Inspection·April 5, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to provide safe storage and labeling of medications when: 1. A Lantus insulin pen (injectable medication to help control elevated blood sugar levels), was found in Medication Cart 3 with no open date written on the pen. 2. Two expired medications were found in Medication Cart 1. These failures had the potential for residents to receive ineffective medication which could lead to a lack of treatment of symptoms for which the medication was prescribed. Findings: 1. During a concurrent observation of Medication Cart 3 and interview with the Director of Nursing (DON), on 4/5/19, at 9:56 AM, an insulin pen was found in a drawer unopened and undated. The medication label indicated the medication was to be refrigerated until opened and discarded 28 days after opened. The DON stated the medication should have been left in the refrigerator until opened or dated. The DON stated when the medication was taken out of the refrigerator it should have dated and then considered opened. The facility policy and procedure titled Medication Storage in the Facility dated 9/25/12, indicated medications requiring refrigeration were kept at temperatures ranging from 36 degrees to 46 degrees in a refrigerator with a thermometer to allow temperature monitoring. 2. During a concurrent observation of Medication Cart 1 and interview with the DON, on 4/5/19, at 10:11 AM, an unopened box of Nitroglycerin (a medication to treat chest pain) sublingual (dissolved under the tongue) tablets 0.3 milligram (mg- a dry unit of measurement) was found with an expiration date of 4/4/19. The DON stated the medication was an as needed medication and the expiration date had passed. During a concurrent observation of Medication Cart 1 and interview with the DON, on 4/5/19, at 10:13 AM, an unopened package of Cyclobensapr (medication used to treat and relax muscle spasms) 10 mg was found with an expiration date of 2/23/19. The DON stated the medication was an as needed medication and the expiration date had passed. The facility policy and procedure titled Medication Storage in the Facility dated 9/25/12, indicated, .Outdated medications were immediately removed from stock, disposed of according to procedures for medications destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 2 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure the kitchen staff demonstrated the appropriate competencies and skills to safely and effectively carry out the functions of the food and nutrition service when: 1. [NAME] 1 failed to follow proper hand hygiene and glove usage while preparing and serving food. 2. [NAME] 2 was not able to verbalize appropriate cool down procedures. These failures placed the 63 residents in the facility at risk of getting food-borne illness. Findings: 1. During an observation of the lunch meal service on 4/2/19, at 11:45 AM, [NAME] 1 used the same gloved hands to touch cooked ham, the paprika container from the spice shelf, and the cooked sweet potatoes. [NAME] 1 then removed her gloves, grabbed a clean spatula, returned to meal service, and donned gloves without washing her hands between tasks. During a concurrent observation of pureed food preparation and interview with [NAME] 1 in the kitchen, on 4/3/19, at 10:58 AM, [NAME] 1 stated there were eight residents on pureed diets and she was preparing 10 servings of pureed Salisbury steak. [NAME] 1 removed the Salisbury steak from the oven; put on gloves without washing her hands; touched a tray, thermometer, counter, and drawer handle; then used a spatula and her gloved hand to stack the Salisbury steak. With the same gloved hands, [NAME] 1 used a thermometer to check the temperature of the Salisbury steak, cleaned the thermometer, and put it away. [NAME] 1 then used the spatula and a gloved hand to transfer the Salisbury steak to a holding tray, removed her gloves, and washed her hands. With bare hands, [NAME] 1 held a measuring cup with her fingers inside, and her thumb outside of the cup; put the measuring cup on the counter; and touched the recipe book. [NAME] 1 then put gloves on her hands without first washing her hands, poured half a cup of milk in the measuring cup, opened the microwave, and put the milk into the microwave. [NAME] 1 proceeded with the same gloved hands to puree fettuccini alfredo. During a concurrent interview with the Registered Dietitian (RD) and review of the facility policy titled Sanitation and Infection Control, Subject: Handwashing dated 2018, on 4/4/19, at 11:44 AM, the policy indicated Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment .When to wash hands .Before and after handling foods . The RD stated dietary servers were to change their gloves and wash their hands if they changed tasks and between touching foods and touching other items such as a microwave or a refrigerator. During a review of the facility Food Service In-service titled Infection control, kitchen sanitation, hand washing dated 3/27/19, indicated [NAME] 1 attended the in-service. The in-service was conducted by the Food and Nutrition Director (FND). The In-service document did not contain documentation of how the competency was evaluated after the In-Service was given. During a record review of [NAME] 1's Competency Checklist for Department of Nutrition and Food Service dated 1/29/19, indicated the competency criteria/task Sanitation: proper hand washing, use gloves correctly change gloves when necessary . before handling ready to eat food, before beginning a different task . The competency document indicated hand washing was performed with a check mark, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 3 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0802 column of the date instruction given and the approved date/initial were left blank. Level of Harm - Minimal harm or potential for actual harm During an interview with FND, on 4/4/19 at 2:11 PM, she stated her check mark on the competency checklists indicated she saw the employee correctly perform tasks over the course of the year by watching the employee and asking the employee questions pertaining to the topics on the competency checklist. FND stated if there were no concerns with the employee's performance, she checked off the task. Residents Affected - Many 2. During a concurrent interview with [NAME] 2 and review of facility document titled .Cooling and Reheating Log, Time and Temperature Log for Potentially Hazardous Food on 4/3/19, at 2:29 PM, [NAME] 2 reviewed the document and stated after two hours the food needed to be 70 degree Fahrenheit (°F), then after an additional four hours needed to be 41 °F or less. If the temperature of the food was 80 degrees F at two hours, [NAME] 2 stated she would keep cooling since they had four more hours to cool the food to 41 degrees F. [NAME] 2 repeated the same process multiple times. The Cooling and Reheating Log indicated This method should not be interpreted as allowing 6 hours to cool food from 140 degrees to 41 degrees! . The facility policy and procedures titled Food Preparation, subject: Cool Down dated 2018, indicated .Food must be cooled to 70 degrees F within two hours and then to 41 degrees F within the next four hours .if food does not reach 41 degrees F within six hours, reheat until the inner temperature reaches 165 degrees F for at least 15 seconds and re-start the process (Allowance one time). During a review of the In-service titled Food Safety and Sanitation: Pre-survey prep with objectives: Reviewing with staff-handwashing .food cooling log . dated 5/2/18, [NAME] 2's signature indicated she attended. The in-service was conducted by RD. The evaluation section in the document indicated RD asked questions of staff to test their knowledge following the in-services, but was not specific about what questions were asked or to which staff. During a record review of [NAME] 2's Competency Checklist for Department of Nutrition and Food Service, dated 1/11/19, indicated one competency criteria/task Cool down (what are cool down logs, how are they used, which food item needs to have a cool down log), but there was no evaluation of competency of cool down procedures on the checklist. There was a check mark next to it dated 1/11/19, but the columns of approved with date/initials and date instruction given were left blank. During a concurrent interview with FND and record review of [NAME] 2's Competency Checklist for Department of Nutrition and Food Service, dated 1/11/19, on 4/4/19 at 2:43pm, she stated the check mark for Cool down (what are cool down logs, how are they used, which food item needs to have a cool down log) meant either she observed [NAME] 2 perform the task correctly or [NAME] 2 answered questions correctly about the task. FND confirmed the column for the date the instruction was given was left blank. The facility policy and procedure titled Orientation, In-service, & Personnel Management undated, indicated, Employee In-service Education indicated, Policy: Employees will be provided with in-services on a regular basis to provide Continuous education .Procedures: .5. Staff will be in serviced monthly on various topics, including but not limited to: a. Sanitation and infection control .g. Food handling (HACCP) and preparation. The facility policy and procedure titled Orientation, In-service, & Personnel Management undated,Employee Orientation Program indicated, Policy: All employees will receive orientation and on-going in-service education to ensure adequate knowledge and competence in all areas of food service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 4 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0802 Level of Harm - Minimal harm or potential for actual harm Procedures: .4. New employees will be trained on the job and competence verified before performing assigned duties. 5. Each new employee and DSS will sign and date a formal record of the orientation, such as an Employee Orientation Checklist and Job Skills Evaluation, upon completion. A copy of the checklist is kept on file . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 5 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD) approved menus were followed for the lunch meal on 4/2/19 when: Residents Affected - Some 1. Ten of 13 sampled residents (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) on a carbohydrate (CC - sugars, starch [foods such as bread], and cellulose [vegetable fibers]) diet were served one-half of a brownie at lunch and the therapeutic diet menu indicated residents should receive one brownie. 2. One of one sampled residents (Resident 23) on a large portion diet was served five and a half ounces of ham instead of four ounces of ham as indicated by the therapeutic menu which resulted in this resident receiving a larger portion than prescribed. 3. One of one sampled residents (Resident 11) on a vegetarian diet was served food items not listed on the vegetarian menu. These failures had the potential to result in residents receiving over nutrition, under nutrition, or repetitive food items which could lead to disinterest of meals and could result in unintended weight loss or gain. Findings: 1. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2/19, indicated the following lunch items were included in the CC diet: 3 ounces glazed ham, one-half baked sweet potato, one-half cup of capri blend vegetables, one cornbread, one brownie, diet beverage, and whole milk. During a concurrent observation of the lunch meal service and interview with Dietary Aid (DA) 1, on 4/2/19, at 11:49 AM, she stated all residents on the CC diet get small (one-half) brownies. During an observation of the lunch meal service on 4/2/19, at 11:49 AM, 10 of 13 residents (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) on the CC diet received the small (one-half) brownie on their lunch trays. During a concurrent interview with the Food and Nutrition Director (FND) and record review of the 4/2/19 therapeutic lunch menu, on 4/2/19, at 12:17 PM, she stated all residents on the CC diet get a small (one half) brownie. After reviewing the therapeutic lunch menu, FND stated all residents on the CC diet should have received a full brownie and instructed the kitchen staff to start giving the residents on the CC diet a full brownie on their tray beginning immediately. During a record review of the lunch meal service diet slip titled Noon Meal - Tuesday, dated 4/2/19, indicated, 10 of 13 residents on the CC diet received one-half brownie (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) instead of one brownie. During an interview with the RD, on 4/4/19, at 11:44 AM, she stated the kitchen staff should have followed the therapeutic menu prescribed portion size and provided one brownie to residents on the CC diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 6 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2/19, indicated, the regular portion of ham was three ounces and a large portion should be four ounces. The menu indicated residents on a fortified diet were to receive six ounces of super soup. During an observation of the lunch meal service, and a concurrent record review of the lunch diet slip titled Noon Meal - Tuesday, dated 4/2/19, at 12:22 PM, indicated Resident 23 was on a regular, fortified, large portion, chopped meat diet. Resident 23 was served two slices of ham chopped, one baked sweet potato, one-half cup of capri blend vegetables, one piece of cornbread, one brownie, diet beverage, and six ounces of super soup. During a concurrent observation and interview with [NAME] 1, on 4/2/19, at 12:23 PM, [NAME] 1 stated she served Resident 23 two slices of ham for the large portion. [NAME] 1 stated all slices of meat were sliced to three ounces prior to cooking. She weighed one slice of ham at three ounces and two slices of ham at five and a half ounces. [NAME] I stated resident 23 received the wrong ham portion size. She stated Resident 23 received five and a half ounces of ham instead of four ounces of ham as indicated by the therapeutic larger portion menu. 3. During a concurrent observation of the lunch meal service and record review of therapeutic diet menu titled Week 3 Tuesday dated 4/2/10, at 12:23 PM, indicated, Resident 11 was given a grilled cheese sandwich, vegetable blend, and a brownie. The therapeutic diet menu did not indicate specific vegetarian diet meal options to serve residents. During an interview with [NAME] 1, on 4/3/19, at 9:40 AM, she stated Resident 11 was the only resident on the vegetarian diet and she would ask the FND what the resident was supposed to be served. FND stated Resident 11 was served vegetarian food items depending on what the facility had available. [NAME] 1 stated Resident 11 would have the veggie patty instead of Salisbury steak for lunch that day. During a concurrent lunch meal observation and interview with Resident 11 in the dining room, on 4/3/19, at 12:35 PM, Resident 11 stated the facility did not have many vegetarian options for her. Resident 11's lunch meal tray consisted of: fettuccini Alfredo, one veggie patty, green beans, pineapple pieces and a roll. During an interview with the FND, on 4/3/19, at 2:34 PM, she stated the facility had a vegetarian resident and a vegetarian menu but they did not use it. FND stated the vegetarian menu was the same as the regular menu except for the meat. FND stated the facility did not follow the vegetarian menu because Resident 11 did not like some of the options. FND stated the cooks communicate amongst themselves to make sure Resident 11 did not have the same thing every meal. FND stated the cooks determined the protein equivalent food option for the resident. She stated Resident 11 was not told of her vegetarian options but Resident 11 could ask if she wanted to know. FND stated the facility did not have a written record of vegetarian protein items Resident 11 had served. During an interview with [NAME] 2, on 4/3/19 at 2:47 PM, she stated Resident 11 would receive a veggie patty for dinner. The FND interrupted the interview and told [NAME] 2 that Resident 11 was served a veggie patty for lunch. [NAME] 2 stated she would change the option and Resident 11 would be served a grilled cheese sandwich for dinner. The FND interrupted the interview once again and told [NAME] 2 that Resident 11 was served a grilled cheese sandwich for lunch the day before. [NAME] 2 stated the facility serves Resident 11 what is on the menu. [NAME] 2 stated she would ask the AM cook what Resident 11 was served for lunch and tried not repeat the same item. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 7 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0803 Level of Harm - Minimal harm or potential for actual harm During a review of facility Vegetarian Menu titled Week 3 .Vegetarian ., dated 4/2/19, indicated, the lunch meal was: sautéed tofu, baked sweet potato, vegetable blend, cornbread with margarine, and brownie. The vegetarian menu dated 4/3/19 indicated, the lunch meal was: black eye pea patty, fettuccini Alfredo, green beans, roll with margarine, and pineapple. The menu dated 4/3/19, indicated, the dinner meal was: Vegetarian chili, green salad, cornbread, and fruit cocktail. Residents Affected - Some During a concurrent interview with the RD and the FND and record review of the Week 3 . Vegetarian Cycle, on 4/4/19, at 10:23 AM, RD and FND stated the facility did not follow the vegetarian menu that was planned and approved. The FND stated the facility did not document and track what they served Resident 11 each day and the cooks did not always accurately communicate about what was served to Resident 11. The RD stated they had a substitution list for the vegetarian menu but had not documented anything regarding Resident 11's preferences on it. The RD and FND stated the facility only had a garden burger patty and no other type of patties. The vegetarian menu had a vegetarian sausage patty, black eye pea patty, oat nut patty, lima bean patty, and vegetable patty listed for the week. The RD stated a variety of vegetarian options was important and the staff needed to follow the menu since she had approved it. The facility policy and procedure titled Menus: Menu Substitution dated 2018, indicated the FND was responsible for supervising meal preparation and service to assure the menu was followed and served as planned. Menu substitutions must be made from the same food group as the omitted item. Menu substitutions remained in effect for the entire menu cycle and should be approved and signed off by the RD. The facility kept a Menu Substitution Record which included the date, food item to be changed, food item substituted and the reason, on file for 30 days. The menu substitutions are noted in writing on the back of the menu or on a separate Menu Substitution Record along with the reason for the change noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 8 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure food was prepared to meet the individual needs of residents on finger food diet for one of one sampled resident (Resident 7) when the kitchen staff failed to cut his country fried steak and sweet potato into cubes according to the therapeutic menu. This failure had the potential to result in the resident not being able to feed himself and unplanned weight loss. Findings: During a review of therapeutic diet menu titled Week 3 Tuesday, dated 4/2/19, indicated, residents were to receive glazed ham, one-half of a baked sweet potato, capri blend vegetables, cornbread, and a brownie. The alternative for glazed ham was country fried steak. The menu indicated finger food diet; ham, one-half of a baked sweet potato, and country fried steak were to be cut into cubes. During an observation of the noon meal service, on 4/2/19, at 12:31 PM, Resident 7 was served country fried steak (cut into strips), one-half of a baked sweet potato (left uncut with skin on), capri blend vegetables, cornbread, and a brownie. During a review of Resident 7's noon meal diet slip, on 4/2/19, at 12:32 PM, indicated, Resident 7 disliked pork and was on a finger food diet which required food to be cut into cubes. During a concurrent interview with the Food and Nutrition Director (FND) and record review of the therapeutic diet menu titled Week 3 Tuesday on 4/2/19, at 12:31 PM, the FND reviewed the therapeutic diet menu and stated the country fried steak and sweet potato should have been cut up into cubes. She stated the kitchen staff did not follow the therapeutic diet menu when they did not cut the meal items into cubes. FND instructed the kitchen staff to remake the plate and the country fried steak and sweet potato were cut into cubes. During an interview with the Registered Dietician (RD), on 4/4/19, at 11:44 AM, the RD stated staff should follow the menu spreadsheet and if it states cubed, the foods should be cut into cubes and not cut in strips or left whole. Record review of the facility's Diet Roster, dated 4/2/19 indicated only one resident (Resident 7) was on a finger food diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 9 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of 63 sampled residents (Resident 62) and food options of similar nutritive value were offered for one of one residents (Resident 11) on a vegetarian diet when: 1) Carrots, a known food dislike, were served on Resident 62's food tray. 2) Resident 11 was served a grilled cheese sandwich that did not follow the grilled cheese sandwich recipe. These failures had the potential to result in decreased food intake, food of lesser nutritive value, and could result in unplanned weight loss, further compromising the nutritional and medical status of residents. Findings: 1. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2019 indicated, 80 gram (gm - a dry unit of measure) Renal (pertaining to the kidney) diet. lunch meal: Three ounces (oz) Sodium Free (SF) pork chop (one each), #8 scoop (half cup) SF noodles, [half cup] of capri blend vegetables (vegetable mixture of green beans, carrots, zucchini, and yellow squash), brownie (one each), beverage (four fluid oz). During a concurrent observation of lunch meal service, interview with Food and Nutrition Director (FND), and review of Resident 62's lunch tray slip, on 4/2/19, at 11:49 AM, the staff began to serve Resident 62's lunch. The lunch tray slip indicated Resident 62 was on an 80 gram Renal, Mechanical soft/ground texture/consistency diet, dislikes carrots. Review of Resident 62's lunch tray ticket indicated, dislikes: .carrots . [NAME] 1 scooped the capri vegetables and attempted to not scoop carrots. Some carrots remained in the scoop and the scooped vegetable blend was placed on Resident 62's plate. Resident 62's lunch tray was placed on the delivery cart ready to leave the kitchen and be served to residents. During the interview, FND stated Resident 62 should not have been served carrots. Facility policy and procedure titled Menu, dated 2018, indicated .5. Menus will provide a variety of foods .and residents' food preference will be taken into consideration . During a review of the facility document titled In-service Education Program dated 11/14/18 indicated; .Staff .regulations regarding the menus, and accuracy on tray line.; the in-service was conducted by Registered Dietitian (RD); and a total of 5 attendants, including [NAME] 1 and FND signed as in attendance of the in-service. During an interview with RD, on 4/4/19 at 11:44 AM, she stated. If a resident did not like carrots then, it should not be on his tray. 2. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2019, indicated the entrée for regular lunch diet was three ounces of glazed ham. Three ounces of ham was equal to 21 grams of protein (one-ounce protein equals to seven grams of protein). During an observation on 4/2/19, at 12:21 PM, in the kitchen, [NAME] 1 prepared a grilled cheese (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 10 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sandwich (vegetarian option) for Resident 11. [NAME] 1 placed two slices of cheese between two slices of whole wheat bread and cooked it on the stove. [NAME] 1 served Resident 11's lunch tray with a grilled cheese sandwich, mixed vegetables and a brownie. During a review of Resident 11's lunch tray slip, dated 4/2/19, indicated Resident 11 was on a regular diet; likes Yogurt, Grilled cheese sandwich, PBJ (Peanut Butter and Jelly) sandwich, Veggie burger, Dislikes milk. [meal] Tray instructions: baked beans; Feed Instructions: VEGETARIAN, NO MEAT. During a review of the package insert for the American cheese used to prepare the grilled cheese sandwich indicated one slice of American cheese had three grams of protein (two slices of cheese equals six grams of protein). During an interview with [NAME] 1, on 4/3/19, at 9:40 AM, she stated Resident 11 was the only resident on a vegetarian diet in the facility. [NAME] 1 stated the vegetarian food choices depended on what the facility had available. During a concurrent observation in the kitchen and interview with [NAME] 1, on 4/3/19, at 9:42 AM, [NAME] 1 weighed two slices of American cheese on the scale. The two slices weighted 1.2 oz and [NAME] 1 stated that one grilled cheese sandwich should have five slices of cheese and not two. Resident 11 received approximately eight grams of protein on her grilled cheese sandwich. During a review of the recipe titled Grilled Cheese Sandwich on Wheat indicated, .Place 3-1/2 oz Cheese (5 slices of 120 CT, if purchased sliced) on dry side of bread . This would be equal to 24.5 grams of protein. During an interview with the facility RD, on 4/4/19, at 11:45 AM, RD stated that resident 11 should have had five slices of American cheese instead of two slices to be equivalent to the regular entrée portion size. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 11 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food and ice in accordance with professional standards for food service safety when: Residents Affected - Many 1. The ice machine was not properly sanitized per manufacturer's specifications. 2. One of two cooks (Cook 1) did not follow proper food handling practices during pureed food preparation and lunch meal preparation. 3. Expired chocolate milk was left in the dairy refrigerator and available for resident use. 4. Expired nutritional supplement was left in medication cart 1 and available for resident use. These failures had the potential for the growth of microorganisms (bacterium, virus, or fungus) and could cause foodborne illness to the 63 residents in the facility. Findings: 1. During a concurrent observation and interview with the Environmental Service Director (ESD), on 4/2/19, at 3:25 PM, the facility's ice machine contained a pinkish orange substance on the side of the trough (elongated container). The ESD confirmed the pinkish orange substance was on the side of the ice machine's trough. During an interview with the ESD, on 4/2/19, at 3:26 PM, ESD stated he cleaned the ice machine monthly and sanitized the removable parts and bin of the machine with the kitchen sanitizer ([Brand Name] quaternary ammonium) which was diluted. The ESD stated he did not run the sanitizer through the ice machine. The ESD stated he had [Brand Name] Cleaner (removes lime scale and mineral deposits from the interior of ice machines) but did not use [Brand Name] Sanitizer on the ice machine. During a record review of the [Brand Name] Indigo Series Ice Machines Installation, Use & Care Manual, dated 9/13, indicated, [Brand Name] Ice Machine Cleaner and Sanitizer are the only products approved for use in [Brand Name] ice machines. Step 15 of the Cleaning/Sanitizing Procedure manual indicated the proper amount of [Brand Name] Sanitizer (three to six ounces depending on the model number) was to be added to the water trough. Step 16 indicated [begin] Auto Ice On, check mark was to be selected and the ice machine would automatically start ice making after the sanitize cycle was complete (approximately 24 minutes). During an interview with the ESD and record review of the [Brand Name] Indigo Series Ice Machines Installation, Use & Care Manual, dated 9/13, on 4/2/19, at 4:11 PM, ESD reviewed the care manual and stated he misunderstood the manufacturer's instructions. ESD stated he used the [Brand Name] Sanitizer on the removable parts and bin of the ice machine. ESD stated he did not run the sanitizer through the ice machine as the manufacturer's manual instructed. 2. During an observation in the kitchen, on 4/2/19, at 11:27 AM, [NAME] 1 was wearing gloves while in the kitchen and used the same gloved hands to check the temperature of chopped ham and sweet potatoes. [NAME] 1 put on oven mitts, took off oven mitts, and touched the sliced ham to rearrange the pieces in the baking pan. [NAME] 1 did not remove gloves or wash hands during the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 12 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an observation of lunch meal preparation in the kitchen, on 4/2/19, at 11:27 AM, [NAME] 1 used the same gloved hands to touch and chop ham, touched the Paprika container, and touched the baked sweet potatoes. [NAME] 1 then removed the gloves, retrieved a clean spatula with her bare hands, returned to the tray line [Meal service line], and put on another pair of gloves without washing her hands. During a concurrent observation of pureed food preparation and interview with [NAME] 1 in the kitchen, on 4/3/19, at 10:58 AM, [NAME] 1 stated there were eight residents on pureed diets and she was preparing 10 servings of pureed Salisbury steak. [NAME] 1 removed the Salisbury steak from the oven; put on gloves without washing her hands; touched a tray, thermometer, counter, and drawer handle; then used a spatula with her gloved hand to stack the Salisbury steak. With the same gloved hands, [NAME] 1 used a thermometer to check the temperature of the Salisbury steak, cleaned the thermometer, and put it away. [NAME] 1 then used the spatula with a gloved hand to transfer the Salisbury steak to a holding tray, removed her gloves, and washed her hands. With bare hands, [NAME] 1 held a measuring cup with her fingers inside, and her thumb outside of the cup; put the measuring cup on the counter; and touched the recipe book. [NAME] 1 then put gloves on her hands, poured half a cup of milk in the measuring cup, opened the microwave, and put the milk into the microwave. [NAME] 1 proceeded with the same gloved hands to prepare the pureed fettuccini alfredo. During an observation of the lunch meal preparation in the kitchen, on 4/3/19, at 11:30 AM, [NAME] 1 put oven mitts over her gloved hands, opened the oven, took out a tray of cooked Salisbury steaks. [NAME] 1 then took off the oven mitts, did not remove her gloves, cleaned the thermometer, and used one gloved hand and the thermometer to touch Salisbury steaks and check temperature. During an observation of the lunch meal service in the kitchen, on 4/3/19, at 11:39 AM, [NAME] 1 used gloved hands to touch rolls, garnish, and plates; chop food; and microwave alternate food choices. [NAME] 1 then returned to the lunch meal service without changing her gloves or washing her hands. During a record review of the facility's Diet Roster, dated 4/2/19, indicated 63 residents had food trays prepared in the kitchen. During an interview with the Registered Dietitian (RD), on 4/4/19, at 11:44 AM, the RD stated dietary servers were to change their gloves and wash their hands if they changed tasks and between touching foods and touching other items such as a microwave or a refrigerator. The facility policy and procedure titled Sanitation and Infection Control Subject: Handwashing dated 2018, indicated food service workers were to properly and frequently wash hands to prevent cross contamination of food supplies or equipment and hands were to be washed before and after handling foods. 3. During a concurrent initial observation in the kitchen and interview with the FND, on 4/2/19, at 9:03 AM, one unopened half gallon and one partial half gallon of chocolate milk were found in the Dairy Refrigerator with a manufacturer's expiration date of 3/31/19. No hand written open dates were on the half gallons. The FND stated the chocolate milk was expired and should have been thrown out. The FND stated the facility follows the manufacturer's expiration date on the carton. The facility policy and procedure titled Suggested Refrigerated Storage Guidelines dated 2018, indicated, .Opened milk should be discarded 7 days after opening or by the expiration date, if first. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 13 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0812 Level of Harm - Minimal harm or potential for actual harm 4. During a concurrent observation of Medication Cart 1 and interview with the Director of Nursing (DON), on 4/5/19, at 10:11 AM, an opened 30-ounce bottle of nutritional supplement was found with approximately 28 ounces left and an expiration date of 11/8/18. The DON stated the nutritional supplement was expired and should have been discarded. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 14 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation during the survey period of 4/2/19 through 4/5/19, the facility failed to maintain rooms that measured at least 80 square feet per resident in 16 of 29 resident rooms. Residents Affected - Some This failure had the potential to place residents and families at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort. Findings: During the initial tour of the facility on 4/5/19, the following rooms did not provide the minimum square footage as required by regulation: Rooms 101, 102, 103, 104, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, and 121. However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Rm # Square Feet # of Residents 101 152 2 102 152 2 103 154 2 104 150 2 110 214 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 15 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0912 3 Level of Harm - Potential for minimal harm 111 146 Residents Affected - Some 2 112 225 3 113 152 2 114 225 3 115 152 2 116 225 3 117 152 2 118 225 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 16 of 17 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 555485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kings Healthcare & Wellness Center LP 851 Leslie Lane Hanford, CA 93230 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 0912 119 Level of Harm - Potential for minimal harm 152 2 Residents Affected - Some 120 226 3 121 154 2 Recommend waiver continue in effect. ---------------------------------------------------------Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ----------------------------------------------------------Administrator Signature Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 17 of 17