Health inspection·January 24, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Order Summary Report (OSR) , dated 1/23/25, the OSR indicated Resident 1 had a physician's order for [Security Bracelet]/Wander Elopement Device due to poor safety awareness[.] During a review of Resident 1's Elopement Evaluation (EE) , dated 5/30/24, the EE indicated Resident 1 was able to ambulate or self-propel wheelchair independently and had expressed a desire to leave [the facility]: e.g., go home, talked about going on a trip, attempted to pack belongings[,] and Resident [1] desire to leave[.] During a review of Resident 1's EE , dated 7/29/24, the EE indicated Resident 1 continued to be able to ambulate or self-propel wheelchair independently and had again expressed a desire to leave [the facility]: e.g., go home, talked about going on a trip, attempted to pack belongings[.] The EE dated 7/29/24 also indicated Resident 1 had additional risk factors identified, including has a history of actual elopement or attempted elopement[,] has a history of wandering that places the [resident] at significant risk of getting to a potentially dangerous place, e.g., stairs, outside facility[,] has a history of wandering that significantly intrudes on the privacy and/or activity of others[,] [was] unable to locate significant landmarks without assistance, e.g., bathroom, dining room, patient room[,] exhibits attempts to maintain daily routines and leisure interests not consistent with their new environment routines that may result in exit-seeking behavior[.] During a review of the facility's Policy and Procedure (P&P) titled Elopement of Resident , dated 7/12/23, the P&P indicated, Residents will be evaluated for elopement risk upon admission, re-admission, quarterly [every three months] and with a change of condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention person-centered care plan will be developed. During an interview on 1/24/25, at 1:50 p.m., with the Director of Nursing (DON), the DON stated, [Resident 1] had not ever attempted to elope from the facility before. She didn't have a [security bracelet on, but we have a [security bracelet] on [Resident 1] now. The DON stated Resident 1 was alert to person only [but did not normally know where she was or what the time and date was] and has forgetfulness. During an observation on 1/24/25, at 1:55 p.m., Resident 1 was observed sitting in a wheelchair near the nursing station, with a security bracelet on her left ankle. During an interview on 1/24/25, at 2 p.m., with the Administrator, the Administrator stated the facility just started using a security bracelet with Resident 1. During an interview on 1/24/25, at 2:30 p.m., with the Administrator, the Administrator stated it was determined Resident 1 did not have a security bracelet on when she eloped from the facility. During an interview on 1/30/25, at 10:22 a.m., with LVN 1, LVN 1 stated she was Resident 1's nurse during the night shift ending on the morning of 1/23/25. LVN 1 stated she was giving medications to Resident 1's roommate at about 4:40 a.m. and noted Resident 1 to be asleep in her bed at that time. LVN 1 stated prior to that, Resident 1 was confused, and had been up all night that night, up in her wheelchair, at the nurses' station, talking to me about her husband and taxes. She was trying to go into other resident rooms, we had to redirect her from going into other's rooms. But I've never seen her try to elope before. LVN 1 stated at approximately 4:50 a.m., a kitchen staff person told her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 2 of 3 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 01/24/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Resident 1 was outside the facility and brought her back inside. LVN 1 stated Resident 1 was wearing a shirt and pajama pants. LVN 1 stated, She was in bed just a few minutes [prior to this. Resident 1] can self-transfer [from bed to wheelchair], she is pretty quick in her wheelchair. LVN 1 stated when Resident 1 was returned to the facility, she was confused. Every time I asked her where she was going, she had a different answer. Residents Affected - Few During a concurrent interview and record review, on 2/4/25, at 11:55 a.m., with the Minimum Data Set Nurse (MDS-N), Resident 1's clinical record was reviewed. The MDS-N stated that Elopement Assessments (EE) are normally done prior to the completion of an MDS, which are conducted no less frequently than quarterly. The MDS-N stated she did not see a quarterly EE performed for Resident 1 for the Quarterly MDS completed on 11/7/24, as required by the facility's P&P titled Elopement of Resident . The MDS-N stated, I do not see one. During a concurrent interview and record review, on 2/4/25, at 12:57 p.m., with the DON, Resident 1's clinical record was reviewed. The DON stated Resident 1's Care Plan regarding her Risk for Elopement was created on 1/23/25. The DON stated she herself initiated this Care Plan and the interventions. The Care Plan Interventions included, Utilize and monitor security bracelet per protocol. The DON stated this Care Plan dated 1/23/25 was the first Care Plan in Resident 1's clinical record regarding her elopement risks. The DON stated Resident 1's EE dated 7/29/24 indicated a significant increase in elopement risk factors over the EE dated 5/30/24. The DON stated she did not consider Resident 1's 7/29/24 EE to be inaccurate but could not find any corroborating evidence elsewhere in the clinical record. The DON stated there should have been another EE done in November 2024, to coincide with the MDS dated [DATE], and could not find one. The DON stated an Elopement Risk Care Plan and corresponding interventions to reduce the risk of Resident 1's elopement risks should have been further evaluated in July 2024, in response to the EE dated 7/29/24. During a review of the facility's Policy and Procedure, dated 12/12/24, titled Tab Alarms, Bed Alarms, [Security Bracelet] System (P&P) , the P&P indicated, [Security Bracelet] would be used for residents at risk for elopement. The [Security] bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed. During a review of the National Weather Service website (NWS) Climatological Data for the facility's area, dated 1/23/25, the NWS indicated the area had an overnight low temperature of 36 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 3 of 3