Hanford Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and distribute food in accordance with professional food service when:1. The food preparation sink was not equipped with a required air gap (a space that helped keep dirty water from getting into clean water). Which had the potential to allow backflow (dirty water flowing backward into clean water) and contaminate (harmful germs or other unsafe substances were present) food, food contact surfaces and equipment. This failure had the potential to expose all 87 residents residing in the facility to contaminated food, food contact surfaces, and an increased risk of foodborne illness. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that four out of eight sampled residents (Resident 1, 5, 8, and 57) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications, when.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a form designed to meet an individual resident's needs by preparing pureed zucchini that did not maintain the consistency required for a prescribed pureed diet for one of nine residents (Resident 10). This failure had the potential to increase the risk of aspiration (food or liquid entering the airway instead of the stomach) by not providing food in the consistency required for the residents prescribed pureed diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for two of five sampled residents (Resident 6 and 12) when:1. Licensed Vocational Nurse (LVN) 5 checked Resident 6's blood sugar using a glucometer (a portable medical device used to measure the amount of sugar in the blood) and did not properly disinfect the glucometer after use.2. LVN 5 checked Resident 12's blood sugar using a glucometer and did not properly disinfect the glucometer after use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of eight sampled residents (Resident 20) when Resident 20's Functional Limitation in Range of Motion was inaccurately coded in the quarterly MDS assessment dated [DATE]. This failure had the potential for Resident 20's need not monitored and met which could lead to further decline in function of lower extremities. [...]

Inspectors wroteNumber of residents sampled: 8Number of residents cited: 1Based on observation, interview, and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of eight sampled residents (Resident 2) when Resident 2's care plan for enteral nutrition (tube feeding [soft, flexible tube inserted directly into the stomach or small intestine ]- way to get liquid food and nutrients directly into the stomach or small intestine when resident cannot safely eat by mouth) was not updated and did not accurately reflect the physician's order for Resident 2's enteral nutrition. This failure had the potential to result in Resident 20's needs not be met. During an observation on 7/14/26 at 9:29 a.m. during initial tour in Resident 2's room, Resident 2 was observed lying in bed, eyes closed and head of bed elevated. [...]

Inspectors wroteNumber of residents sampled: 8Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure nail care was provided for two of eight sampled residents (Resident 11 and Resident 53) when Resident 11 and Resident 53's fingernails were long and dirty with dark brown built up underneath their nails. This failure had the potential for Resident 11 and Resident 53 in sustaining avoidable skin related injuries like cuts, skin tears, scrapes and scratches which can lead to skin infection (invasion and growth of germs in the body). During a concurrent observation and interview on 7/4/26 at 9:28 a.m. during initial tour in Resident 11's room, Resident 11 was lying in bed with eyes open. Resident 11 stated he was in the hospital due to poor circulation in his lower legs and had to amputate both legs above the knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the environment was free of hazards and adequate supervision was provided to prevent accidents for one of three residents, Resident 96, when nursing staff had assessed Resident 96 as a high risk for falls, were aware of Resident 96's history of falls, and previous Left hip fracture and failed to provide the level of supervision necessary to meet Resident 96's needs. The Occupational Therapy and Physical Therapy evaluation indicated Resident 96 required moderate assistance with toileting and was not independent with transfers between the bed and wheelchair. Nursing staff failed to implement supervision and interventions to address Resident 96's needs. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the daily nurse staffing information publicly posted for a facility with a census of 89 residents reflected the actual hours worked by nursing staff. This failure had the potential to provide residents, resident representatives, visitors and the public with inaccurate information regarding the facilities' daily nurse staffing levels, limiting their ability to make informed decisions based on the facilities' actual staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a psychiatric consultation recommendation was reviewed, communicated to the interdisciplinary team (IDT) and the attending physician and appropriately followed up for one of eight sampled residents (Resident 56). This failure had the potential to delay the evaluation and implementation of a recommended intervention intended to address the residents emotional and psychosocial needs and could have affected the facilities ability to ensure timely behavioral health services.

Inspectors wroteBased on observation and interview, the facility failed to account for and periodically reconcile controlled drugs (medications or chemicals that the government tightly regulates because they carry a risk of being misused, causing addiction, or leading to dependence) when the facility was unable to provide documentation indicating periodic reconciliation of controlled drugs was being completed. This failure had the potential to result in controlled drug discrepancies and medication diversion (the illegal transfer, theft, or misuse of prescription medications from their intended path). During a concurrent observation and interview on 7/16/26 at 8:28 a.m. with the Director of Nursing (DON), in her office, the DON was observed with the Consultant Pharmacist (CP) actively destroying controlled medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was eight percent. There were 25 opportunities for errors and two medication errors occurred for two of five sampled residents (Resident 6 and Resident 12) when:1. Licensed Vocational Nurse (LVN) 5 administered 8 units of Novolin R (a short-acting insulin used to decrease blood sugar) instead of the prescribed Humulin R (a short-acting insulin) to Resident 6.2. LVN 5 administered 8 units of Novolin R instead of the prescribed Humulin R to Resident 12. This failure resulted in two medication errors and had the potential to result in dosing mistakes from concentration differences, unexpected blood sugar fluctuations, and possible allergic reactions.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program for three of six sampled residents (Residents 3, 5 and 6) when: 1. Resident 5 ' s oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. 2. Resident 3 and Resident 6 ' s oxygen concentrator filters were covered with dust and lint. These failures placed Residents 3, 5 and 6 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of six sampled residents (Resident 4) when Resident 4 was administered 4.5 L/min (liters-unit of measurement)/min (minute) of oxygen via Nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 2L/min of oxygen per physician's order. This failure had the potential to put Resident 4 at risk to oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; it can cause coughing and trouble breathing; in severe cases it can even cause death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of six sampled residents (Residents 1 and 4) when: 1. Nursing staff were aware of Resident 1's cognitive impairment (difficulties with mental processes such as memory, attention, reasoning, and decision making), poor safety awareness, impulsive behaviors of getting up from bed without using the call light, history of falls, and did not implement effective interventions to prevent falls. These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents who were hospitalized were permitted to return to the skilled nursing facility (SNF-a healthcare facility that provides a higher level of care that what is typically offered in assisted living or residential care) for one of seven residents (Resident 5) when the facility refused to take Resident 5 back after Resident 5 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH-is a healthcare facility that provides short-term, intensive treatment for patients with serious medical conditions). This failure placed Resident 5 at risk for psychosocial harm by not allowing the resident to return to the SNF and caused her to be transferred to a different SNF. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of six sampled residents (Resident 4) when Resident 4 was assessed as being a fall risk, had known behaviors of standing up without staff supervision and the facility did not put a fall risk care plan with effective interventions into place to prevent falls. This failure resulted in Resident 4 falling eight times, on 1/19/25, 1/23/25, 1/28/25 at 8:45 a.m., 1/28/25 at 3:17 p.m., 2/2/25, 2/4/25, 2/10/25 and 2/14/25 placing the resident at risk for significant injuries. (Cross reference F689)

Inspectors wroteBased on interview and record review, the Administrator (ADM) failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning when the administrator was aware of multiple falls for one of six sampled residents (Resident 1) and did not ensure the Interdisciplinary Team implemented effective fall prevention interventions. These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. [...]

Inspectors wroteBased on interview and record review the facility failed to identify and develop an effective QAPI (Quality Assurance and Performance Improvement-a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program when the facility ' s QAPI failed to utilize resident fall data to establish an effective safety plan for fall prevention for one of six sampled residents (Residents 1). These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for five out of fourteen sampled residents (Resident 51, Resident 75, Resident 84, Resident 342, and Resident 343) when: 1. Resident 51's care plan was not developed and implemented to address the use of an assistive device transfer pole (an adjustable pole that is installed from ceiling to floor and used to assist in transfers). This failure had the potential to result in Resident 51 not receiving appropriate, consistent, and individualized care to ensure safe transfer needs are met to prevent injury. 2. Resident 75's care plan was not developed and implemented to address toenail assessment and condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for two of ten sampled residents (Resident 31 and 67) when: 1. Resident 31's CP was not revise for his non-compliance with the use oxygen (O2). This failure put Resident 31 at risk of not receiving the appropriate oxygen administration and not having his oxygen needs met. 2. Resident 67's CP was not reviewed and revised to reflect the need to use prescription glasses. This failure resulted Resident 67's ability to maintain adequate vision and had the potential to increase risk for falls and limit functional independence. These failures resulted for Resident 31 not receiving oxygen as prescribed by the physician and Resident 67 decreased ability to maintain adequate vision which had the potential risk for falls and limit functional independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled Residents (Resident 75) received toenail care consistent with professional standards of practice when Resident 75's toenails were long, yellow, hard thick, curled, and separated from the nail bed. This failure resulted in Resident 75's toenails to become long, curled, and painful which had the potential to lead to ingrown toenails, infection, or injury.

Inspectors wroteBased on observations, interviews and record records, the facility failed to provide pharmaceutical services for all controlled medications (medications that have the potential for abuse or addiction) and non-control medications when periodic reconciliation (a process which validates that the controlled medication inventory amount on hand is what is expected) was not completed for all residents with standing and as needed orders for controlled medications. This failure resulted in inadequate record keeping ensuring accurate inventory of controlled medications, prompt identification or potential for diversion of controlled medications.

Inspectors wroteBased on interview and record review, the Pharmacy Consultant (PC) failed to identify and report to the facility irregularities related to: 1. Resident 16 's Hemoglobin (Hgb - protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels was 8.1 to 8.3 gm/dL (grams per deciliter- unit of measure) for five months with no Hgb level goal. This failure had the potential risk for Resident 16 to experience tiredness and weakness with no intervention. 2. Resident 16, a kidney failure disease (-a long term disease that occurs when the kidneys are damaged and cannot filter blood properly) patient, was administered Ascorbic Acid (Vitamin C) 500 milligrams (mg- unit of measure) without Vitamin C blood monitoring. This failure had the potential risk for Resident 16 to result in toxicity from continued and unmonitored dose of Vitamin C administration.

Inspectors wroteBased on observation, interview and record review the facility failed to perform adequate lab monitoring, order medications without adequate indications for use for Resident 16 when: 1. Resident 16's Hemoglobin (Hgb - protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels was 8.1 to 8.3 gm/dL (grams per deciliter- unit of measure) for five months with no Hgb level goal and Procrit [medication use to treat anemia- condition in which the body does not have enough healthy red blood cells or Hgb] medication was given to correct low Hgb levels without iron lab monitoring. This failure had the potential risk for Resident 16 to experience blood loss without adequate intervention. 2. Resident 16 received Ascorbic Acid (Vitamin C) without Vitamin C blood monitoring and dose. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure two of two residents (Resident 43 and Resident 67) were free from unnecessary psychotropic (drugs that affect brain activities with mental processes and behaviors) medications when: 1. Resident 43 was prescribed Aripiprazole (antipsychotic medication that helps treat mental health conditions) for behaviors of auditory hallucinations and delusions with no documentation of such behaviors; ineffective monitoring for behavior of sadness as evidence by no target goal for behavior care planned; ineffective monitoring for behaviors of distress; no non-pharmacological (behavioral) interventions were implemented for Bupropion (antidepressant medication). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 11.11 percent. There were 27 opportunities for errors and three medication errors occurred for three of nine sampled residents (Resident 72, Resident 73, and Resident 70) when: 1. Resident 72's blood glucose (simple sugar - the body's primary source of energy from food) was assessed after Resident 72 began eating lunch. 2. Resident 73 was administered Olmesartan (medication used to lower blood pressure) and Resident 73's blood pressure was below ordered parameters. 3. Resident 70 was administered a medication not ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when: 1. The room temperature for two of two medication storage rooms was not monitored. This failure had the potential risk for medications to be exposed in extreme temperatures which could alter the medication chemical composition and reduce shelf life. 2. Resident 40 and Resident 11 discontinued medications were stored in the west wing medication cart, and Resident 16's discontinued ointment medication was stored in the east wing treatment cart. This failure had the potential risk to result in a medication error. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety for 90 of 91 sampled residents when: 1. A towel and a pair of rubber gloves were found on the floor behind the 3-compartment wash station. 2. The stove top had caramel colored residue under the grill and pan supporter, dark shiny residue was on the grill, pan supporter and stove elements, and yellow particles sprinkled on the inner burners. 3. Four pieces of toasted bread were on the floor behind the toaster. 4. The resident refrigerator had food residue on the door shelving and ice buildup in the freezer. 5. The four tiles in front of the ice machine were cracked and broken with missing pieces which created an uneven surface and exposed a dark colored flooring. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices for three of five sampled residents (Residents 31, 43, and 54) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete with section D - (physician/NP (Nurse Practitioner)/PA (Physician Assistant) License Number, NP Certificate Number, Physician/NP/PA Phone Number fields were not filled in, and the physician and the Resident or Resident Responsible Party (RP - legally recognized decision maker) signature and/or date fields were missing. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective infection prevention and control program for four of 14 sampled residents (Residents 29, 31, 73 and 84) when: 1. Resident 29's urinary catheter (a flexible tube that drains urine from the bladder into a bag) bag was dragging on the ground while being pushed in his wheelchair. This failure placed Resident 29 at potential risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 2. Resident 29's urinary catheter bag was laying on the floor. This failure placed Resident 29 at potential risk for cross contamination. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident's transfer or discharge notification to the state long term care Ombudsman (resident advocacy agency) office for one of 23 sampled residents (Resident 87) when Resident 87 was transferred to the General Acute Care Hospital (GACH). This failure resulted for the long-term care Ombudsman not being aware of Resident 87's transfer and discharge circumstances should appeals be filed by the residents or their representative.

Inspectors wroteBased on interview and record review the facility failed to provide written information to of the facility's bed hold policy for one of six sampled residents (Resident 16) when Resident 16 was not provided written information regarding the facility's bed hold policy upon his transfer to the hospital This failure violated the right of Resident 16 to be informed in writing of the facility's bed hold policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for one of six sampled residents (Resident 342) when Resident 342's Oxygen (O2) therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order and the O2 tubing (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) was not labeled when it was put into use allowing for tracking when it needs to be replaced to prevent bacterial contamination. This failure resulted in Resident 342 not receiving her oxygen therapy on 1/21/25 which could led to shortness of breath, fatigue, and the potential to developed respiratory infection from the use of contaminated O2 tubing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach for two of three sampled residents (Resident 20 and 65) when call lights were observed clipped to privacy curtains and out of reach. This failure had the potential for Resident 20 and 65 not to receive help when in need or in the event of an emergency.

Inspectors wroteBased on observation and staff interview during the survey period from 1/21/25 through 1/24/25, the facility failed to ensure each bedroom had 80 square feet of usable living space for residents in four different rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]).

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice for one of seven sampled residents (Resident 1) when license nurse did not administered Resident 1's physician's order for omeprazole (medication for gastroesophageal reflux disease [GERD]-a condition which causes stomach acid to flow back into the esophagus [tube between the mouth and stomach]) 20 milligrams (mg- unit of measurement) for seven consecutive days and the physician was notified of the missed doses. This failure resulted in Resident 1 not receiving the omeprazole on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24 and placed Resident 1 at potential risk to experience symptoms of GERD such as heartburn [burning sensation in the chest], sensation of a lump in the throat, chest pain, difficulty swallowing and nausea.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure they periodically reassessed and documented a resident's mental capacity prior to allowing a resident to make life-sustaining treatment decisions for 1 (Resident #2) of 2 residents reviewed for advance directives. The facility also failed to identify or arrange for an appropriate representative when Resident #2 was assessed as being unable to make health care decisions.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to accurately assess and document a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 (Resident #66) of 3 residents reviewed who received dialysis.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to ensure a registered nurse (RN) worked at least eight consecutive hours a day on two (11/10/2023 and 11/11/2023) of the previous 30 days.

Inspectors wroteBased on interviews and facility document and policy review, the facility failed to ensure daily staffing information postings contained all required information, including the total number and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), or licensed vocational nurses (LVNs), and certified nursing assistants (CNAs), and the resident census for each shift. This was noted during the review of daily staff postings for the timeframe from 11/01/2023 through 12/04/2023 and had the potential to affect all residents in the facility.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to provide at least 80 square feet per resident in four of four multiple occupancy resident rooms (Rooms 106, 108, 110, and 119). This failure had the potential to decrease resident freedom of mobility and could compromise the provision of care.

Inspectors wroteF-689 S/S D Based on interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) who was a high risk for elopement (a patient who is incapable of adequately protecting himself, and who departs the healthcare facility unsupervised and undetected) when Resident 1 eloped from the facility on 9/6/23. This failure placed Resident 1's safety at risk for injuries when Resident 1 was found in a restaurant 8 miles away from the facility on 9/6/23.