Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kings Healthcare & Wellness Center Lp during CMS and state inspections, most recent first.
Failure to Submit Accurate PBJ Staffing Data: The facility failed to submit complete and accurate PBJ direct care staffing data to CMS by the required deadline, including agency and contract staff. The ADM stated Corporate submitted the wrong quarter’s information, resulting in CMS showing no data submitted for the quarter. The PR said payroll hours are entered into the system and Corporate pulls that information to submit PBJ data to CMS, and the ADM stated the PBJ data was important for meeting resident staffing needs and supporting the Facility Assessment.
A resident’s O2 was not set at the ordered flow rate, and the resident’s tubing and NC were not labeled or stored appropriately when not in use. Another resident received O2 without a physician order or care plan, while a high fall-risk resident was observed in bed with the bed raised in the highest position instead of the lowest position. RN, LVN, CNA, and DON interviews confirmed the deviations from ordered care and facility fall protocol.
A resident was observed with a bottle of vitamin C stored at the bedside and stated she had been taking one to three tablets daily from home supply. Staff had seen the medication in the room, but there was no physician order or completed MSA for bedside storage or self-administration. The LVN and DON confirmed the resident should have had both an order and assessment, and that the facility's policy was not followed.
Missing Care Plan for Cervical Collar Use: A resident with central cord syndrome and a cervical spinal cord injury was observed wearing a C-collar, and the OSR showed an order for the collar to be worn at all times. An LVN stated the resident arrived with the collar but had no care plan in place upon admission, and the DON stated the care plan should have been started on admission and used to guide safe care and monitoring of the collar.
Incomplete Daily Nurse Staffing Posting: The facility posted a staffing information sheet that did not identify whether the listed hours were anticipated or actual hours worked by RN, LVN, and CNA staff. The DSD stated the posted form reflected projected hours and did not use the CDPH 612 DHPPD form for the breakdown of actual patient care hours, while payroll completed the DHPPD form separately using documented actual hours. The DON stated the DHPPD information was important for residents and visitors to know staff hours and census.
Incorrect Documentation of Controlled Substance Administration: An LVN administered Morphine Sulfate oral solution to a resident who was lying in bed with facial grimacing and moaning, then signed the routine narcotic log instead of the as-needed log for the dose given. The LVN acknowledged the error, and the DON stated controlled substances must be documented on the correct INR based on whether the medication is routine or PRN; the facility policy required immediate, accurate entry of the date, time, amount, and nurse signature after administration.
Expired food items were found in the kitchen freezer when 4 single-serve ice cream cups and an opened box of kielbasa sausage were observed past their use-by dates. The CDM, RD, and DON stated kitchen staff were expected to label food correctly and discard items by the use-by date, but the items remained in the freezer despite being expired. The facility's kitchen training materials also stated all shifts were responsible for checking for expired items and discarding them immediately.
Improper Glucometer Disinfection Between Resident Uses: An LPN and another LPN used only one germicidal wipe to clean a glucometer after blood glucose testing multiple residents, but the meter did not remain visibly wet for the required two-minute contact time. The IP and DON reviewed the manufacturer instructions, which required cleaning and disinfection after each resident use and a two-minute wet time, and the DON stated staff had not followed the facility policy or manufacturer guidance.
The facility failed to provide rooms that met the minimum size requirement of 80 square feet per resident in 16 out of 29 rooms. Despite this, residents and staff reported that the room sizes did not impact the care provided. The facility did not have a policy on room size, and a waiver was requested to remain in effect.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS, including agency and contract staff, based on payroll and other verifiable and auditable data by the required deadline. During the Facility Entrance Conference, the Administrator and DON reviewed the CMS Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 1 2026 and found that the report showed no data submitted for the quarter. The Administrator stated the PBJ data had been submitted for the wrong quarter and that Corporate headquarters notified her of the error, but it was too late to submit the correct information before the deadline. During interviews, the Payroll Coordinator stated that hours are entered into the payroll system and Corporate Office pulls the payroll information from that system to submit PBJ data to CMS, and that Corporate would notify the Administrator if a reporting quarter was missed. The Administrator later stated that Corporate submitted the wrong information to CMS for the PBJ reporting quarter and that the PBJ data should have been submitted before the reporting deadline. The Administrator also stated the PBJ data was important to meet resident staffing needs and that the Facility Assessment was based on resident diagnoses and needs, with PBJ helping ensure staffing was in place for resident care.
Oxygen Therapy and Bed Safety Deficiencies
Penalty
Summary
Resident 34 was observed wearing oxygen by nasal cannula, but the oxygen flow rate was not set according to the physician order. The record showed an order for oxygen at 3 liters per minute continuously, yet during observation the oxygen was set at 2.5 liters per minute. RN 1 stated the rate should have been 3 liters per minute and that oxygen was considered a medication that staff should follow as ordered. The DON also stated staff should have followed the physician orders and that nurses should check the oxygen setting whenever they entered the resident’s room. Resident 34’s oxygen tubing and nasal cannula were also not handled and labeled as required. At one point the resident was observed with tubing and a nasal cannula on the floor, and later the resident was wearing oxygen tubing that was not labeled with the date and time it was placed. Another set of tubing and a nasal cannula was seen on the resident’s bed. RN 1 stated the old tubing should have been discarded if it was on the floor, that it should not have been placed back on the bed, and that the new tubing should have been labeled so staff would know when to change it. The DON stated only RNs were to connect, disconnect, and set oxygen, and that the tubing should have been changed and labeled. Resident 78 was observed wearing oxygen by nasal cannula, and the record showed oxygen saturation measurements documented while the resident was wearing the cannula. However, the medical record contained no physician order or care plan for oxygen therapy, and LVN 1 stated there were no orders for oxygen use in the chart. RN 1 and the DON stated that if a resident came from the hospital on oxygen, staff were to check for discontinuation orders and contact the physician for orders if oxygen was to continue. Resident 76, who was identified as a high fall risk with confusion and a history of falls, was observed lying in bed with the bed raised in the highest position off the ground. CNA 2 stated the bed should always be in the lowest position, and LVN 2 and the DON stated facility fall protocol required the bed to be kept low for a resident at high risk for falls.
Bedside Self-Administration Without Order or Assessment
Penalty
Summary
The facility failed to ensure that one of nine sampled residents, Resident 43, was assessed for safe bedside storage and self-administration of medication. During observation and interview, Resident 43 was found sitting on her bed with a bottle of brand name C 1000 mg vitamin C on top of her bedside table. Resident 43 stated the bottle had been brought from home, had been kept at her bedside for some time, and that she took one to two vitamin tablets daily, sometimes up to three tablets per day depending on what she remembered. She also stated facility staff had seen the bottle in her room and had never said anything about it. Record review and staff interviews showed Resident 43 did not have a physician's order for Vitamin C or for medication self-administration, and there was no completed Medication Self-Administration Assessment form. The LVN stated the resident should have had both an order and an assessment to store and self-administer medications. The DON stated residents required a physician's order and an MSA to self-administer medications at bedside, and acknowledged the facility's policy was not followed for Resident 43. Resident 43 had a BIMS score of 15 and was alert and able to verbalize needs and concerns.
Missing Care Plan for Cervical Collar Use
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for Resident 81 for the use of a cervical collar. During an initial tour on 6/1/26 at 9:35 a.m., Resident 81 was observed lying in bed with eyes opened and a C-Collar in place, and the resident did not answer questions asked. The resident's Face Sheet dated 6/4/26 showed admission to the facility with diagnoses including Central Cord Syndrome and unspecified cervical spinal cord injury. During a concurrent interview and record review on 6/3/26 at 2:35 p.m., the OSR showed an order for a C-collar to the neck at all times with a start date of 6/1/26. LVN 4 stated Resident 81 arrived wearing a C-Collar and did not have a care plan in place for the C-Collar upon admission, and that a care plan should have been initiated at the time of admission. During an interview on 6/4/26 at 12:41 p.m., the DON stated a care plan for the C-Collar should have been started upon admission, that the nurse developed the care plan based on the resident's assessment and needs, and that the absence of a C-Collar care plan may increase the risk of complications, such as neurological injuries. The facility's policy stated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon admission and that the facility must develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure daily nurse staffing information posted for residents and visitors included all required information. During observation, a staffing information document was seen posted in the hallway on 6/3/26, but it did not show whether the hours listed were anticipated or actual hours worked by licensed and non-licensed staff. The deficiency involved the required posting of the total number and actual hours worked by RN, LVN, and CNA staff, which was not clearly provided for the 61 residents and visitors who could view the posting. During interviews and record review, the DSD stated she was responsible for staff scheduling and completing the staffing information form and that the posted document reflected anticipated hours of licensed and non-licensed patient care staff. She also stated she did not use the CDPH 612 form for the breakdown of patient care hours for CNAs and nurses, while the payroll coordinator stated the DHPPD form was completed the next day using documented actual hours of nurses and CNAs and kept in a binder. The DON stated the DHPPD information was important so residents and visitors were aware of staff hours and census, and that she was responsible for the accurate daily posting of licensed and non-licensed staffing hours.
Incorrect Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure controlled substance medications were administered and recorded accurately for one resident. During a medication administration observation, the resident was in bed with facial grimacing and moaning when an LVN prepared and administered Morphine Sulfate oral solution, 0.5 ml (10 mg), ordered every 4 hours as needed for moderate pain. After administering the medication, the LVN documented it on the resident’s Individual Narcotic Record, but signed the routine Morphine Sulfate narcotic log instead of the as-needed narcotic log. During the concurrent interview and record review, the LVN stated there were separate narcotic records for routine Morphine Sulfate every 6 hours and as-needed Morphine Sulfate every 4 hours, and acknowledged signing the wrong record. The resident’s Order Summary Report showed both routine and as-needed Morphine Sulfate orders. The DON stated nursing staff were expected to accurately sign the INR and that routine and as-needed narcotics should be documented on the corresponding record. The facility policy stated that when a controlled medication is administered, the licensed nurse must immediately enter the date, time, amount administered, and signature on the accountability record and MAR after the medication is actually administered.
Expired Food Items Found in Kitchen Freezer
Penalty
Summary
The facility failed to ensure food was stored and served safely in accordance with professional standards of food service safety when, during a concurrent observation and interview in the kitchen, 4 single-serve pre-prepared ice cream cups were found in the freezer with a use-by date of 5/29/26 and an opened box of kielbasa rope sausage was found with a use-by date of 5/22/26. The ice cream cups were 3 days past the use-by date, and the sausage was 10 days past the use-by date. The Certified Dietary Manager stated kitchen staff were expected to accurately label food items with received, opened, and use-by dates and to discard items by the labeled use-by date, and that food retained past the use-by date was considered expired and needed to be removed from the kitchen. During interviews, the RD stated all food items were expected to be accurately and correctly labeled by kitchen staff with received, opened, and use-by dates, and that adhering to labeled use-by dates was important to prevent the serving of expired food items. The DON stated kitchen staff were expected, per food safety standards of practice and facility policy, to correctly label food items and remove them from the kitchen by the use-by date, and acknowledged that these standards were not followed when the freezer contained the expired ice cream cups and kielbasa sausage. A review of the facility's Diet Type Report showed 57 residents received food from the kitchen, and the facility's in-service materials stated all shifts were responsible for checking for expired items and discarding them immediately.
Improper Glucometer Disinfection Between Resident Uses
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when licensed nurses did not follow manufacturer instructions for disinfecting glucometers after use on residents. During observations, LVN 3 and LVN 4 performed blood glucose testing on Resident 13, Resident 21, Resident 40, Resident 65, and Resident 85, then used one germicidal disposable wipe to clean the glucometer after each resident use. The glucometer was placed on the medication cart and allowed to air-dry, but it was observed to become dry within about one minute rather than remaining visibly wet for the required two-minute contact time. During the observation with LVN 3, a two-minute timer was started after the glucometer was wiped, but the device did not remain wet for the full two minutes. LVN 3 stated she cleaned the glucometer with one germicidal wipe after resident use and allowed it to air-dry for two minutes, but the glucometer did not remain wet for that period. Similar observations were made with LVN 4, who also used one germicidal wipe to clean the glucometer after testing Resident 85 and Resident 65, with the glucometer not remaining wet for two minutes. The Infection Preventionist and DON reviewed the glucometer manufacturer guidance and the germicidal wipe instructions, which required the meter to be cleaned and disinfected after each resident use and the treated surface to remain wet for two minutes. The Infection Preventionist stated the glucometer should be cleaned and disinfected per manufacturer guidelines to prevent the spread of communicable diseases and blood-borne pathogens. The DON stated nursing staff had not followed manufacturer guidelines or facility policy and procedure when only one germicidal wipe was used, and that the glucometer was not properly cleaned and disinfected between resident use.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, 16 out of 29 rooms in the facility did not meet this requirement, with room sizes ranging from 71 to 77 square feet per resident. This deficiency was identified through a Client Accommodations Analysis conducted on January 13, 2025. Despite the non-compliance with room size regulations, no residents voiced concerns about the room sizes during the initial tour of the facility. However, during a Resident Council meeting, two residents mentioned that the rooms felt small, but they did not believe it affected the care they received. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that the room sizes did not impact the care provided to residents. The Assistant Administrator confirmed that the facility did not have a policy regarding room size. Housekeeping staff also stated that the room measurements were accurate and did not affect care. Despite the deficiency in room size, the facility requested that a waiver continue in effect, as documented by the Health Facilities Evaluator Supervisor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hanford Post Acute | 0.9 mi | ★★★★★ | 17 | 0 |
| Brighton Post Acute | 2.2 mi | ★★★★★ | 25 | 0 |
| Kingsburg Center | 15.6 mi | ★★★★★ | 19 | 0 |
| Bethel Lutheran Home | 17.7 mi | ★★★★★ | 17 | 0 |
| Westgate Gardens Care Center | 17.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.