the facility, and was at risk for elopement. LVN 1 stated there should have been a care plan made for Resident 1 on elopement risk as soon as she was identified as being at risk. During an interview with Resident 2 on 9/13/23 at 8:50 am, Resident 2 stated she had been Resident 1's roommate. Resident 2 stated Resident 1 was always talking about going home and had said she had a check coming, and a lot of food stamps waiting for her. Resident 2 stated Resident 1 was always saying she was leaving in a couple days. During a concurrent interview and record review with SSD on 9/13/23 at 8:57 am, Resident 1's records were reviewed. SSD confirmed Resident 1 did not have a care plan initiated for wandering or elopement and there had been no communication to the transportation company regarding Resident 1 being a wandering risk. During a concurrent interview and record review with Minimum Data Set Coordinator (MDSC) on 9/13/23 at 9:12 am, Resident 1's Minimum Data Set (MDS) section C (Brief Interview for Mental Status/ BIMS) (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055573 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)