Health inspection·May 21, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few imaging technique which uses sound waves to create pictures of internal structures like organs and tissues inside the body) imaging used to look at the speed of blood flow and the structure of veins and/or arteries (blood vessel that carries blood away from the heart) which uses both Doppler (type of ultrasound which aims to assess blood flow) and conventional ultrasound imaging] ordered per [Doctor of Medicine (MD)] for dependent edema [swelling from fluid which pools due to gravity in the hands, feet and legs] .Author: [LVN 5] . The WSD indicated, .Effective Date: [DATE] .Resident . able to make needs known to staff .Will continue with current [Plan of Care (POC)] as ordered .Signed By: LVN 3] . LVN 1 stated, Resident 1 was able to make her needs known to the staff and answer the staff's questions appropriately. LVN 1 stated, a WSD for every resident was required to be completed every week. LVN 1 stated, a schedule was in a binder at the nurse's station and indicated which days and shifts each resident was to be assessed every week, according to room number. LVN 1 stated, Resident 1's last WSD was completed on [DATE] and there was no WSD completed on [DATE]. LVN 1 stated, the WSD was important to assess for any new changes to the Resident 1 and to follow up on those changes with Resident 1's physician, Representative Party (RP) and the Director of Nursing (DON). LVN 1 stated, Resident 1 was sent to the hospital on [DATE] due to a lower leg DVT. During an interview on [DATE] at 10:28 a.m. with LVN 2, LVN 2 stated, a WSD should have been completed on every resident once a week. LVN 2 stated, the WSD was a head-to-toe assessment performed by the nurse to assess for any changes or abnormalities to Resident 1. LVN 2 stated, if there was an issue identified with Resident 1, then the resident would have a nursing assessment performed every day. LVN 2 stated, the WSD was important to perform every week because the nurses could catch a change with Resident 1 like a skin change or other abnormality within the resident. LVN 2 stated, if a change was identified, a Change in Condition (CIC) form would be completed and Resident 1's physician, RP and the administrator would be notified. During a concurrent interview and record review on [DATE] at 11:10 a.m. with the DON, the Station 1 Weekly Summaries and Skin Assessments (WSSA), dated [DATE], and Resident 1's Change in Condition Evaluation (CIC), dated [DATE] were reviewed. The WSSA indicated, .[Night Shift- the shift that facility staff work from 10:00 p.m. until 6:30 a.m. (NOC)] .SUNDAY .1b .NOC SHIFT- please do the weekly summary and body checks for the day you come in (before midnight) . The CIC indicated, .New onset of dark spot to Left lower leg medial [situated towards the middle of the body] area accompanied with pain .This started on XXX[DATE] .Monitored left lower leg pain complaint and noted darkening spot-on medial area. Able to get a copy of doppler study of the lower legs and notified MD of the result. MD ordered to send out to hospital for further evaluation and treatment. MD order carried out. [Responsible Party (RP)] (daughter) notified and amenable resident to be send out to [name of acute care hospital] .Describe skin changes .Discoloration .Site .Left lower leg (front) .New onset of dark spot to left lower leg medial area accompanied with pain .Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain) .5 .Signed By .[Registered Nurse (RN)] . The DON stated, Resident 1's physician ordered an ultrasound of her legs and was completed on [DATE]. The DON stated, on [DATE], Resident 1's daughter was concerned about Resident 1's leg and Resident 1 was complaining of pain. The DON stated, the nurse noticed Resident 1's left lower leg had a dark spot on the medial area of the leg. The DON stated, Resident 1 went to the hospital on [DATE] and was still at the hospital. The DON stated, the final results of the ultrasound were faxed to the facility on the evening of [DATE] and had shown severe bilateral (both sides) arterial (pertaining to an artery) disease, no hemodynamically (how blood flows through your blood vessels) significant stenosis (abnormal narrowing) and a possible occlusion (blockage) of the left proximal (nearer to the center of the body or the point of attachment to the body) deep femoral artery (DFA- a blood vessel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 2 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few in the leg which supplies blood to the thighs and buttocks). The DON stated, a WSD was a head-to-toe assessment completed on each resident every week. The DON stated, the expectation was a WSD was completed to catch new abnormalities or changes with the residents. The DON stated, the WSD was important to ensure care of the Resident's problem before it gets worse. The DON stated, any changes identified during the WSD were reported to the MD, RP and DON. The DON stated, the WSD provided a way for those changes to the residents to be followed up on further. The DON stated, Resident 1's last WSD was completed on [DATE] and she left for the hospital on [DATE]. The DON stated, the CIC on [DATE] showed Resident 1 had a new onset of a dark spot to her left lower leg accompanied by 5/10 (a pain level of 5 based on a based on a scale where 1 is the lowest pain and 10 is the most severe pain) pain. The DON stated, the nurse contacted Resident 1's MD, notified him of the final ultrasound results in addition to the current assessment. The DON stated, based on all the information, the MD ordered for Resident 1 to be sent to the hospital. The DON stated, according to the WSSA, Resident 1 should have had a WSD completed on [DATE] but it was not completed. During a concurrent interview and interview on [DATE] at 12:02 p.m. with the DON, Resident 1's PN, dated [DATE], and MD Progress Note (MDPN) dated [DATE] was reviewed. The PN indicated, [DATE] [6:11 a.m.] .[Doctor] review final results for doppler study gave new order for vascular consult [an appointment with a physician who specializes in the vessels that carry blood in the body] and to elevate bilateral lower extremities. orders carried out resident made aware .Author: [LVN 4] . MDPN indicated, .[DATE]. Upon review of the final results for doppler study the new order is for vascular consult to be scheduled and to elevate bilateral lower extremities .[DATE]. Resident seen today for routine follow- up .had Doppler recently per previous notes but no results are in [computer charting system] .Due to patient's advanced age and multiple comorbid [relating to multiple diseases or medical conditions present in a patient at the same time] conditions patient at high risk for multiple medical complications including but not limited to .DVT . The DON stated, the MD ordered a vascular consult to be made for Resident 1 and to elevate her legs based on the ultrasound results. The DON stated, a vascular consult was never made for Resident 1. The DON stated, there was no documentation of any attempts made to obtain a vascular consult appointment. The DON stated, Resident 1 had not received a WSD since [DATE], did not have a vascular consult appointment made for her and then was sent to the hospital where she was diagnosed with a DVT. During a phone interview on [DATE] at 2:32 p.m. with LVN 3, LVN 3 stated, she was Resident 1's nurse on [DATE] during the AM shift (the shift that facility staff work from 6:00 a.m. until 2:30 p.m.). LVN 3 stated, she received report from the NOC shift nurse on [DATE] who had cared for Resident 1 during the prior night. LVN 3 stated, the NOC shift nurse reported staff attempted to get Resident 1 up from bed and Resident 1's lower extremities had turned a purple color so they laid her back down. LVN 3 stated, because of Resident 1's lower extremity discoloration, the nurse had called Resident 1's MD and received an order to obtain an ultrasound of both lower legs. LVN 3 stated, Resident 1's ultrasound was completed during her AM shift on [DATE]. LVN 3 stated, she had sent the MD a picture of Resident 1's preliminary ultrasound results to MD's cell phone on [DATE]. LVN 3 stated, the MD did not respond to the message so she documented a PN indicating there were no new orders at the time. LVN 3 stated, a WSD was completed once a week for every resident in the facility according to the WSSA. LVN 3 stated, the WSD was important in order to get an update on the resident and assess for any changes from the resident's baseline, which were documented by the nurse. LVN 3 stated, a CIC would be completed if there was a change from baseline. LVN 3 stated, a CIC required the nurse to notify the resident's physician, RP and DON. LVN 3 stated, it was important to follow physician's orders to get the resident the care they needed regarding any underlying issues or new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 3 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm diagnoses they may have had. LVN 3 stated, if the physician gave an order for a vascular consult to be made for a resident, the nurse would have entered an order in the computer charting system, create a PN and notified the DON. LVN 3 stated, the DON, Assistant Director of Nursing (ADON) or a unit manager would have carried out the order and scheduled the consult, according to the physician's orders. Residents Affected - Few During a phone interview on [DATE] at 2:53 p.m. with LVN 4, LVN 4 stated, a WSD was a head-to-toe assessment performed on each resident once a week. LVN 4 stated, a WSD was important to complete every week to assess for any changes which may have developed or progressed since the previous week. LVN 4 stated, she had texted the MD Resident 1's final ultrasound results on [DATE] at approximately 3:00 a.m. and the MD had responded back they already knew Resident 1 needed a vascular consult. LVN 4 stated, the MD did not specify who already knew about the vascular consult. LVN 4 stated, there was no order in the computer charting system so she put in the order for the Resident 1's vascular consult on [DATE]. LVN 4 stated, she gave report to the AM shift nurse on [DATE] and told her about the MD's response to the final ultrasound results and the AM shift nurse responded saying everybody knew about the vascular consult. LVN 4 stated, the former ADON was the staff member who normally handled all the resident's referrals and appointments. LVN 4 stated, she was not informed by management who was in charge of creating the appointments currently, but assumed the new ADON would make the appointments. LVN 4 stated, it was important to follow the physician's orders in order to prevent the resident's condition from getting worse and being overlooked. During a phone interview on [DATE] at 4:48 p.m. with RN, RN stated, she worked with Resident 1 on [DATE] during the PM shift (the shift that facility staff work from 2:00 p.m. until 10:30 p.m.). RN stated, Resident 1's daughter wanted RN to assess Resident 1's left lower leg on [DATE] because it appeared abnormally swollen. RN stated, she assessed Resident 1's left lower leg and noticed some increased swelling compared to Resident 1's right lower leg. RN stated, she searched in the computer charting system and saw PNs about an ultrasound which was completed for Resident 1, but could not find any results. RN stated, RN asked the DON about where she could find Resident 1's final ultrasound results and the DON instructed RN to call the diagnostic imaging company to obtain the results. RN stated, she received the final results from the [DATE] ultrasound on [DATE] via fax and RN stated she saw there may be a possible occlusion according to the ultrasound results. RN stated, she immediately sent the results to the MD but he did not reply that night. RN stated, she informed the [DATE] NOC shift nurse about the ultrasound results, the swelling to Resident 1's left lower leg and they were awaiting a reply from the MD. RN stated, the MD texted RN back on the morning of [DATE] and RN forwarded the message to the nurse working the [DATE] AM shift. RN stated, she worked the PM shift on [DATE] and around 2:30 p.m., she finished receiving report and went to check on Resident 1. RN stated, Resident 1 had a significant change with increased swelling and a dark-colored spot to the left lower medial leg with 5/10 pain. RN stated, this increased change to Resident 1's condition coupled with the ultrasound results showing a possible clot (clumps that occur when blood hardens from a liquid to a solid) made her contact the MD again. RN stated, the MD immediately ordered Resident 1 to be sent out to the hospital. RN stated, an emergency room (ER) doctor from the hospital Resident 1 was sent to had called RN and informed her Resident 1 was diagnosed with a DVT. RN stated, a DVT can travel to the heart and cause a heart attack (occurs when blood flow to the heart is blocked, depriving the heart muscle of oxygen) or travel to the brain and cause a stroke (occurs when blood flow to the brain is disrupted, leading to damage or death of brain tissue). RN stated, a WSD was a head-to-toe assessment required to be completed on every resident in the facility and divided up evenly according to a schedule. RN stated, a WSD was completed to check for changes to the resident because often elderly residents would not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 4 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few tell you about their problems, so the nurse needed to complete an assessment to look for those changes. RN stated, a WSD helped identify changes to vital signs (measurements of the body's most basic functions), swelling, new skin conditions or other changes beyond the resident's usual baseline. RN stated, it was important to follow physician's orders because there could be harm to the resident if orders aren't followed. RN stated, the facility's goal was to heal the resident. During a phone interview on [DATE] at 1:09 p.m. with LVN 5, LVN 5 stated, on [DATE], Resident 1's daughter had Resident 1 sitting up in bed and Resident 1's legs became discolored. LVN 5 stated, Resident 1's legs looked pinkish, reddish, not quite purple in color. LVN stated, Resident 1 also had swelling to one leg, but could not recall which leg had more swelling than the other. LVN 5 stated, Resident 1's daughter had stated Resident 1 had never seen a vascular physician before and requested some sort of scan to be performed because Resident 1 had some issues with blood flow to her feet. LVN 5 stated, she elevated Resident 1's feet, contacted the MD and he ordered a doppler scan for Resident 1's legs. LVN 5 stated, although she did notify Resident 1's physician of the change in condition, she did not complete a CIC form on [DATE] and should have completed a CIC form. LVN 5 stated, a CIC form was completed when there was a change identified in the resident. LVN 5 stated, a CIC required the nurse to notify the resident's physician, RP, and the DON. LVN 5 stated, a CIC prompted the MD to respond with orders and the staff would follow the orders. LVN 5 stated, a CIC sometimes prompted the nurses to monitor a resident more closely for 72 hours. LVN 5 stated, a CIC was important because it provided documentation of what change occurred, created a plan to look further into the change in condition, and treated the Resident accordingly. LVN 5 stated, Resident 1 should have received the treatment and care she required to better her health, ensure dignity and for her overall well-being. During a phone interview on [DATE] at 1:39 p.m. with the MD, the MD stated, Resident 1 had a blood clot in her leg and was sent to the hospital on [DATE]. The MD stated, Resident 1 had swelling to her lower extremities so he ordered the Duplex scan. The MD stated, the preliminary results for the Duplex scan came back on [DATE] and appeared normal so he wanted to wait for the final results to come in. The MD stated, Resident 1's final Duplex scan results from [DATE] showed a possible occlusion of the DFA with severe bilateral lower extremity (BLE- both lower legs) peripheral artery disease (PAD- condition where narrowed blood vessels reduce blood flow to the legs or arms). The MD stated, he had ordered Resident 1 to receive a vascular consult and for staff to elevate Resident 1's feet to help reduce the swelling. The MD stated, he does not remember if staff made him aware if Resident 1 was in pain or not. The MD stated, Resident 1 was sent out to the hospital on [DATE] because Resident 1 complained of pain in addition to the [DATE] Duplex scan results. During an observation and interview on [DATE] at 2:12 p.m. with Resident 1 in her hospital room, Resident 1 was laying in her hospital bed. Resident 1 stated, her leg was sore. During an interview on [DATE] at 2:20 p.m. with the Hospital RN Charge Nurse [HRNCN], the HRNCN stated, Resident 1 came from the Skilled Nursing Facility for shortness of breath (SOB) and discoloration to her leg. HRNCN stated, Resident 1 was diagnosed with a left lower extremity DVT. HRNCN stated, Resident 1 had a successful suction thrombectomy [medical procedure which involves the removal of a blood clot from a blood vessel] with the removal of a large amount of chronic [continuing over a long time] and acute [sudden onset] clots and an Inferior Vena Cava (IVC) filter (small, metal device placed in a large blood vessel in the abdomen to prevent blood clots from traveling to the lungs which can be life-threatening) placed. During a concurrent phone interview and record review on [DATE] at 11:32 a.m. with the DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 5 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few Resident 1's Preliminary Lower Arterial Ultrasound Report (PLAUR), dated [DATE], and Resident 1's Lower Bilateral Arterial Final Report (LBAFR), dated [DATE] were reviewed. The PLAUR indicated, PRELIMINARY LOWER ARTERIAL ULTRASOUND REPORT XXX[DATE] .12:27 pm .[Resident 1] .Indication: Edema .RIGHT/ LEFT/ BOTH LEGS WERE EVALUATED TO ASSESS ARTERIAL FLOW .TECHNICALLY ADEQUATE/ INADEQUATE STUDY . The PLAUR indicated, handwritten ovals were circled around the words BOTH LEGS and ADEQUATE. The LBAFR indicated, .PROCEDURE: Lower Bilaterial Arterial. The DON stated, signs and symptoms of a DVT were swelling, pain and a difference in appearance between one leg and the other leg. The DON stated, a venous ultrasound was needed to confirm a DVT diagnosis, not an arterial ultrasound. The DON stated, according to the PLAUR and LBAFR, Resident 1 had a lower extremity arterial ultrasound completed. The DON stated, the only ultrasound completed for Resident 1 during her admission to the skilled nursing facility was on [DATE]. The DON stated, a CIC was conducted when nurses identified any symptoms and symptoms of any changes like abnormal swelling or other changes to the resident's condition that wasn't there previously. The DON stated, the nurses were expected to contact the resident's physician, family and sometimes the DON when a CIC was completed. The DON stated, a CIC was important to communicate changes to the physician, follow physician's orders and resolve issues to prevent the issues from developing further. The DON stated, when LVN 5 had identified a change to Resident 1's legs on [DATE], a CIC should have been completed. The DON stated, if RN identified a change to Resident 1's legs on [DATE], a CIC should have been completed. The DON stated, on [DATE], she had told RN to call the imaging diagnostic company to obtain the final ultrasound results from [DATE]. The DON stated, it was important for residents to receive the care and treatment they require because otherwise the resident's problems and concerns could progress negatively. During a phone interview on [DATE] at 1:05 p.m. with the MD, the MD stated, when an ultrasound was ordered, the diagnostic imaging company could assess both the veins and arteries or sometimes just the arteries. The MD stated, Resident 1 had two prior ultrasound scans completed during her hospitalization prior to admission at the skilled nursing facility and both scans were negative for DVTs. The MD stated, a DVT could have developed at any time. The MD stated, Resident 1 was sent to the hospital on [DATE] due to the acute pain, swelling and skin changes. During a phone interview on [DATE] at 2:02 p.m. with the US Imaging Company Co-Owner (USIC), the USIC stated, the MD's order for Resident 1's US on [DATE] was may have duplex scan to bilateral extremities to rule out edema. The USIC stated, the order did not state which extremities the MD wanted the ultrasound to be performed on so the US technician needed to clarify the order. The USIC stated, LVN 5 confirmed the order and another nurse revised the order at the facility on [DATE]. The USIC stated, Resident 1 had a bilateral lower extremity arterial ultrasound performed on [DATE]. The USIC stated, the US results on [DATE] showed Resident 1 had severe bilateral arterial disease, no arterial stenosis and a possible occlusion of the left proximal DFA. The USIC stated, a DVT would have only been able to be seen on a venous ultrasound, not an arterial ultrasound. During a review of Resident 1's Hospital US Final Report (USFR), dated [DATE], the USFR indicated, .US Lower [Extremity] Vein Duplex [Left] .There is no evidence of deep venous thrombosis .Unremarkable left lower extremity duplex venous ultrasound . During a review of Resident 1's PN, dated [DATE], the PN indicated, .Ultrasound doppler scan performed this shift .[related to] edema noted to bilateral lower extremities. Preliminary report sent to MD, [no new orders] at this time. Final report pending .Author: [LVN 3] . During a review of Resident 1's LBAFR, dated [DATE], the LBAFR indicated, .PROCEDURE: Lower Bilaterial Arterial .a real-time lower extremity arterial Doppler study with image documentation was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 6 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few performed .REASON FOR EXAM .Peripheral vascular disease .CONCLUSION: 1. Severe bilateral lower extremity arterial disease. 2. No hemodynamically significant stenosis is identified on either side. 3. Possible occlusion of [left proximal] DFA . The LBAFR indicated, the fax date and timestamp at the top of pages one and two was [DATE] at 11:01 p.m. The LBAFR indicated, a handwritten note at the bottom of page one which specified Sent to [MD]. During a review of Resident 1's PN, dated [DATE], the PN indicated, .Notified MD of resident's severe pain on left lower leg when touched. With a spot with darkened color. MD ordered to send out to hospital. MD order carried out .sent out to [name of acute care hospital] .Author: [RN] . During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, .Darkening spot on left lower leg- medial area accompanied with pain . Interventions .Coordinate with health team members on the results of the diagnostic studies .Monitor for any changes and notify [Doctor of Medicine (MD)] .Notify MD and RP . During a review of Resident 1's MDPN, dated [DATE], the MDPN indicated, .Electronically Signed and Reviewed by [MD] [DATE] [10:25 p.m.] .[DATE]. The patient was sent out to acute for severe [left lower extremity (LLE)] pain. There was suspicion for DVT . Reports from 5/8 show severe BLE PAD and possible occlusion of left proximal DFA unknown chronicity [how long condition has persisted over time]. In the absence of DVT on [preliminary] results patient was not started on blood thinners [medications that help prevent blood clots from forming or growing larger] or statins [type of medication used to reduce levels of fats in the blood]. Risk factors will include a recent diagnosis of cancer .and limited mobility [ability to move] . During a review of Resident 1's Hospital Hospitalist History & Physical (H&P), dated [DATE], the H&P indicated, .Patient presents with .SOB .swelling and discoloration to left lower calf sent out to [rule out] DVT .Patient endorses progressive swelling and pain in her left lower leg over the past week .Denies history of DVT or [Pulmonary Embolism- a sudden blockage of a blood vessel in the lungs, typically caused by a blood clot that has traveled from another part of the body, often a leg vein (PE)] .Has outpatient arterial doppler .Severe bilateral lower extremity arterial disease .No hemodynamically significant stenosis is identified on either side .Possible occlusion of [left proximal] DFA .LLE edema and tenderness . During a review of Resident 1's Hospital [Interventional Radiology - medical specialty that performs various minimally invasive procedures using medical imaging guidance (IR)] Thrombectomy Venous Left Final Results (IRT), dated [DATE], the IRT indicated, .PROCEDURE: Left lower extremity DVT thrombectomy .Left lower extremity swelling and pain found to have extensive DVT .DVT thrombectomy was requested .Suction thrombectomy was performed of the left lower extremity with aspiration [drawing something out using a sucking action] of large amount of clot . During a review of Resident 1's Interdisciplinary Progress Notes (IPN), dated [DATE], the IPN indicated, .Brought forward for review; resident [complained of] pain to LLE, nurse noted darkening spot to medial lower extremity. MD notified and ordered to send resident to acute [due to] doppler study showing possible occlusion of [left proximal] DFA. Resident sent out to acute care . During a review of Resident 1's Hospital Hospitalist Daily Progress Note (HDPN), dated [DATE], the HDPN indicated, .As per IR .Extensive LLE DVT Successful suction thrombectomy with removal of large amount of chronic and acute thrombus .Successful placement to infrarenal [situated below the kidney] IVC filter . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 7 of 8 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 05/21/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's Order Summary Report (OSR), dated [DATE], the OSR indicated, .Elevate [bilateral] lower extremities every shift for related to edema XXX[DATE] .May have Vascular consult XXX[DATE] .May send out to hospital for further evaluation and treatment XXX[DATE] . During a review of the facility's document titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), dated 5/22, the document indicated, .The primary purpose of this position is to provide nursing care to residents under the supervision of a physician and/or registered nurse .Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care .Monitor residents for and immediately report developments of acute changes of condition .Maintain documentation of all nursing care and services provided to residents .Transcribe telephone, verbal .orders from providers as appropriate .Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care .Must be able to communicate information concerning a resident's condition . During a review of the facility's document titled, Registered Nurse (RN), dated 5/22, the document indicated, .The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician .Ensure .periodic comprehensive assessments and care plans are completed with required timeframes .Initiate requests for consultations or referrals as requested .Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc .Provide nursing services to residents in accordance with scope and practice, facility policies and professional standards of care .Monitor residents for developments of acute changes of condition .conduct assessments and notify the provider as needed .Monitor the chronic health conditions of residents; be familiar with reportable changes and potential causes for concern .Maintain documentation of all nursing care and services provided to the residents .Transcribe telephone, verbal .orders from providers as appropriate .Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served .Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care .Must be able to communicate information concerning a resident's condition . During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, dated [DATE], the P&P indicated, .PURPOSE .to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition .A Facility must immediately inform the resident, consult with a Resident's physician and/or [Nurse Practitioner], and notify, consistent with his/her authority, Resident Representative when there is .A signific[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055573 If continuation sheet Page 8 of 8