Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingsburg Center during CMS and state inspections, most recent first.
A resident with a complex medical history, including TBI and a VP shunt, was found on an air loss mattress set to 245–285 lbs despite weighing 124.4 lbs. The NM confirmed the setting was incorrect and that no physician order for the mattress could be located. An LVN assigned to the resident acknowledged she did not know the correct settings, had not been checking weight settings, and later verified the resident’s actual weight in the record. The DSD stated staff were supposed to be trained on air loss mattress use and weight-based settings but could not produce training or in-service records for the LVN or the RN who had cared for the resident at the time of a prior fall. The ADM reported there was no facility policy for air loss mattress use, that staff were expected to follow the manufacturer’s instructions, and that the mattress settings used were not aligned with those instructions.
A resident with multiple comorbidities experienced leg discoloration and swelling, prompting a physician order for a vascular consult and leg elevation. Nursing staff failed to schedule the consult, did not complete required weekly assessments, and did not document changes in condition as required. These failures delayed appropriate care, resulting in the resident being hospitalized for a DVT and requiring surgical intervention.
A resident with dementia and moderate cognitive impairment eloped from the facility due to the failure to conduct a quarterly elopement assessment and implement necessary interventions. The resident was found outside in a confused state, highlighting inadequate supervision and the absence of a security bracelet, which was only applied after the incident.
The facility did not post the results of the most recent survey in an accessible location for residents and their representatives. The State Survey Binder, located near the DON's office, lacked the results of the last recertification survey. Both the ADM and DON confirmed the omission, acknowledging that the results should have been available. This failure potentially violated residents' rights to access survey results as per the facility's policy.
The facility failed to employ a full-time dietitian or qualified dietetic services supervisor, leading to inadequate oversight of food service operations. The Registered Dietitian provided limited consultation, primarily focusing on clinical work, and did not review or approve the facility menu. This lack of oversight resulted in issues with kitchen staff competency, menu adherence, and food preparation, placing residents at risk for compromised nutrition.
The facility failed to follow the planned menu, serving incorrect items and portions to residents, including serving steamed spinach instead of creamed spinach, using the wrong scoop size for mechanical diced ham, and providing fortified mashed potatoes instead of whipped sweet potatoes. A resident on a vegetarian diet was repeatedly served egg salad, contrary to the planned menu. The Registered Dietitian had not reviewed the menu, and the kitchen staff did not adhere to the expected guidelines.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. A resident's oxygen tubing was improperly stored, increasing infection risk. Another resident's medication syringe was not cleaned properly, posing a bacterial infection risk. Additionally, a CNA did not wear appropriate PPE while caring for a resident on enhanced precautions. These actions were contrary to the facility's policies and professional guidelines.
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. A resident was given escitalopram for depression without consent until late August, while another received sertraline without complete consent. A third resident was administered buspirone for anxiety without valid consent. The facility's policy requires informed consent before starting such medications, which was not followed.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident, admitted with an indwelling urinary catheter, lacked a care plan for its management. Another resident, treated for a UTI, did not have a timely care plan to monitor their condition. The facility's policy required individualized care plans, but these were not implemented, resulting in potential unmet care needs.
The facility failed to maintain professional standards in medication management for two residents. One resident continued to be monitored for side effects of a discontinued anticoagulant, leading to inaccurate documentation. Another resident's medications were prepared by an LVN but administered by an IP, contrary to policy, risking medication errors. Both incidents highlight lapses in following established procedures.
Two residents in the facility were found with long, dirty fingernails, indicating a failure in personal hygiene care. Despite being cognitively intact, both residents could not recall when their nails were last trimmed. Interviews revealed that CNAs were responsible for daily nail care, while nurses handled diabetic residents' nails. The facility's policy required regular cleaning and trimming to prevent infections, but this was not followed, leading to the deficiency.
Two residents in an LTC facility did not receive the correct oxygen flow rates as per physician orders. One resident with COPD and asthma received four liters per minute instead of two, while another resident with multiple health issues received one liter per minute instead of two. These discrepancies were confirmed by LVNs and highlighted by the DON, emphasizing the importance of following physician orders to prevent adverse effects.
Two residents were found using bed rails without proper assessment, physician's orders, or informed consent. One resident had severe cognitive impairment and was on hospice care, while the other was cognitively intact. Staff acknowledged the lack of necessary documentation, which should have been completed within 24 hours of admission, as emphasized by the DON and DSD.
A long-term care facility experienced a medication error rate of 6.9%, exceeding the acceptable threshold. One resident did not receive metformin due to unavailability, potentially affecting blood sugar levels. Another resident had a lidocaine patch applied for over 12 hours, contrary to physician orders, risking skin irritation. The facility's policies on medication administration and ordering were not adhered to, contributing to these deficiencies.
The facility failed to properly label and store medications, affecting three residents. Two residents' medications lacked expiration date labels, and a resident's insulin pen was missing a label, risking incorrect administration. Additionally, loose pills were found on the floor in a medication storage room, increasing the risk of medication errors.
The facility failed to accommodate the food preferences of several residents, leading to potential nutritional deficiencies. Residents were served food items they disliked, such as sweet potatoes and ham, without being offered suitable alternatives. Additionally, a resident's preference for cold food was not documented, resulting in a period where he did not eat. Interviews with staff revealed a lack of communication and adherence to facility policies regarding meal preference updates.
The facility failed to maintain proper sanitation practices in food preparation areas. Observations revealed that a food service worker and a kitchen supervisor used sanitation solutions with insufficient concentration to clean food service equipment and areas. The facility's policy mandates maintaining cleanliness and sanitation in food preparation and service areas.
A resident with severe cognitive deficits was not provided privacy during medical procedures by an LVN, who failed to close the privacy curtain or door while checking blood pressure and administering medication. This was observed and confirmed by staff interviews, highlighting a breach of the facility's policies on dignity and resident rights.
A resident with an indwelling urinary catheter was not accurately assessed in the MDS, as the diagnosis was not coded. Despite being admitted with the catheter, there was no order, diagnosis, or care plan documented. Facility staff, including an LVN, MDSN, and MRD, confirmed the oversight, and the DON acknowledged the failure to document the necessary information.
A facility failed to update a resident's care plan after discontinuing insulin medication, despite the resident's diagnoses of diabetes mellitus type 2, hypertension, end-stage renal disease, anemia, and pain. Staff interviews revealed that the care plan was not individualized to the resident's needs, as it continued to include insulin. The facility's policy required ongoing assessment and timely updates to care plans.
A resident did not receive their metformin medication for two days because it was unavailable, as observed by an LVN. The facility's policy requires nurses to ensure medication availability and reorder in advance, but this was not followed. The DON confirmed the responsibility of nurses to contact the pharmacy for timely delivery.
The facility failed to ensure effective food and nutrition services, as a staff member did not follow menus and recipes, leading to incorrect meal preparation and failure to accommodate residents' dietary preferences. Several residents received meals that did not align with their dietary restrictions, and the facility's training and competency evaluation processes were inadequate.
The facility failed to properly prepare pureed food, as a whole green bean was found in a pureed salad on a test tray. This was observed during a lunch meal service, and the CDM confirmed the error. The staff member used a handheld blender for preparation, contrary to the facility's guidelines requiring a smooth consistency. Despite completing an in-service on texture modification, the staff's competency was unclear.
A resident did not receive the physician-prescribed double portion meal due to a failure in communication and documentation within the facility. The resident's meal ticket did not reflect the correct diet order, and the kitchen was not informed of the double portion requirement until days later. Staff interviews confirmed the oversight, and the facility's policy for reviewing dietary orders was not effectively implemented.
The facility failed to maintain a comfortable environment in the kitchen, with temperatures recorded between 89.4 and 93.6 degrees Fahrenheit. Staff confirmed the kitchen is usually warm, and a broken A/C remote controller prevented proper cooling. The facility's policy highlighted the need for ventilation, but the issue persisted, potentially increasing the risk of heat-related illnesses among staff.
The facility failed to create a care plan for a resident at risk of elopement, despite multiple assessments identifying the risk. Staff interviews revealed a lack of communication and adherence to policies, resulting in the resident successfully leaving a dialysis center against medical advice.
Improper Use of Air Loss Mattress and Lack of Staff Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an air loss mattress was used in accordance with the manufacturer’s instructions and that staff were trained and competent in its use for one resident. Surveyors found that the resident, who weighed 124.4 lbs, was lying on an air loss mattress with the weight setting dialed to 245–285 lbs. The Nurse Unit Manager (NM) confirmed during observation that the mattress was set at the maximum weight and acknowledged that this was not correct for the resident’s actual weight. The NM also stated that the mattress should be set according to the resident’s weight and that incorrect settings would affect the therapeutic effect of the mattress. The resident had a significant medical history, including traumatic brain injury, status post ventriculoperitoneal shunt placement, hypertension, and venous thromboembolism. He had been admitted to a hospital for diaphoresis, shortness of breath, and high blood pressure, and was then readmitted to the facility for acute rehabilitation. The resident had experienced a fall at the facility on a prior date while on an air loss mattress, and the NM reported that the facility’s review of that fall did not identify any issues with the mattress settings or functionality at that time. However, during the current survey, the NM was unable to locate a physician’s order for the use of an air loss mattress for this resident. When the LVN assigned to the resident was interviewed at the bedside, she confirmed that the mattress was set at 245–285 lbs and stated she was unsure what the settings should be for this resident. She indicated she did not know the resident’s current weight, only that he did not appear to weigh 245–285 lbs, and stated she believed she would need to check physician orders for the correct settings. Upon review of the medical record, the LVN verified the resident’s most recent weight of 124.4 lbs and acknowledged that setting the wrong weight on the air loss mattress was not acceptable and had the potential to cause pressure injuries and harm. She also stated she had not been aware that she should be checking the weight settings on the air loss mattress. The Director of Staffing Development (DSD) reported that she was responsible for staff training and stated that staff were trained on the use of air loss mattresses and that correct weight settings were important. She agreed that a 245–285 lb setting for a resident weighing 124.4 lbs was not safe and not aligned with the instructions for use. However, upon further review, the DSD confirmed that she could not find any training or in-service records indicating that the LVN assigned on the day of the survey or the RN assigned at the time of the resident’s fall had received training on air loss mattress use. The Administrator (ADM) stated that the facility did not have a policy for air loss mattress use and that staff were expected to follow the manufacturer’s instructions. He also confirmed that there were no training records for the nurses assigned to the resident at the time of the fall and on the survey date. Review of the manufacturer’s instructions for the air loss mattress showed that the mattress is intended for pressure injury treatment and prevention and that the dial should be set to the correct weight of the resident. The user manual warned that improper operation could cause injury and specified that only qualified personnel trained in the treatment and prevention of pressure injuries should operate the device. The ADM acknowledged that the resident’s mattress weight setting was not aligned with the instructions for use. The combination of an incorrectly set air loss mattress, lack of a physician order for its use, and absence of documented staff training or competency on air loss mattress operation constituted the deficiency identified by the surveyors.
Failure to Follow Physician Orders and Complete Required Assessments Leads to Delayed DVT Diagnosis
Penalty
Summary
A deficiency occurred when nursing staff failed to provide treatment and care in accordance with physician orders and professional standards for a resident who exhibited changes in her lower extremities, including discoloration and swelling. Despite the nurse's assessment and subsequent notification to the physician, which resulted in an order for a vascular consult and elevation of the resident's legs, the vascular consult was never scheduled. There was also no documentation of any attempts to obtain the consult, and the required weekly head-to-toe assessment was not completed as scheduled. Additionally, when changes in the resident's condition were observed, the required Change in Condition (CIC) documentation was not completed on multiple occasions. The resident involved had a medical history that included acute respiratory failure with hypoxia, COPD, hypertension, difficulty in walking, and abnormal posture. She was cognitively intact and able to communicate her needs. The initial change was noted when her legs became discolored and one leg was more swollen than the other. The physician was contacted and ordered a duplex scan, but the scan performed was an arterial ultrasound rather than a venous study, which would have been necessary to diagnose a DVT. The results indicated severe bilateral arterial disease and a possible occlusion, prompting the physician to order a vascular consult and leg elevation. However, the consult was not arranged, and the resident did not receive the ordered follow-up care. As a result of these failures, there was a delay in addressing the resident's symptoms, which led to an acute change in her condition, including increased pain and swelling. The resident was ultimately sent to the hospital, where she was diagnosed with a deep vein thrombosis (DVT) in her left leg and underwent a surgical thrombectomy. The lack of timely assessments, failure to complete required documentation, and not following physician orders contributed to the delay in treatment and escalation of the resident's condition.
Failure to Conduct Elopement Assessment and Implement Interventions
Penalty
Summary
The facility failed to conduct a quarterly elopement assessment for a resident, as required by their policy, and did not implement necessary interventions when the resident's risk factors for elopement increased significantly. The resident, who had dementia and was moderately cognitively impaired, was admitted in May 2024 and had expressed a desire to leave the facility on multiple occasions. Despite these indicators, the facility did not perform the required elopement assessment in November 2024, nor did they update the resident's care plan to address the increased risk. On the morning of January 23, 2025, the resident was found outside the facility in a confused state, having left without the staff's knowledge. The resident was seen by staff in bed at 4:40 a.m., but by 4:50 a.m., she was outside with a passerby who was calling 911. The resident was returned to the facility without injury, but the incident highlighted the lack of adequate supervision and preventive measures, such as a security bracelet, which was only applied after the incident. Interviews with facility staff, including the Director of Nursing and the Minimum Data Set Nurse, revealed that the resident's care plan regarding elopement risks was only created after the incident. The facility's policy required elopement risk assessments to be conducted quarterly and with any change in condition, but this was not adhered to, leading to the resident's unsupervised exit from the facility.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 83 residents, their families, and legal representatives. During an observation, it was noted that the State Survey Binder, located in the hallway near the Director of Nursing's office, did not contain the results of the last recertification survey conducted on July 14, 2023. This omission was confirmed during a review of the binder, which was undated, and through interviews with both the Administrator and the Director of Nursing. Both the Administrator and the Director of Nursing acknowledged that the survey results should have been included in the binder and made accessible to everyone. The facility's policy on Resident Rights, dated December 2021, guarantees residents the right to examine survey results, which was not upheld in this instance. The absence of the survey results in the binder potentially violated the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction.
Deficiency in Food Service Oversight and Dietitian Consultation
Penalty
Summary
The facility failed to comply with federal regulations regarding the oversight of food service operations by not employing a full-time dietitian or a qualified dietetic services supervisor (DSS) as required by the California Code, Health and Safety Code - HSC S 1265.4. The facility employed a Certified Dietary Manager (CDM) who worked only 32 hours a week and was not qualified as a full-time DSS. The CDM was also a district manager for a contract food service company, overseeing multiple facilities, and was not present full-time at the facility. The Kitchen Supervisor (KS) was in a manager-in-training program and was not yet qualified, with the CDMs providing only limited oversight. During the re-certification survey, several issues were identified, including kitchen staff competency, not following the planned menu, improper food preparation, and failure to accommodate resident food preferences. The Registered Dietitian (RD) was working remotely and had limited in-person presence, providing only 8 hours of consultation per week. The RD did not review or approve the facility menu and was primarily focused on clinical work rather than food service operations. The RD's contract did not include responsibilities for food service oversight or frequent consultation with the KS. Interviews with facility staff, including the Administrator and Regional Resource RD, revealed awareness of the RD's limited role and the lack of oversight in food service operations. The RD's contract and scope of work were limited, and there was no documentation to validate frequent consultation with the KS. The facility's failure to employ a qualified full-time DSS and ensure adequate RD consultation placed residents at risk for receiving incorrect food items and compromised nutrition.
Failure to Follow Planned Menus and Dietary Guidelines
Penalty
Summary
The facility failed to adhere to the planned menu for residents, leading to several discrepancies in meal preparation and service. On October 8, 2024, steamed spinach was served instead of the planned creamed spinach to 79 out of 81 residents. Additionally, the incorrect scoop size was used for serving mechanical diced ham to residents on dysphagia advanced and mechanical diets, which did not align with the dietary guidelines. Furthermore, fortified mashed potatoes were served instead of whipped sweet potatoes to residents on puree and dysphagia mechanical diets. Another significant issue involved Resident 133, who was on a vegetarian diet but was repeatedly served egg salad, which was not part of the planned menu. This resident expressed dissatisfaction with the lack of variety and the repetitive nature of the meals provided. The kitchen staff, under the direction of the Kitchen Supervisor, failed to follow the menu and recipes as outlined, leading to these discrepancies. Interviews with the Registered Dietitian and the Kitchen Supervisor revealed expectations for staff to follow menus and recipes, which were not met. The Registered Dietitian had not reviewed or approved the facility menu, which is a requirement according to the facility's policy. These failures in menu adherence had the potential to impact residents' nutritional needs and overall satisfaction with their meals.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One deficiency involved Resident 52, whose oxygen nasal cannula tubing was found on top of the oxygen concentrator without being stored in a protective plastic bag. This oversight was confirmed by multiple staff members, including a CNA, LVN, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, all of whom acknowledged that the tubing should have been bagged to prevent infection. The facility's policy and procedure on infection prevention and control, as well as professional guidelines, were not adhered to in this instance. Another deficiency was noted with Resident 48, whose medication syringe was stored in a wet plastic bag with an orange liquid at the tip. The LVN responsible for administering medication to Resident 48 did not rinse the syringe before or after use, which was contrary to infection control practices. The Infection Preventionist and the Director of Nursing both recognized this as an infection control issue, emphasizing the need for proper cleaning and storage of syringes to prevent bacterial growth. The facility's policy on administering medication and professional references on syringe cleaning were not followed. A third deficiency involved Resident 54, who was on Enhanced Standard/Barrier Precautions. CNA 7 provided personal care to Resident 54 without wearing a gown, despite the resident being on enhanced precautions due to an open dialysis port. Interviews with the Infection Preventionist, another CNA, and the Director of Nursing highlighted the requirement for staff to wear gowns and gloves when providing care to residents on such precautions. The facility's in-service training and policy on Enhanced Standard/Barrier Precautions were not implemented correctly in this case.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents, which is a requirement to ensure residents are fully informed about the risks and benefits of their treatments. Resident 3 was administered escitalopram oxalate for depression from June to August without informed consent being obtained until late August. This oversight was confirmed during an interview with a registered nurse who acknowledged that the medication was administered daily without the necessary consent. Similarly, Resident 13 was given sertraline for depression from August to mid-October without a complete informed consent. The registered nurse reviewing the case confirmed that the consent was incomplete and that the medication should not have been administered without it. The responsibility for ensuring informed consent was noted to lie with the licensed nurses. Resident 64 was administered buspirone for anxiety from late August to mid-October without an accurate informed consent. The registered nurse and the Director of Staff Development both confirmed that the consent was not valid, and the medication should not have been given. The facility's policy requires that informed consent be obtained by the prescriber before the initiation of psychotropic medications, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 75, who was admitted with an indwelling urinary catheter due to acute kidney failure and other conditions, did not have a care plan for the catheter's use. Despite being in the facility for several weeks, no care plan was initiated to guide the nursing staff in managing the catheter, as confirmed by interviews with the LVN and MDS Nurse. The facility's policy required a comprehensive care plan to be developed within seven days of admission, but this was not done for Resident 75. Similarly, Resident 29, who was admitted with multiple diagnoses including diabetes and end-stage renal disease, did not have a timely care plan for a urinary tract infection (UTI). The resident was started on antibiotics following a positive test for E-coli and ESBL, but the care plan was only created several days later. Interviews with the LVN and Infection Preventionist revealed that the care plan should have been initiated when the change in condition was noted, to monitor the resident's response to treatment and update the care team. The Director of Nursing acknowledged that the care plans were not patient-centered and should have been updated promptly to reflect changes in the residents' conditions. The facility's policy emphasized the importance of individualized care plans to meet residents' medical, physical, mental, and psychosocial needs, but this was not adhered to in these cases, resulting in potential unmet care needs for the residents involved.
Medication Management and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure professional standards of quality in the care of two residents, leading to deficiencies in medication management and documentation. For Resident 29, licensed nurses continued to sign off on monitoring for side effects of an anticoagulant medication that had been discontinued. This resulted in inaccurate documentation and monitoring of the resident's medical symptoms, as the staff was checking for side effects of a medication that was no longer being administered. The oversight was acknowledged by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who confirmed that the physician's order should have been updated to reflect the discontinuation of the medication. In the case of Resident 55, a Licensed Vocational Nurse (LVN 1) prepared the resident's medications but did not administer them due to her pregnancy and the resident being on enhanced barrier precautions. Instead, the Infection Preventionist (IP) administered the medications prepared by LVN 1, which is against the facility's policy. This practice could lead to medication errors, as the person administering the medication did not prepare it. Both LVN 1 and the IP acknowledged that this was not an acceptable practice, and the DON confirmed that the facility's policy requires the same nurse to prepare and administer medications. The report highlights the importance of accurate documentation and adherence to medication administration protocols to ensure resident safety. The deficiencies observed in the care of Residents 29 and 55 demonstrate lapses in following established procedures, which could potentially lead to adverse outcomes for the residents involved.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for two residents, Resident 233 and Resident 32, as observed by surveyors. Both residents were found to have long fingernails with black particles underneath, indicating a lack of regular cleaning and trimming. Resident 233 expressed dissatisfaction with the condition of his nails and could not recall the last time they were cut. Interviews with the Director of Staff Development (DSD) and Certified Nursing Assistant (CNA) 8 revealed that CNAs were responsible for daily cleaning and trimming of fingernails, while nurses were tasked with cutting the nails of diabetic residents. Despite these responsibilities, the necessary care was not provided, leading to the potential risk of infections or skin injuries. Resident 233 was admitted with multiple diagnoses, including diabetes mellitus type 2, peripheral vascular disease, and hypertension, and was cognitively intact with a BIMS score of 15. Similarly, Resident 32, who also had diabetes mellitus type 2 among other conditions, was cognitively intact with a BIMS score of 14. The facility's policy on nail care, revised in 2018, emphasized the importance of daily cleaning and regular trimming to prevent infections and skin problems. However, the failure to adhere to this policy resulted in the observed deficiencies in nail care for these residents.
Failure to Administer Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 13 and Resident 33, by not administering oxygen at the flow rates ordered by their physicians. Resident 13, who was diagnosed with chronic obstructive pulmonary disease and unspecified asthma, was observed receiving oxygen at a flow rate of four liters per minute, contrary to the physician's order of two liters per minute. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) who was unsure why the flow rate was set incorrectly. The Director of Nursing (DON) emphasized that oxygen is considered a medication and should be administered as per the physician's order to avoid potential adverse effects such as oxygen toxicity. Resident 33, who had a history of hypertension, type 2 diabetes mellitus, pneumonia, and acute respiratory failure with hypercapnia, was also found to be receiving oxygen at an incorrect flow rate. The resident was observed with a flow rate of one liter per minute, while the physician's order specified two liters per minute. This error was noted during an assessment by an LVN, who acknowledged the potential for respiratory distress and hypoxia due to the decreased oxygen flow. The DON reiterated the importance of adhering to physician orders and checking oxygen settings at the beginning of each shift to prevent such issues. The facility's policies and procedures for medication administration and oxygen therapy were reviewed, highlighting the requirement for medications, including oxygen, to be administered as prescribed. The failure to follow these protocols resulted in both residents not receiving the necessary respiratory care, potentially leading to serious health complications.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for two residents, leading to a deficiency in care. Resident 48, who had severe cognitive impairment and was on hospice care, was observed with both side rails raised without a physician's order, care plan, or informed consent. The clinical record for Resident 48 indicated a previous safety evaluation recommended against the use of side rails, yet they were still in use. Licensed Vocational Nurse (LVN) 5 confirmed that necessary documentation and orders were not in place, which was crucial for ensuring resident safety. Similarly, Resident 133, who was cognitively intact, was also found using bed rails without the required physician's order, care plan, or safety evaluation. LVN 6 acknowledged the absence of necessary documentation and stated that such forms should be completed within 24 hours of admission. The Director of Nursing (DON) and Director of Staff Development (DSD) both emphasized the importance of obtaining physician's orders, care plans, safety assessments, and consents for the use of side rails to ensure they are used for their intended purpose. The facility's policy underscored the need for individualized patient assessments and documentation of risk-benefit assessments in the patient's medical chart.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 6.9 percent. One incident involved a Licensed Vocational Nurse (LVN) who did not administer metformin to a resident during a medication pass because the medication was unavailable. The resident, who had a history of diabetes, hypertension, and unspecified multiple injuries, missed two doses of metformin, which could potentially lead to elevated blood sugar levels. The Director of Nursing (DON) acknowledged that the nurse should have ensured the medication was available and contacted the pharmacy when it was not. Another incident involved a resident who had a lidocaine patch applied for more than the recommended 12 hours. The patch was supposed to be removed at bedtime to prevent skin irritation and potential side effects. The resident, who was severely cognitively impaired, had been receiving the patch twice daily for the past two months. The Pharmacist Consultant confirmed that the patch should be removed every 12 hours, and the DON stated that the nurses should have followed the physician's order to remove the patch at night. The facility's policies and procedures were reviewed, indicating that medication errors should be reported and that medications should be administered according to prescriber orders. The policies also outlined the process for ordering and receiving medications from the pharmacy to ensure timely delivery. However, these procedures were not followed in the cases of the metformin and lidocaine patch, leading to the observed deficiencies.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored according to professional standards, affecting three residents. For two residents, medications such as Fluticasone Propionate and Albuterol Sulfate were not labeled with expiration dates, which was confirmed during an observation and interview with an LVN. The facility's policy required medications to be labeled with expiration dates, and the lack of labeling was acknowledged by the Infection Preventionist and the Director of Nursing, who emphasized the importance of labeling to prevent the use of expired medications. Another deficiency was observed with a resident's insulin pen, which was missing a label. The insulin pen was found in a medication cart with a bag that had a label, but the pen itself did not. This was confirmed by an RN, who stated the importance of labeling to ensure the correct medication is administered to the right resident. The Pharmacist Consultant and the Director of Nursing both confirmed that insulin pens should have labels on both the bag and the pen to prevent mix-ups and ensure resident safety. Additionally, four loose medication pills were found on the floor in a medication storage room, and one and a half pills were found in a red medication bin. An LVN confirmed that loose pills should not be on the floor and should be disposed of properly to prevent medication errors. The Pharmacist Consultant and the Director of Nursing reiterated that medications should be destroyed in designated bins and that loose pills on the floor were unacceptable.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of several residents, leading to potential nutritional deficiencies. During a lunch meal observation, it was noted that Resident 44, who was on a carbohydrate-controlled diet and disliked potatoes, was served sweet potatoes. Similarly, Resident 75, who was on a regular dysphagia mechanical diet and disliked ham and pork, was served ham. Resident 184, on a consistent carbohydrate, dysphagia advanced diet, also received ham despite disliking it. The kitchen supervisor confirmed these discrepancies and removed the ham from the trays of Residents 75 and 184, substituting it with egg salad. However, the facility's menu indicated Salisbury steak as the regular alternate entree, which was not provided. The facility also failed to provide alternate options for residents who disliked certain food groups. Resident 31, who disliked spinach, was not given an alternate vegetable, and Resident 39, who disliked spinach and sweet potatoes, was not provided with suitable alternatives. The kitchen staff did not prepare the alternate food items listed on the menu, such as the Capri vegetable blend, which was supposed to be available as an alternative to creamed spinach. Interviews with the kitchen supervisor and registered dietitian revealed that the expectation was for the kitchen staff to follow residents' likes and dislikes and offer alternate food items when necessary. Additionally, Resident 52's preference for cold food was not documented on his meal ticket, despite his severe cognitive impairment and the family's repeated requests for cold food alternatives. The resident's meal ticket did not reflect his preferences, leading to a two-week period where he did not eat because he was not provided with cold food. Interviews with staff, including a CNA, LVN, and the Director of Nursing, indicated that it was the responsibility of the nursing staff to communicate meal preference updates to the kitchen. The facility's policy required that food preferences be obtained within 72 hours of admission and updated as needed, but this was not adhered to in Resident 52's case.
Improper Sanitation Practices in Food Preparation
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety due to improper sanitation practices. During an observation in the kitchen, a food service worker used a sanitation solution with a concentration of zero parts per million (ppm) to wipe down a food service cart, which was below the required 200 ppm. The worker acknowledged the correct concentration and subsequently corrected the solution. In a separate observation, the kitchen supervisor used a similarly ineffective sanitation solution to clean around a food processor, with the test strip barely changing color, indicating insufficient concentration. The facility's policy requires all food preparation and service areas to be maintained in a clean and sanitary condition, with food contact surfaces cleaned and sanitized after each use.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, specifically in maintaining privacy during medical procedures. A Licensed Vocational Nurse (LVN) checked the resident's blood pressure and administered medication without closing the privacy curtain or door, allowing staff, residents, and visitors to see inside the room. This lack of privacy was observed during two separate instances, one while checking blood pressure and another while administering medication. Interviews with the LVN and other staff, including the Infection Preventionist and Director of Nursing, confirmed that the LVN did not provide the necessary privacy, which is a right of the resident. The resident involved had a severe cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and was diagnosed with hemiplegia, hemiparesis, and aphasia. The facility's policies on dignity and resident rights emphasize the importance of maintaining privacy during care and treatment, which was not adhered to in this case. The failure to provide privacy was acknowledged by the LVN and other staff members, who stated that it was standard practice to ensure privacy during such procedures.
Inaccurate MDS Assessment for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the diagnosis of an indwelling urinary catheter. During an observation and interview, it was noted that the resident had an indwelling urinary catheter, which was not coded in the MDS assessment. The resident was admitted with diagnoses including anxiety, kidney failure, and neuromuscular dysfunction, and had a moderate cognitive deficit. Despite the presence of the catheter, there was no corresponding order, diagnosis, or care plan documented in the resident's records. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Minimum Data Set Nurse (MDSN), and the Medical Records Director (MRD), revealed that the resident was admitted with the catheter, but the necessary documentation was missing. The LVN confirmed the absence of an order and diagnosis for the catheter, while the MDSN acknowledged that the catheter use was coded but not the diagnosis. The MRD, who was also a licensed nurse, was unaware of the catheter until reviewing the records and confirmed that the required documentation was only initiated days after the resident's admission. The Director of Nursing (DON) stated that the catheter was re-inserted after an unsuccessful attempt to discontinue it, due to the resident not voiding for eight hours. The DON admitted that the licensed nurse should have entered the order and obtained a diagnosis from the physician. The facility's policy on urinary catheters emphasized the need for valid medical justification and timely discontinuation, which was not adhered to in this case.
Failure to Update Care Plan After Insulin Discontinuation
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for a resident when the care plan was not updated to reflect the discontinuation of insulin medication. The resident, who was admitted with diagnoses including diabetes mellitus type 2, hypertension, end-stage renal disease, anemia, and pain, had their insulin medication discontinued on a specific date. However, the care plan was not updated to reflect this change, which was identified during a review of the resident's electronic Medication Administration Record (eMAR). Interviews with facility staff, including an LVN and the Director of Nursing (DON), revealed that the care plan should have been updated to match the resident's current needs and goals. The LVN acknowledged that the care plan needed to be individualized and that failing to update it could lead to missed issues for the resident. The DON confirmed that the care plan was not personalized or individualized to the resident's needs when it continued to include insulin after its discontinuation. The facility's policy and procedure on care plans emphasized the need for ongoing assessment and timely updates to reflect changes in the resident's condition.
Failure to Administer Metformin Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident, specifically Resident 48. Resident 48's metformin, a medication used to control high blood sugar, was not available for administration on two consecutive days. This lapse was observed during an interview with a Licensed Vocational Nurse (LVN) who confirmed that the medication was unavailable and acknowledged the potential for Resident 48's blood sugar to increase due to the missed doses. The facility's policy requires licensed nurses to ensure medications are available and to reorder them five days in advance. However, this procedure was not followed, as evidenced by the interviews with the LVNs and the Director of Nursing (DON), who stated that the nurse responsible for administering the last dose should have contacted the pharmacy to ensure timely delivery. The failure to administer metformin was documented in Resident 48's electronic medical administration record, which showed missed doses on two specific days.
Deficiency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that support personnel effectively carried out the functions of food and nutrition services, as evidenced by the actions of a staff member, [NAME] 1, who did not follow menus and recipes. During a lunch meal observation, [NAME] 1 prepared spinach incorrectly, using only 10 pounds of frozen spinach instead of the required 16 pounds for 80 servings, leading to a shortage. Additionally, the tray line did not include alternate vegetables or entrees as specified in the menu, resulting in residents receiving meals that did not accommodate their dietary preferences or restrictions. Several residents were affected by these discrepancies. For instance, a resident who disliked spinach received a meal with spinach, and another resident who disliked the potato group received sweet potatoes. Furthermore, a resident on a dysphagia mechanical diet who disliked ham and pork was served ham. These actions were confirmed by the Kitchen Supervisor, who acknowledged the residents' dietary preferences and made adjustments by serving egg salad instead of ham. The facility's training and competency evaluation processes were also found lacking. Although [NAME] 1 had completed online in-services on texture modification and plate presentation, there was no documentation of in-services regarding following recipes or menu spreadsheets. The Registered Dietitian had offered to conduct in-services, but the kitchen staff had not requested them. The competency checklist for [NAME] 1 was signed off by the Kitchen Supervisor, but observations during the survey indicated concerns with [NAME] 1's competency in preparing mechanically altered foods and assembling resident meal trays correctly.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared in the proper form, as evidenced by the presence of a whole green bean in a pureed salad served on a test tray. This incident was observed during a lunch meal service, where meals were being prepared and placed on trays in the kitchen. The surveyors ordered a regular and puree test tray, and upon inspection of the puree test tray, a whole green bean was found in the pureed salad. This was confirmed during an interview with the Certified Dietary Manager (CDM), who acknowledged that the presence of a whole green bean in the puree salad was not acceptable. Further investigation revealed that the staff member responsible for preparing the puree salad used a handheld blender to prepare the green bean salad with Italian dressing. A review of the facility's Corporate Recipe for Marinated Bean Salad indicated that for pureed diets, the ingredients should be blended until smooth. Additionally, the facility's Diet and Nutrition Care Manual specified that all foods for a Dysphagia Puree (Level 1 Diet) must be of a moist, pudding-like consistency without particles. Although the staff member had completed an online in-service on texture modification, the content and competency assessment of the in-service were unclear.
Failure to Follow Physician-Prescribed Diets
Penalty
Summary
The facility failed to ensure that physician-prescribed diets were followed for Resident 6, who did not receive his ordered double portion meal for lunch on 10/8/24. This oversight was identified during an observation in the dining room where Resident 6 was served a regular portion instead of the prescribed double portion. A review of Resident 6's Meal Ticket revealed that it did not list the order for a double portion diet. Interviews with staff, including a CNA and LVN, confirmed that the meal ticket should reflect the prescribed diet, and the LVN acknowledged that Resident 6's diet order was for double portions, which was necessary due to his declining health. Further investigation revealed that the order for double portions was not communicated to the kitchen until 10/10/24, as stated by the Account Manager and Certified Dietary Manager. The Director of Nursing confirmed that the order for double portions should have been documented on the meal ticket and communicated to the kitchen staff. The facility's policy indicated that the Dietary Manager should review the attending physician's dietary order within 72 hours of admission, but this process was not effectively followed, leading to the deficiency.
Inadequate Kitchen Cooling Leads to Staff Discomfort
Penalty
Summary
The facility failed to provide a comfortable environment in the kitchen for staff, as evidenced by consistently high temperatures recorded during observations. On multiple occasions, the surveyor's thermometer recorded temperatures ranging from 89.4 to 93.6 degrees Fahrenheit in the kitchen. Interviews with staff confirmed that the kitchen is usually warm, and the Certified Dietary Manager (CDM) acknowledged that one of the air conditioning (A/C) units was not functioning due to a lack of a remote controller. The Facility Maintenance Director (FMD) confirmed that the A/C units had been in place for over eight years, and there was only one remote for both units, which was broken, preventing staff from verifying the A/C settings. The facility's policy and procedure, as well as a sanitation and food safety checklist, indicated the need for proper ventilation in the kitchen. However, the checklist noted that the kitchen office and emergency food room were hot, with a recommendation to install a wall A/C unit in the office. The high temperatures in the kitchen, combined with the lack of functional A/C units, created an environment that could potentially increase the risk of heat-related illnesses among staff. The facility's failure to address the broken remote controller and ensure adequate cooling in the kitchen contributed to the deficiency.
Failure to Create Care Plan for Elopement Risk
Penalty
Summary
The facility failed to create a care plan for a resident at risk of elopement, despite multiple indicators and assessments identifying the risk. The resident had a history of elopement from previous skilled nursing facilities and had attempted to leave against medical advice from a dialysis center. Despite these clear signs, no care plan was developed to address the resident's elopement risk, and the resident successfully left the dialysis center against medical advice on a subsequent occasion. Interviews with staff revealed a lack of communication and adherence to the facility's policies and procedures regarding elopement risk. The Social Service Director was aware of the resident's history but did not ensure a care plan was in place. The Licensed Vocational Nurse acknowledged that the resident often expressed a desire to leave and had documented an attempted elopement, but no care plan was created. The Minimum Data Set Coordinator and Director of Staff Development also confirmed that the resident was not included in the facility's Wander Risk Binder, and no interdisciplinary team meeting was held to address the risk. The facility's policy required an elopement risk assessment and the development of a person-centered care plan for residents identified as at risk. However, this policy was not followed. The Director of Nursing confirmed that no care plan was made, and there was no communication with the dialysis center to monitor the resident. The failure to create and implement a care plan for the resident's elopement risk led to the resident successfully leaving the dialysis center against medical advice.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 485 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kingsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Lutheran Home | 3.6 mi | ★★★★★ | 19 | 0 |
| Rolling Hills Care Center | 4.3 mi | ★★★★★ | 21 | 0 |
| Palm Village Retirement Comm. | 7.2 mi | ★★★★★ | 1 | 0 |
| Vineyard Care Center | 8 mi | ★★★★★ | 2 | 0 |
| Sierra View Homes | 8.3 mi | ★★★★★ | 18 | 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 July 2026) and official state health department websites.