Kingsburg Center

In the surveyor’s words

From the most serious findings on record at Kingsburg Center, in the surveyor’s own words.

• Actual harm, isolatedF684May 21, 2025

  Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) received treatment and care in accordance with professional standards of practice when nurses assessed both of Resident 1's legs as discolored and one leg as swollen on [DATE], contacted the physician for orders and did not follow physician's orders to obtain a vascular consult ordered on [DATE]. A Change in Condition (CIC- documentation completed when nurse's identify a change from a resident's baseline condition) was not completed on [DATE] due to the changes in Resident 1's legs. The nurse assessed Resident 1's left leg as more swollen than the right leg on [DATE] and failed to complete a CIC. […]

• Actual harm, isolatedF689Jan 21, 2022

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received adequate supervision and assistance in personal care when Resident 1, who was assessed to need two person assistance, had an ordered low air loss mattress, was provided care by Certified Nursing Assistant (CNA) 1 on [DATE] without the benefit of two person assist. This failure resulted in Resident 1 falling from bed on the opposite side while CNA was turning Resident 1. Resident 1 fell to the floor and sustained a laceration to the scalp (head), a skin tear to the left elbow and a vertebral fracture (C4, Cervical vertebrae 4, cervical spine from the base of the skull down to the top of the shoulders labeled C1-C7) and required transport to the hospital for higher level of care. […]

• No harm, potential for more than minimal, widespreadF801Jun 5, 2026

  Based on interviews and record reviews, the facility failed to ensure the food service manager met state requirements when the Dietary Account Manager (DAM) hired for this role did not meet the qualifications required for food service managers.This failure had the potential to place residents at risk for compromised food safety and inadequate oversight of dietary operations for the 75 residents who received food from the kitchen.Findings: During a review of the California Health and Safety Code (HSC) 1265.4, dated 1/1/25, the California Health and Safety Code 1265.4 indicated seven qualification pathways of the full-time position responsible for the day-to-day operation of dietetic services. […]

• No harm, potential for more than minimal, widespreadF577Oct 14, 2024

  Based on observation, interview, and record review the facility failed to post the results of the most recent survey document titled Statement Survey Binder in a place readily accessible for 83 of 83 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction. Findings: During an observation on 10/10/24 at 9:31 a.m., a binder titled, State Survey Binder was located in the hallway near the Director of Nursing's (DON) office. During a review of the facility's, State Survey Binder binder, undated, the binder did not contain results for the facilities last recertification survey conducted on 7/14/23. […]

• No harm, potential for more than minimal, widespreadF801Oct 14, 2024

  Based on observation, interview and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established State standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full-time; and 2. Ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the Food and Nutrition Services department. […]