Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hanford Post Acute during CMS and state inspections, most recent first.
Three residents receiving oxygen therapy were found to have deficiencies in the maintenance of their oxygen concentrators: one was operating without a filter, while two others had filters covered in dust and lint. The IP and DON confirmed that these conditions did not meet facility policy or manufacturer requirements, and that licensed nurses were responsible for ensuring proper cleaning and assembly of the equipment.
A resident with multiple respiratory and cardiac conditions was given 4.5L/min of oxygen via nasal cannula instead of the physician-ordered 2L/min. Staff interviews and record reviews confirmed there was no documentation or physician order to justify the increased oxygen flow, and facility policy requiring adherence to physician orders was not followed.
A resident with a history of constipation, who was cognitively intact and dependent on staff for ADLs, repeatedly refused continence care and brief changes over several days. Staff did not adequately monitor or document bowel movements, assess for abdominal distention, or notify the physician in a timely manner. No bowel protocol or alternative interventions were implemented. This resulted in the resident developing a severe fecal impaction, requiring hospital transfer, and ultimately led to septic shock and death.
Two residents with cognitive impairment and poor safety awareness experienced multiple falls due to the facility's failure to provide adequate supervision and implement effective, individualized fall prevention interventions. Despite repeated unwitnessed falls and injuries, staff relied on ineffective measures such as reminders and environmental adjustments, and did not consistently update care plans or provide one-on-one monitoring, resulting in repeated injuries and, for one resident, a fatal outcome.
A resident with multiple medical and cognitive impairments was identified as a fall risk but did not have a comprehensive fall prevention care plan or effective interventions implemented upon admission. The resident experienced multiple falls before any fall risk interventions were added to the care plan, and staff did not document or provide adequate supervision as required by facility policy.
A resident with dementia and mobility issues experienced multiple unwitnessed falls due to inadequate supervision and ineffective fall prevention interventions, despite staff awareness of the resident's high fall risk. The resident sustained repeated injuries, including lacerations and a subdural hematoma, ultimately resulting in hospitalization and death. Staff interviews confirmed that necessary one-on-one monitoring and supervision were not provided, and existing interventions did not address the causes of the falls.
A facility failed to use QAPI data effectively to develop a fall prevention program, resulting in a resident experiencing multiple unwitnessed falls, repeated injuries requiring emergency care, and ultimately a fatal subdural hematoma.
The facility failed to implement comprehensive care plans for five residents, leading to deficiencies in care. A resident's care plan did not address the use of a transfer pole for safe transfers, while another's lacked toenail assessment despite complaints of pain. Two residents' care plans failed to include oxygen therapy services, resulting in noncompliance with prescribed treatments. Additionally, a resident's preference for a high bed position was not care planned, posing a risk of injury. These deficiencies reflect a lack of individualized care plans that address residents' needs and physician orders.
Two residents in an LTC facility did not have their care plans updated to reflect their current needs. One resident, with multiple health conditions, was non-compliant with prescribed oxygen therapy, and the care plan was not revised to address this. Another resident, with severe cognitive impairment, did not have her need for prescription glasses included in her care plan, impacting her ability to perform daily activities. The facility's policies require care plans to be updated as conditions change, but this was not done in these cases.
A resident with Alzheimer's, Type 2 Diabetes, and diabetic neuropathy experienced long, painful toenails due to the facility's failure to provide appropriate care. Despite the resident's complaints, staff did not assess or document the condition, nor was a podiatry consult requested. Facility policies required diabetic residents to receive toenail care from a podiatrist, but this was not followed, leading to potential complications.
The facility failed to conduct periodic reconciliation of controlled medications, as observed during an interview with the ADON and DON. The controlled medication log sheets lacked reconciliation, and the Pharmacy Consultant confirmed it was not part of the current policy. This oversight led to inadequate record-keeping and potential risks of medication diversion.
A Pharmacy Consultant failed to report irregularities in a resident's drug regimen review. The resident, with iron deficiency anemia and kidney failure, had consistently low hemoglobin levels without a documented goal, and was given 500 mg of Vitamin C daily without monitoring, risking toxicity. The DON and ADON confirmed the absence of necessary documentation and monitoring.
A resident with iron deficiency anemia and acute kidney failure received Procrit without a target Hgb goal or iron lab monitoring, and Ascorbic Acid without Vitamin C level checks. The facility's failure to monitor these parameters posed potential health risks, as confirmed by the DON and pharmacy consultant.
Two residents were prescribed psychotropic medications without proper documentation or non-pharmacological interventions. One resident was given Aripiprazole for hallucinations and delusions without evidence of such behaviors, and another had Olanzapine changed from PRN to routine without a psychosis assessment. There was ineffective monitoring and no gradual dose reduction attempts, increasing the risk of adverse reactions.
The facility's medication error rate was 11.11%, exceeding the acceptable threshold. Errors included a resident's blood glucose being checked post-meal, another resident receiving Olmesartan despite low blood pressure, and a third resident being given a medication not ordered by the physician. These actions were against the facility's medication administration policy.
The facility failed to monitor room temperatures in medication storage areas, risking medication efficacy. Discontinued medications were not removed from carts, posing a risk of errors. Inhalers lacked open date labels, risking expired medication use. A resident's medication lacked updated administration directions, risking incorrect dosage. Staff acknowledged these issues, highlighting the need for adherence to policies.
The facility failed to maintain food service safety standards, affecting 90 residents. Observations revealed unsanitary conditions, including a towel and gloves on the floor, a dirty stove, and food residue in the resident refrigerator. Additionally, cracked tiles in front of the ice machine posed a safety and infection risk. These deficiencies increased the risk of cross-contamination and foodborne illness.
A facility failed to ensure complete POLST forms for three residents, leading to potential non-compliance with their end-of-life care preferences. The forms lacked essential information such as physician contact details and signatures, which are necessary for the POLST to be valid. This deficiency could result in staff performing CPR on residents with DNR orders, as the incomplete forms do not clearly communicate the residents' wishes.
The facility failed to maintain effective infection control practices, as observed with several residents. A resident's urinary catheter bag was found on the floor, contrary to policy, posing a risk of infection. Additionally, oxygen nasal cannulas for two residents were improperly stored, increasing the risk of cross-contamination. Staff interviews confirmed these practices were against facility guidelines.
A facility failed to notify the state LTC Ombudsman of a resident's transfer to a GACH, as required by policy. The resident, with conditions including muscle weakness and end-stage renal disease, was transferred due to shortness of breath. Interviews with the DON and SSD confirmed the omission, highlighting a lapse in following the facility's transfer or discharge procedures.
A resident was not provided with written information about the facility's bed hold policy upon transfer to the hospital. Interviews revealed that notifications were made only via phone, contrary to the facility's policy requiring written notice at admission and at the time of transfer. This oversight violated the resident's right to be informed of the bed hold policy.
A resident with COPD did not receive continuous oxygen therapy as ordered, and the oxygen tubing was not labeled for replacement, leading to potential bacterial contamination. The resident reported tiredness and difficulty breathing, and staff confirmed the oversight in administering the prescribed therapy.
Two residents in the facility were found with call lights clipped to privacy curtains, out of reach, contrary to their care plans. One resident had severe cognitive impairment and mobility issues, while the other required maximum assistance with personal care. Staff interviews confirmed that call lights should be within reach to ensure residents can request help.
The facility was found to have four resident rooms with less than the required 80 square feet of space per resident. Rooms 106, 108, 110, and 119 each housed four residents, with space per resident ranging from 73.7 to 79.5 square feet. Despite this deficiency, the rooms met the residents' needs for privacy, storage, and accessibility, and a waiver for the space requirement was recommended to continue.
A resident with GERD did not receive their prescribed omeprazole for seven consecutive days due to a failure by the nursing staff to administer the medication and document the reasons for the omission. The LVN did not notify the physician about the missed doses, and the facility's policies requiring documentation and timely administration of medications were not followed.
Failure to Maintain Clean and Properly Assembled Oxygen Concentrators
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three of six sampled residents who were receiving oxygen therapy. One resident's oxygen concentrator was found to be operating without a filter installed, as observed during a room inspection. The Infection Preventionist (IP) and Director of Nursing (DON) both confirmed that the concentrator should not be used without a filter, and that it is the responsibility of licensed nurses to ensure the cleanliness and proper assembly of such equipment. Facility policy and the manufacturer's manual both require that the filter be present and cleaned regularly. Additionally, two other residents were observed using oxygen concentrators with filters that were covered in dust and lint. The IP stated that the filters should be cleaned at least once a week and as needed, and that using dirty equipment is not acceptable. The DON also confirmed that the expectation is for licensed nurses to clean the concentrators twice a week and as needed, in accordance with facility policy and job descriptions that require maintaining a clean and sanitary environment. Record reviews for all three residents showed that they had medical conditions such as COPD, congestive heart failure, and generalized muscle weakness, and were receiving oxygen therapy as ordered by their physicians. The observations and interviews revealed that the required maintenance and cleaning of oxygen concentrators were not being performed as per facility policy, job descriptions, and manufacturer instructions, resulting in the identified deficiencies.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, hypertension, dyspnea, and asthma was administered supplemental oxygen at a rate of 4.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This was observed during a routine check, and the Infection Preventionist confirmed that the oxygen setting was not in accordance with the physician's order. The physician order summary and progress notes did not indicate any clinical justification or documentation for increasing the oxygen flow above the prescribed amount. Interviews with facility staff, including the Infection Preventionist, Minimum Data Set Nurse, and Director of Nursing, confirmed that the oxygen administration did not follow professional standards or facility policy, which require verification and adherence to physician orders for medication administration, including oxygen. The facility's policy and job descriptions also specify that licensed nurses are responsible for reviewing and following physician orders, but this was not done in this instance.
Failure to Monitor and Intervene for Constipation Leading to Fatal Fecal Impaction
Penalty
Summary
A facility failed to ensure that a resident with a known history of constipation received necessary treatment and care in accordance with facility policies, procedures, and professional standards of practice. The resident, who was cognitively intact and dependent on staff for activities of daily living, repeatedly refused continence care and brief changes over several days. Despite these refusals and the resident's infrequent bowel movements, nursing staff did not adequately monitor or document bowel movements, assess for abdominal distention, or notify the physician in a timely manner about the ongoing refusals and lack of bowel movements. The facility also did not implement a bowel protocol or alternative interventions to prevent complications from constipation and impaction. Multiple staff interviews revealed that neither licensed nurses nor CNAs could confirm whether the resident had regular bowel movements, as the resident often refused care and staff did not perform or document necessary assessments. Although the resident was on a PRN stool softener, it was not administered because staff could not confirm the need due to lack of documentation and assessment. The physician was reportedly informed verbally of the refusals but did not provide new orders, and there was no documentation of these communications or of any interdisciplinary team meetings or care conferences to address the ongoing refusals and risks. The facility's own policy required detailed documentation and physician notification in cases of treatment refusal, but these steps were not consistently followed. As a result of these failures, the resident developed a severe fecal impaction, presenting with altered mental status and hypotension, and was transferred to an acute care hospital. There, a large amount of hardened stool was removed, but the resident deteriorated rapidly, developed septic shock, and died later that day. The deficiency was directly linked to the lack of monitoring, assessment, documentation, and timely intervention in response to the resident's ongoing refusals and known risk factors for constipation and impaction.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for two residents with known cognitive impairments, poor safety awareness, and histories of impulsive behaviors and multiple falls. For one resident, staff were aware of his moderate cognitive impairment, unsteady gait, and repeated incidents of getting out of bed without assistance, yet did not provide the necessary supervision or one-on-one monitoring. Despite multiple unwitnessed falls occurring in his room, interventions remained limited to reminders to use the call light and environmental adjustments, which staff acknowledged were ineffective due to the resident's inability to remember or comply. This resident experienced several unwitnessed falls resulting in injuries, including lacerations requiring emergency care and ultimately a fatal subdural hematoma following repeated falls. Another resident, also with moderate cognitive impairment and a history of brain injury, muscle weakness, and poor balance, was assessed as a fall risk but did not have a fall prevention care plan or interventions in place prior to his first fall. The resident exhibited impulsive behaviors, such as standing up suddenly and attempting to ambulate without assistance, leading to eight falls within a 30-day period. Staff interviews confirmed that the resident required constant supervision to prevent falls, but interventions were limited to periodic checks and environmental cues, which did not prevent further incidents. Documentation showed that care plans and interventions were not consistently updated or implemented in response to the resident's escalating fall risk and repeated incidents. Facility policies reviewed indicated that individualized, resident-centered fall prevention plans should be developed and revised as needed, and that residents identified as high risk should not be left unsupervised while out of bed. However, the facility did not follow these protocols, as evidenced by the lack of effective supervision and failure to implement or update care plans in response to ongoing falls. Staff and administration acknowledged that the interventions in place were insufficient to address the residents' needs and prevent avoidable accidents, resulting in repeated injuries and, in one case, death.
Failure to Develop and Implement Timely Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the fall risk of a resident who had multiple medical conditions, including a history of skull fracture, muscle weakness, gait and mobility abnormalities, diabetes, cognitive communication deficit, and several neurological disorders. Upon admission, the resident was assessed as having moderately impaired cognition and was identified as a fall risk, with behaviors such as standing up without staff supervision. Despite these assessments, no fall risk care plan or effective interventions were put in place prior to the resident's first fall. The resident experienced eight falls over a period of less than a month, with incidents occurring in various locations such as the bed, wheelchair, dining room, and near the nurses' station. Staff interviews revealed that the resident was confused, impulsive, and unable to safely stand without assistance, yet continued to attempt to do so. Although the resident was placed on frequent checks, these interventions were not documented in the care plan, and more intensive supervision, such as 1:1 monitoring, was not implemented. Staff acknowledged that the resident's need for supervision and specific fall prevention strategies were not addressed in the care plan until after several falls had already occurred. Record reviews and staff interviews confirmed that the care plan lacked fall prevention interventions until well after the resident's risk had been established and multiple falls had taken place. The facility's own policies required the development of a comprehensive, person-centered care plan with measurable objectives and timely interventions based on resident assessments. However, the care plan for this resident was not initiated on admission, and the necessary interventions to address the resident's high fall risk and supervision needs were not included or implemented in a timely manner.
Failure to Implement Effective Fall Prevention and Supervision
Penalty
Summary
The facility administrator failed to provide consistent administrative oversight and resources to ensure that a resident at high risk for falls received adequate supervision and individualized care planning. Despite being aware of multiple falls experienced by the resident, the administrator did not ensure that the Interdisciplinary Team implemented effective fall prevention interventions. The resident, who had diagnoses including dementia, gait abnormalities, and osteoarthritis, was assessed as moderately cognitively impaired and at high risk for falls. Staff interviews confirmed that the resident was confused, did not follow commands, attempted to get out of bed without assistance, and required supervision and continuous monitoring, which were not provided. The resident experienced a series of unwitnessed falls in his room over several months, each time being found on the floor next to his bed. Interventions such as keeping the call light within reach and encouraging its use were in place, but staff acknowledged these measures did not address the underlying causes of the falls, as the incidents occurred when the resident was unsupervised. The resident sustained injuries from these falls, including lacerations above the left eye that required emergency department visits for sutures. The resident was also on blood-thinning medication, increasing the risk of serious injury from falls. Following additional falls, the resident suffered a subdural hematoma and other head injuries, ultimately leading to hospitalization and death. The facility's policy required that fall prevention plans be reviewed and revised as appropriate, especially if a resident continued to fall. However, the administrator acknowledged that not enough fall interventions were implemented to keep the resident safe, and the necessary supervision and monitoring were not provided, resulting in repeated injuries and the resident's eventual death.
Failure to Use QAPI Data for Fall Prevention Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program, specifically by not utilizing resident fall data to establish a comprehensive safety plan for fall prevention. Despite tracking the number of falls and using the data to incentivize staff with rewards such as pizza parties for fall-free periods, the administrator was unable to articulate how this data was used to ensure an effective fall prevention program. The QAPI committee's activities did not translate into actionable strategies to address repeated falls, as required by the facility's own QAPI policy and job descriptions. As a result of these deficiencies, a resident experienced multiple unwitnessed falls over several months, leading to repeated injuries, including lacerations that required emergency department visits and sutures. The resident ultimately suffered a subdural hematoma following a fall, which contributed to their death. The facility's failure to analyze and act upon fall data as part of its QAPI process directly resulted in ongoing harm to the resident.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to deficiencies in their care. Resident 51's care plan did not address the use of a transfer pole, an assistive device necessary for safe transfers due to the resident's muscle weakness and mobility issues. Despite being identified as a fall risk and requiring the transfer pole, the care plan lacked specific instructions, potentially compromising the resident's safety during transfers. Resident 75's care plan failed to address toenail assessment and condition, despite the resident's complaints of pain and discomfort due to long, thick, and curled toenails. The resident, who has Alzheimer's Disease and Type 2 Diabetes with Diabetic Neuropathy, did not receive appropriate toenail treatment and monitoring, as the condition was not identified in daily assessments or documented in the medical record. Similarly, Resident 342's care plan did not include oxygen therapy services or address noncompliance with these services, resulting in the resident not receiving continuous oxygen therapy as prescribed for their COPD. Resident 343's care plan did not address noncompliance with maintaining a low bed position, despite the resident's history of seizures and risk of injury from falls. The resident preferred the bed in a high position, which was not care planned to ensure safety. Lastly, Resident 84's care plan did not include oxygen therapy services, leading to the resident's nasal cannula being found on the floor, contrary to the physician's order for continuous oxygen therapy. These deficiencies highlight the facility's failure to provide individualized care plans that reflect the residents' conditions, needs, and physician orders.
Failure to Revise Care Plans for Oxygen and Vision Needs
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for two residents, leading to deficiencies in their care. Resident 31, who was diagnosed with conditions such as metabolic encephalopathy, pulmonary edema, and heart failure, was observed not using his prescribed oxygen therapy. Despite having a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, the resident was non-compliant, and the care plan was not updated to address this non-compliance. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged that the care plan should have been revised to reflect the resident's current condition and interventions needed to manage the non-compliance. Resident 67, who had severe cognitive impairment and was diagnosed with muscle weakness, dementia, and diabetes mellitus, was found without her prescription glasses, which were placed out of reach. The resident's care plan did not include the need for glasses, despite a vision report recommending new reading glasses to improve vision and quality of life. The Minimum Data Set (MDS) Coordinator admitted that the care plan should have been updated to ensure the resident's need for glasses was addressed, as it was crucial for maintaining her functional independence and reducing fall risk. The facility's policies and procedures require that care plans be comprehensive, person-centered, and revised as residents' conditions change. However, in these cases, the care plans were not updated to reflect the residents' current needs, leading to potential risks for the residents. The facility's failure to revise the care plans in a timely manner resulted in Resident 31 not receiving oxygen as prescribed and Resident 67 not having access to her glasses, which could impact her ability to perform daily activities.
Failure to Provide Appropriate Toenail Care for Resident
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 75, who was admitted with diagnoses including Alzheimer's Disease, Type 2 Diabetes, and diabetic neuropathy. Despite Resident 75's complaints of long, painful toenails, no Certified Nursing Assistant (CNA), Licensed Vocational Nurse (LVN), or provider assessed his toenails. Observations revealed that Resident 75's toenails were long, yellow, hard, thick, curled, and separated from the nail bed, which could lead to further complications. Interviews with facility staff, including CNAs, LVNs, the Infection Preventionist (IP), and the Director of Nursing (DON), indicated that there was a breakdown in communication and documentation regarding Resident 75's toenail condition. CNAs were expected to report any resident complaints or changes in condition, including toenail issues, to the licensed nurse, who would then document and address these concerns. However, this process was not followed, and Resident 75's toenail issues were not documented or care planned, nor was a podiatry consult requested. The facility's policies and procedures required that residents with diabetes receive toenail care from a podiatrist, and any toenail concerns should be reported to the Social Services Director (SSD) for referral. Despite these policies, Resident 75's toenail condition was not identified or documented in the medical record, and no podiatry services were consulted. This oversight resulted in Resident 75 experiencing pain and discomfort, with the potential for further complications due to the lack of appropriate toenail care.
Failure to Conduct Periodic Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not conducting periodic reconciliation of controlled medications for residents with standing and as-needed orders. During an observation and interview, it was found that the controlled medication log sheets stored in a locked cabinet lacked periodic reconciliation. The Assistant Director of Nursing (ADON) was unsure if there was a process in place for this reconciliation. The Director of Nursing (DON) confirmed that periodic reconciliation was not being conducted, acknowledging its importance in preventing medication diversion and ensuring residents receive proper treatment. Further interviews revealed that the Pharmacy Consultant (PC) stated that periodic reconciliation was not included in the facility's policy and procedure, although it was deemed important to prevent diversion. A review of the facility's policy and procedure from 2001 indicated that controlled substance inventory should be monitored and reconciled to identify loss or potential diversion. The consultant pharmacist or designee was supposed to routinely monitor controlled substance storage records, but this was not being implemented, leading to inadequate record-keeping and potential risks of medication diversion.
Pharmacy Consultant Fails to Report Drug Regimen Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities in the drug regimen review for a resident with iron deficiency anemia and kidney failure. The resident's hemoglobin (Hgb) levels were consistently low, ranging from 8.1 to 8.3 gm/dL over five months, without a documented Hgb goal. This oversight meant there was no clear target to assess the effectiveness of the anemia treatment, which included Procrit injections. The Director of Nursing (DON) confirmed the absence of a Hgb goal in the resident's medical record, emphasizing its importance for evaluating treatment efficacy. Additionally, the resident, who had kidney failure, was administered 500 mg of Ascorbic Acid (Vitamin C) daily without monitoring Vitamin C blood levels. This lack of monitoring posed a risk of Vitamin C toxicity, as excessive Vitamin C can lead to oxalate buildup, potentially causing kidney stones and other complications. The Assistant Director of Nursing (ADON) was unable to provide documentation for iron and Vitamin C labs, indicating they had not been conducted. The PC acknowledged that typically, a lower dose of Vitamin C is recommended for residents with chronic kidney disease to avoid such risks.
Inadequate Monitoring of Drug Regimen and Lab Tests
Penalty
Summary
The facility failed to adequately monitor and manage the drug regimen of a resident, leading to potential health risks. The resident, diagnosed with iron deficiency anemia and acute kidney failure, received Procrit to treat low hemoglobin (Hgb) levels. However, the facility did not establish a target Hgb goal, nor did they conduct necessary iron lab monitoring. The resident's Hgb levels remained consistently low over several months, and the Director of Nursing (DON) acknowledged the absence of a documented Hgb goal, which is crucial for assessing the effectiveness of the treatment. The pharmacy consultant also emphasized the importance of having a goal for Hgb levels to determine the need for alternative interventions. Additionally, the resident was administered Ascorbic Acid (Vitamin C) without appropriate monitoring of Vitamin C blood levels. The DON and Assistant Director of Nursing (ADON) confirmed that no documentation for iron and Vitamin C labs was available, indicating that these tests had not been conducted. The pharmacy consultant noted that for residents with chronic kidney disease, a lower dose of Vitamin C is typically recommended. The lack of monitoring for Vitamin C levels posed a risk of toxicity due to unmonitored dosing.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 43 and Resident 67, were free from unnecessary psychotropic medications. Resident 43 was prescribed Aripiprazole for behaviors of auditory hallucinations and delusions, despite no documentation of such behaviors. Additionally, there was ineffective monitoring for behaviors of sadness, as evidenced by the lack of a target goal for behavior care planning, and no non-pharmacological interventions were implemented for Bupropion. Observations and interviews revealed that there was no documentation of hallucinations and delusions, and the care plan did not specify the types of distress to monitor. Resident 67's Olanzapine order was changed from as needed to routine upon admission without an assessment for a psychosis diagnosis. There were no non-pharmacological interventions attempted prior to the implementation of Olanzapine and Lorazepam, and there was ineffective monitoring for behaviors, as evidenced by the absence of a target goal in the care plan. Furthermore, there was inadequate side effect monitoring for Olanzapine and Lorazepam, and no gradual dose reduction was attempted for Olanzapine. Interviews with staff indicated a lack of documentation for verbal aggression and non-pharmacological interventions. The deficiencies in the facility's handling of psychotropic medications for Residents 43 and 67 resulted in the potential for unnecessary medication use, increasing the risk of medical interactions and adverse reactions. The Director of Nursing and pharmacy consultant acknowledged the lack of documentation and the importance of non-pharmacological interventions and measurable goals in care plans. The facility's failure to document and implement appropriate interventions and monitoring contributed to the potential for harm to the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an 11.11 percent error rate. This was observed during a medication pass where three errors occurred involving three residents. For one resident, a blood glucose check was performed after the resident had started eating, contrary to the physician's order to check before meals. This led to an inaccurate assessment of the resident's blood glucose level, which could affect insulin administration. Another resident was administered Olmesartan despite having a blood pressure reading below the ordered parameters, which could potentially cause the resident's blood pressure to drop further. Additionally, a third resident was given a medication that was not ordered by the physician, as the administered tablet contained only sennosides and not the prescribed combination of sennosides and docusate. These errors were contrary to the facility's policy and procedure for administering medications, which requires verification of the right medication, dosage, and administration method.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during a survey. The room temperature for two medication storage rooms was not monitored, which posed a risk of medications being exposed to extreme temperatures, potentially altering their chemical composition and reducing their shelf life. During interviews, staff members acknowledged the absence of temperature logs and the importance of monitoring room temperatures to maintain medication effectiveness. Additionally, discontinued medications for two residents were found stored in the west wing medication cart, and another resident's discontinued ointment was stored in the east wing treatment cart. This oversight could lead to medication errors, as discontinued medications were not removed and discarded as per facility policy. Staff interviews confirmed that discontinued medications should have been removed to prevent potential administration errors. Furthermore, inhaler medications for multiple residents stored in the respiratory therapy cart lacked open date labels, increasing the risk of administering expired medications. The facility's policy required labeling of open medications to prevent the use of expired and ineffective drugs. An interview with the Assistant Director of Nursing highlighted the expectation for labeling medications with open and expiration dates to avoid adverse reactions and decreased efficacy. Lastly, a resident's medication in the treatment cart did not have an updated administration direction label, which could result in incorrect dosage and frequency administration.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain professional standards for food service safety, affecting 90 out of 91 sampled residents. During an observation, a towel and a pair of rubber gloves were found on the floor behind the three-compartment wash station, which the Dietary Aide acknowledged should not have been there due to the risk of cross-contamination. Additionally, the stove top was observed to have caramel-colored residue, dark shiny residue, and yellow particles, indicating it had not been cleaned properly. The Dietary Aide confirmed that the stove should be cleaned daily to prevent microbial growth that could lead to foodborne illness. Further observations revealed four pieces of toasted bread on the floor behind the toaster, which the Cook stated was due to a dislodged toaster panel. The Cook acknowledged that bread on the floor could lead to cross-contamination and pest infestation. The resident refrigerator was also found to have food residue and ice buildup, which the Certified Dietary Manager (CDM) stated should have been cleaned according to the schedule. The CDM noted that the presence of food residue could lead to foodborne illness. Additionally, four tiles in front of the ice machine were cracked and broken, creating an uneven surface. The CDM had notified the Director of Environmental Services (DES) about the issue, but repairs were delayed due to the need to order replacement tiles and wax. The Director of Nurses (DON) and DES both acknowledged that the broken tiles posed a safety hazard and infection risk, as they were difficult to sanitize. These deficiencies collectively increased the risk of cross-contamination and foodborne illness for the residents receiving food from the kitchen.
Incomplete POLST Forms in LTC Facility
Penalty
Summary
The facility failed to ensure accurate and complete medical records in accordance with professional standards of practice for three residents. The Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 31, 43, and 54 were found to be incomplete. Specifically, the forms lacked essential information such as the physician's license number, phone number, and signatures from both the physician and the resident or their responsible party. These omissions were identified during interviews and record reviews conducted by the surveyors. Resident 31 was admitted with multiple diagnoses, including metabolic encephalopathy, pulmonary edema, and dementia, and was found to have a POLST form that was missing critical information. The Medical Records Coordinator acknowledged that the incomplete POLST could lead to staff performing CPR on a resident who had a Do Not Resuscitate (DNR) order, as the POLST serves as a physician's order indicating the resident's end-of-life care preferences. The Licensed Vocational Nurse (LVN) also confirmed that the POLST was not fully completed, which could result in the resident's wishes not being honored in an emergency. Similarly, Resident 43, who was severely cognitively impaired, and Resident 54, who had Parkinson's disease and other health issues, also had incomplete POLST forms. The missing information on these forms included the physician's contact details and signatures, which are necessary for the POLST to be valid. The Director of Nursing (DON) stated that the expectation was for all POLST forms to be fully completed and signed, as they dictate the resident's code status and guide staff in emergency situations. The failure to complete these forms could result in the residents' end-of-life wishes not being respected, as staff would default to performing CPR in the absence of a valid DNR order.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for several residents, as observed during a survey. Resident 29's urinary catheter bag was found dragging on the ground while being pushed in a wheelchair, and later, the bag was observed lying on the floor in the resident's room. This was against the facility's policy and procedure for urinary catheter care, which mandates that catheter tubing and drainage bags be kept off the floor to prevent cross-contamination. Interviews with the Infection Preventionist and the Director of Nursing confirmed that these practices were unacceptable and posed a risk of infection to Resident 29. Resident 31's oxygen nasal cannula tubing was improperly stored, wrapped around the handle of the wheelchair, and the oxygen humidifier bottle was found on the floor. This improper storage was noted during an observation in the resident's room. The facility's lesson plan on oxygen supply handling and storage requires that such items be stored in bags when not in use to prevent contamination. The Infection Preventionist acknowledged that these practices could lead to cross-contamination and respiratory infection. Similar deficiencies were observed with Residents 73 and 84, where their oxygen nasal cannulas were not stored properly. Resident 73's nasal cannula was placed on top of the oxygen concentrator, and Resident 84's nasal cannula was found on the floor. Both instances were against the facility's guidelines, which require that oxygen tubing be stored in a clean, dry place, preferably in a bag, to prevent contamination. Interviews with staff, including a Respiratory Therapist and the Infection Preventionist, confirmed that these practices were not in compliance with the facility's infection control policies.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the state long-term care Ombudsman of a resident's transfer to a General Acute Care Hospital (GACH). This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including muscle weakness, end-stage renal disease, and chronic obstructive pulmonary disease, was transferred to the hospital due to shortness of breath. However, the facility did not send a copy of the transfer or discharge notification to the Ombudsman, as required by their policy. Interviews with the Director of Nursing and the Social Services Director confirmed that the Ombudsman was not notified by any means, such as phone, fax, or email. The Social Services Director acknowledged that the facility's policy and procedure for transfer or discharge was not followed, emphasizing the importance of notifying the Ombudsman as a patient advocate. The facility's policy, dated October 2022, clearly states that the Ombudsman should be notified at the same time as the resident and their representative in cases of transfer or discharge.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to a resident, identified as Resident 16, upon his transfer to the hospital. This deficiency was identified during interviews and record reviews. Licensed Vocational Nurse (LVN) 5 confirmed that Resident 16 was only notified of the bed hold policy via phone call and did not receive any written documentation. The Business Office Manager (BOM) also stated that Resident 16, being a long-term resident, was not given written notification of the bed hold policy at the time of his hospital transfer, as it was assumed unnecessary. The Director of Nursing (DON) corroborated that notifications were made only over the phone, and no written policy was provided to Resident 16. The facility's policy, titled "Bed-Holds and Returns," dated October 2022, mandates that all residents or their representatives receive written information about the facility and state bed-hold policies. This policy requires that residents be provided written notice at least twice: once in advance of any transfer, such as during admission, and again at the time of transfer, or within 24 hours if the transfer was an emergency. The failure to adhere to this policy resulted in Resident 16 not being informed in writing of the bed hold policy, violating his right to be informed of the facility's policies regarding bed holds during his absence.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for Resident 342, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The deficiency was identified when Resident 342's oxygen therapy was not administered according to the physician's order, and the oxygen tubing was not labeled to track when it needed to be replaced. This oversight was observed during a visit to Resident 342's room, where the oxygen concentrator was found turned off, and the nasal cannula tubing was tucked under the resident's pillow without a label indicating its first use. Interviews with Resident 342 and facility staff revealed that the resident did not receive the prescribed continuous oxygen therapy at 2 liters per minute via nasal cannula. The resident reported using oxygen only at night since admission and expressed feelings of tiredness and difficulty breathing. Licensed Vocational Nurses (LVNs) and the Infection Preventionist confirmed that the oxygen therapy was not administered as ordered, and the tubing was not labeled for replacement, which could lead to bacterial contamination. Further interviews with the Director of Nursing (DON) and Respiratory Therapists (RTs) highlighted the responsibility of licensed nurses to administer oxygen therapy as prescribed and to label the tubing for timely replacement. The facility's job description and policies emphasized the importance of following physician orders and maintaining proper oxygen equipment handling. Despite these guidelines, the failure to administer oxygen therapy as ordered and to label the tubing for replacement was evident, resulting in the deficiency.
Call Lights Out of Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential risk of them not receiving help when needed. Resident 20, who was readmitted with generalized muscle weakness, gait and mobility abnormalities, and a history of falling, was observed with a call light clipped to the privacy curtain, out of reach. This resident had a severe cognitive impairment, as indicated by a BIMS score of five. The care plan for Resident 20 specified that the call light should be within reach, but this was not adhered to during the observation. Similarly, Resident 65, who was admitted with hemiplegia, a history of falling, and cognitive communication deficits, was also found with a call light clipped to the privacy curtain, out of reach. This resident had no cognitive impairment, as indicated by a BIMS score of thirteen, and required maximum assistance with toileting and personal hygiene. The care plan for Resident 65 also indicated that the call light should be within reach. Interviews with staff, including a CNA, LVN, and the DON, confirmed that the call lights should have been placed on the bed within reach, not on the bedrail or privacy curtain, to ensure residents could request assistance when needed.
Space Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure that each resident bedroom provided the required 80 square feet of usable living space per resident. During the survey period, it was observed that four different rooms, specifically rooms 106, 108, 110, and 119, housed four residents each, with each resident having less than the mandated 80 square feet of space. Room 106 provided 79.5 square feet per resident, room 108 provided 73.7 square feet, room 110 provided 75 square feet, and room 119 provided 79.2 square feet per resident. Despite the space deficiency, the rooms were noted to meet the residents' needs in terms of privacy, storage, and accessibility for nursing care and mobility. The report suggests that the health and safety of the residents were not adversely affected by the space limitations, and a waiver for the space requirement was recommended to continue.
Failure to Administer Prescribed Medication for GERD
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident diagnosed with gastroesophageal reflux disease (GERD), among other conditions. The resident was prescribed omeprazole, a medication for GERD, to be administered daily. However, the medication was not administered for seven consecutive days, and there was no documentation indicating the reason for the missed doses or notification to the physician about the omission. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) responsible for administering the medication did not document the reasons for withholding the medication, nor did they notify the physician of the missed doses. The Medication Administration Report (MAR) showed blank entries and codes indicating the medication was not given, but the reasons were not documented in the progress notes. The Assistant Director of Nursing (ADON) confirmed the lack of documentation and stated that the physician should have been notified to consider alternative medication options. The facility's policies and procedures require medications to be administered as prescribed and any deviations to be documented, including reasons for withholding medication. The failure to administer the medication as ordered and the lack of documentation and communication with the physician were identified as departures from the standards of nursing care, potentially placing the resident at risk for increased symptoms of GERD.
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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) |
|---|---|---|---|---|
| Kings Healthcare & Wellness Center Lp | 0.9 mi | — | 0 | 0 |
| Brighton Post Acute | 1.5 mi | — | 24 | 0 |
| Kingsburg Center | 14.7 mi | — | 3 | 0 |
| Bethel Lutheran Home | 16.8 mi | — | 17 | 0 |
| Rolling Hills Care Center | 17.1 mi | — | 0 | 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 August 2026) and official state health department websites.