Hanford Post Acute

In the surveyor’s words

From the most serious findings on record at Hanford Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF694Mar 26, 2021

  Based on observation, interview, and record review, the facility failed to follow their facility intravenous (IV: in the vein - medications or fluids flowing directly into a vein) therapy policy and procedure and pharmacy standards of practice for IV fluid administration, procurement (obtaining), preparation and infection control standard of practice for 23 of 23 sampled residents (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53) when: 1. […]

• Immediate jeopardy, widespreadF725Mar 26, 2021

  Based on observation, interview, and record review, the facility failed to have sufficient number of qualified licensed nurses (LN) with appropriate IV (Intravenous- In a vein) competencies, training and skill sets to safely administer Intravenous (IV-medications or fluids flowing directly into a vein) fluid therapy to 23 of 23 sampled residents (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53) who received IV therapy during a COVID-19 outbreak in [DATE] when Licensed Nurses (LN) administered potentially unsterile and unsafe physician assistant (PA) ordered [MEDICATION(S)] ((IV solution - a mixture of sterile solution composed of water, [MEDICATION(S)] [salt], sodium [MEDICATION(S)] [salt], potassium chloride [potassium salt],… […]

• Actual harm, patternF684Mar 26, 2021

  Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice and conduct Respiratory decline, IV therapy need and wound assessment of residents for 24 of 24 (Residents 10, 12, 13, 17,18, 19, 20, 27, 28, 30, 32, 33, 37, 35, 36, 45, 46, 47, 48, 49, 50, 51, 52, and 53) residents when: 1. Residents 32, 35 and 36 were diagnosed with [CONDITION(S)] CoV2 (COVID-19- a serious contagious respiratory [Lung] infection transmitted from person to person) on [DATE] and [DATE] and nursing staff did not conduct respiratory (oxygen) decline Registered Nurse (RN) assessments, oxygen status monitoring and did not identify and promptly act on signs and symptoms of deteriorating respiratory status. […]

• Actual harm, isolatedF684Apr 4, 2025

  Based on interview and record review, the facility failed to ensure residents receive necessary treatment and care in accordance with facility's policies and procedures and professional standards of practice for one of thirteen residents (Resident 12) when Resident 12 who had a known history of constipation, with infrequent bowel movements and refusing continence care for several days and nursing staff did not notify the doctor and implement interventions to prevent complications. […]

• Actual harm, isolatedF689Apr 4, 2025

  Based 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. […]