Inspection·January 23, 2024

F 0697 Level of Harm - Actual harm Residents Affected - Few for Resident 1 and noticed Resident 1's hip was internally rotated with the knee flexed (lower leg bent) and the left hip joint protruded (sticking out). The COTA stated when she touched Resident 1's foot Resident 1 yelled Ow. The COTA stated on 1/24/23 Resident 1 was able to stand on her left leg during therapy. During interview on 2/8/23, at 10:12 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was assigned to Resident 1 on 1/25/23 during the day shift. CNA 2 stated at around 6:40 a.m., she went to Resident 1's room and checked on Resident 1. CNA 2 stated she noticed Resident 1's left leg was bent at the knee and in a weird position. CNA 2 stated, When I went in there and barely touched her, she just screamed. CNA 2 stated Resident 1 refused to get up for breakfast or dressed and transferred to the wheelchair which was not normal for her. CNA 2 stated Resident 1 does not normally refuse getting dressed and up to her wheelchair. CNA 2 stated she notified LVN 2 of Resident 1's change in behavior. CNA 2 stated screaming is not normal for Resident 1. CNA 2 stated Resident 1 is confused but can say when she is in pain. During an interview on 2/8/23, at 10:34 a.m., with Resident 1, Resident 1 stated she did not remember what happened to her hip. During a review of Resident 1's physician orders titled, Order Summary Report (OSR), dated 2/2023, the OSR indicated, .hydrocodone-acetaminophen [a medication used to treat severe pain] 5-325 mg [milligrams- unit of measurements] Give 2 tablet[s] by mouth every 6 hours as needed for Severe Pain (8-9) . During a concurrent interview and record review on 2/8/23, at 10:43 a.m., with LVN 1, Resident 1's Medication Administration Record (MAR), dated 1/2023, was reviewed. The MAR indicated Resident 1 was administered hydrocodone-acetaminophen 5/325 mg, 2 tablets on 1/25/23 at 5:11 a.m. for severe pain, 8 of 10 . LVN 1 stated LVN 3 did not document a pain reassessment after an hour of having administered pain medication to Resident 1 to ensure the pain medication was effective and Resident 1 was comfortable. LVN 1 stated the expectation was to do a pain reassessment an hour after administration of pain medication. During a concurrent interview and record review on 2/8/23, at 11:31 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Orders-Administration Note (OAN), dated 1/25/23 at 5:11 a.m. was reviewed. The OAN indicated, . hydrocodone-acetaminophen give 2 tablet[s] by mouth every 6 hours as needed for Severe Pain (8-9) . Resident c/o [complains of] lower extremity [leg] pain 8/10 on pain scale, not relieved by non-pharm [pharmacological] methods (pain management utilizing alternative therapies such as comfort therapy without the use of pain medication) . The ADON stated Resident 1 had a history of hip replacement surgery and LVN 3 should have assessed Resident 1's lower extremity including range of motion, positioning, and neurovascular assessment (to evaluate sensory, motor function, and blood circulation of the leg) to determine the cause of the pain. The ADON stated LVN 3 did not perform a pain reassessment after an hour of administering the pain medication to Resident 1. The ADON stated LVN 3 did not follow the facility's policy and procedure to perform a pain reassessment after an hour of pain medication administration to ensure the pain medication was effective in relieving pain. The ADON stated if LVN 3 would have done a pain reassessment she should have known the pain medication was ineffective and notified the physician. During a review of Resident 1's Order Note (ON), dated 1/25/23, at 9:23 a.m., the ON indicated, .This writer [LVN 2] was notified by therapy staff that patient was complaining of pain to her left hip and that her hip looked displaced . [name of physician] notified via phone. New order obtained: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 2 of 4 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 01/23/2024 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 0697 Send to [name of acute care hospital emergency room] for further evaluation r/t [related to] intractable pain [severe, persistent pain not controlled with standard medical care] to left [hip] . Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's ED [Emergency Department] Physician Notes (EPN), dated 1/25/23, at 10:48 a.m., the EPN indicated, .BIBA [brought in by ambulance] with left hip pain . patient status is post (after) left hip replacement . patient noted to be in pain on arrival . surgical history . hip arthroplasty hemi (left partial) (a surgical procedure in which the surgeon removes the diseased part of the hip joint and replaces them with new artificial parts) 10/16/2022) . Hip arthroplasty revision (Left) [reoperation of hip replacement] (11/20/2022) . Labs/imaging reviewed . + [positive for] left hip dislocation . During a phone interview on 2/8/23, at 3:21 p.m., with LVN 2, LVN 2 stated she was assigned to Resident 1 on 1/25/23 during the day shift. LVN 2 stated she was called into Resident 1's room by the COTA around 9:00 a.m. LVN 2 stated Resident 1's left leg was turned inward with the knees tucked in and her hip looked out of alignment. LVN 2 stated Resident 1 was moaning in pain, guarding (involuntary reaction to protect an area of pain) her hip, and crying. LVN 2 stated Resident 1's physician was notified and gave an order to send Resident 1 to the ED. LVN 2 stated when a resident complained of pain the process was to assess the cause of the pain, location, pain level from one to 10 and administer pain medication if needed. LVN 2 stated the pain should be reassessed within one hour of administering pain medication and the physician should be notified if the medication was ineffective. During a phone interview on 2/8/23, at 5:06 p.m., with LVN 3, LVN 3 stated she was assigned to Resident 1 on 1/24/23 during the night shift which started at 7 p.m. and ended on 1/25/23 at 7 a.m. LVN 3 stated on 1/25/23 at 5 a.m., she was near Resident 1's room and CNA 3 was changing Resident 1. LVN 3 stated, I could hear her [Resident 1] grunt in pain when the CNA changed her brief. LVN 3 stated when she assessed Resident 1's pain she noticed both legs were bent with the left leg positioned to the side, but she thought Resident 1's leg had just fallen asleep. LVN 3 stated Resident 1 requested pain medication at that time. LVN 3 stated CNA 3 told her it was unusual for Resident 1 to complain of pain. LVN 3 stated, I didn't want to move her too much, so I didn't do a full assessment [of her leg]. LVN 3 stated she did not perform an assessment to Resident 1's leg considering the odd position of the leg and Resident 1's complaint of severe pain. LVN 3 stated she should have performed an assessment to Resident 1's leg. LVN 3 stated she did not perform a pain reassessment after an hour in which she had administered pain medication to Resident 1. LVN 3 stated it was important to perform a pain reassessment to ensure the pain medication was effective, and to look for further cause and notify the physician if the pain continued. LVN 3 stated the physician was not notified of Resident 1's severe pain not relived by the pain medication. During a telephone interview on 2/9/23, at 7:48 a.m., with CNA 3, CNA 3 stated she was assigned to Resident 1 on 1/24/23 during night shift which started at 11 p.m. and ended on 1/25/23 at 7 a.m. CNA 3 stated when she entered the room on 1/25/23 at 5:00 a.m. she had noticed Resident 1's knee was pulled up to her chest which was not her normal position. CNA 3 stated, She [Resident 1] was in really bad pain when I tried to take off her brief. CNA 3 stated Resident 1 whimpered in pain and was not able to turn herself in bed. CNA 3 stated Resident 1 normally turned herself during care, but at that time it required 2 CNAs to move her and change her brief. During a review of Resident 1's nurses note titled, OAN, dated 1/25/23, at 9:07 a.m., the OAN indicated, .PRN [as needed] Administration was: Ineffective . Patient still complaining of severe pain to left hip during movement. Repositioned patient, patient is comfortable when not moving patient. Notified [name of physician] via phone . Sending patient to acute [hospital] due to intractable pain . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 3 of 4 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 01/23/2024 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 0697 Follow up [note] to: 1/25/23 5:11 a.m . Level of Harm - Actual harm During an interview on 5/23/23, at 1 p.m., with the Director of Nursing (DON), the DON stated on 1/25/23 around 9 a.m., she was notified by the rehabilitation therapist Resident 1's left leg was abnormally positioned and complained of severe pain with movement. The DON stated Resident 1 had a previous hip replacement done on 10/16/22. The DON stated, She [Resident 1] was in bed lying on her back and the left leg was bent to the back. I could tell just from looking at her the hip was dislocated. The DON stated she did an investigation into Resident 1's hip dislocation. The DON stated, At some point between 2 a.m. and 5 a.m. her [Resident 1] legs must have been crossed and the hip dislocated. The DON stated when she interviewed LVN 3, LVN 3 stated she did an assessment when she noticed Resident 1's left leg internally rotated. The DON stated when she reviewed Resident 1's clinical record, she was unable to locate an assessment, or a progress note from LVN 3. The DON stated LVN 3 did not document her nursing assessment of Resident 1's leg. The DON stated if the assessment was not documented that indicated it had not been done. The DON stated she reviewed Resident 1's MAR and was unable to find a pain reassessment after LVN 3 administered pain medication to Resident 1 on 1/25/23 at 5:11 a.m. to assess if the pain medication was effective or not. The DON stated LVN 3 did not follow the facility's policy and procedure (P&P) for pain management. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 11/2016, the P&P indicated, .facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible . After medications/interventions are implemented, the licensed nurse will reevaluate the resident's level of pain within one hour . if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician . Pain Assessments will be maintained in the resident's medical record . During a professional reference review, retrieved from https://my.clevelandclinic.org/health/diseases/22222-hip-dislocation titled, Hip Dislocation, dated 12/21/21, the reference indicated, .Hip dislocation occurs when the ball joint [junction of two or more bones] of your hip (femur [thigh bone]) pops out of its socket . It's a medical emergency . A dislocated hip is acutely [severity of sudden onset] painful and disabling . Immediate care reduces the chance of long-term complications . A dislocated hip is a medical emergency . It causes acute pain and disables your leg until it's corrected . It can also cause secondary injuries to the surrounding blood vessels [tubes through which blood circulates through the body], nerves [fibers that sends and receives messages between the body and the brain], ligaments [band of tissue that connects bones and joints] and tissues [group of cells] . Hip dislocation can cause long-term damage, especially if it's not treated right away . If you're looking at the injury from the outside, you'll first notice that your leg is locked in a fixed position rotated either inward or outward. About 90% of the time, your hip joint is forced backward out of its socket (posterior dislocation), which leaves your knee and foot pointed inward . symptoms of hip dislocation . Acute pain . leg is rotated inward or outward . Hip is visibly out of place . A trained healthcare provider can often identify a dislocated hip by looking at it . Surgery may also be recommended when your displaced hip is an artificial hip replacement . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555485 If continuation sheet Page 4 of 4