Other·August 21, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health Licensing and Certification during the ABBREVIATED Survey for Complaint CA 00577865 and Facility Reported Incident CA 00575456. Representing the California Department of Public Health: 28531, RN, HFEN, and 39982, RN, HFEN. The inspection was limited to the specific complaint and incident investigated and does not represent the findings of a full inspection of the facility. ONE DEFICIENCY was issued for complaint: CA 00577865 and Facility Reported Incident CA 00575456.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/20/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure one of three residents, Resident 1, was free from accidents and injury when Certified Nursing Assistant (CNA) 1 and CNA 2 failed to check the sling (a hammock like device to hold the resident during transfer) of a mechanical lift was securely attached to the lift before transfer. Resident 1 was suspended in the sling three and one half feet above the ground when the sling came unhooked from the mechanical lift causing Resident 1, who had osteopenia (thin, fragile bones) and was unable to bear weight on her legs, to slide out of the sling and contact the floor with her feet. As a result of this failure Resident 1 sustained a left femur (thigh) bone fracture (break), and fractures of the right tibia and fibula (two lower leg bones) in both the proximal (upper) and distal (lower) areas of both bones. Resident 1 experienced pain and was transported to the general acute care hospital (GACH) for evaluation and treatment of her leg fractures and remained in the GACH for five days before transfer to a new and unfamiliar skilled nursing facility (SNF). Findings: Resident 1's Admission Record indicated Resident 1 was a 92-year-old female, originally admitted to the SNF facility on 7/11/11 with diagnoses that included Rheumatoid Arthritis (a disease that occurs when the immune system attacks healthy joints, causing symptoms such as pain, swelling, stiffness, and loss of physical function), Contracture (shortening and tightening of a muscle which causes the joint to freeze up and will not allow it to straighten out) of the right thigh muscle, Polyosteoarthritis (type of arthritic joint disease that results from breakdown of joint cartilage and underlying bone involving 5 or more joints simultaneously), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Pain in the right hip, and other abnormalities of gait and mobility. Review of facility investigative report, fax dated 2/28/18, and signed by the facility Administrator (Admin) indicated Resident 1's accident and injury occurred on 2/23/18. The report indicated, "... [Resident 1] had a two person assist while being transferred and the lift and sling were in good working order. As she was sitting in her chair with the sling attached to the lift, her front left loop [of the sling] had some slack in it and when the lift began to rise it slipped from its slotted position. This caused the resident to begin to slide to where she was held in a standing position and then lowered to the floor both for her safety and for the two [Certified Nursing Attendants] CNA's that were helping her..." On 3/6/18 at 1:30 p.m., during an interview, the Director of Nursing (DON) stated, "...She's [Resident 1] brittle. We knew she had history of multiple fractures..." The DON stated Resident 1 did not return to the SNF after evaluation and treatment of her broken bones at the GACH. The DON stated Resident 1 was placed elsewhere per family request. On 3/6/18 at 1:35 p.m., during an interview, CNA 1 stated on 2/23/18 CNA 2 asked for help to get Resident 1 back into bed. CNA 1 stated they used a mechanical lift to transfer Resident 1 back to bed. CNA 1 stated the sling was in place under Resident 1 from an earlier transfer when staff had gotten her up into the chair. CNA 1 stated, "We pushed the lift into position, connected the straps [inserted the loop of the strap over the hook on the lift], lifted, pulled the chair out and while suspended in the air the resident began to slide to her left [began to slide out of the sling]." CNA 1 stated she and CNA 2 supported Resident 1's upper body FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which was still partially supported by the lift, to an upright standing position. CNA 1 stated Resident 1's feet touched the ground and then they lowered Resident 1 to the ground. CNA 1 stated, "She [Resident 1] was moaning, "Oh, my legs hurt." CNA 1 stated Resident 1 did not indicate where her legs hurt. CNA 1 stated if they had tugged on the straps and ensured they were well seated on the lift hooks before lifting and moving the chair out from underneath Resident 1, the accident could have been avoided. CNA 1 stated if they had tugged on the straps, and lifted without moving the chair, they could have lowered Resident 1 back down on the chair and adjusted the strap to remove the slack. CNA 1 stated, "Keeping the chair in place longer, would be what I would do differently." On 5/10/18 at 1:05 p.m., during an interview and concurrent observation, CNA 1 demonstrated use of the mechanical lift. CNA 1 demonstrated step-by-step how she used the lift on 2/23/18, the day of Resident 1's accident with injury. CNA 1 stated, "The step of checking that the strap [loop] was securely hooked on the hook [of the mechanical lift] before lifting and moving the chair got missed." On 5/10/18 at 1:41 p.m., during an interview, CNA 2 stated on 2/23/18 she used the mechanical lift to transfer Resident 1 from a chair back to bed. CNA 2 stated, "When we [CNA 1 and CNA 2] lifted [Resident 1] everything was fine. Then when we moved the wheelchair under her she started sliding. We realized one of the hooks had come undone and she was sliding to the side where the hook had come off." CNA 2 stated Resident 1 was suspended in the sling approximately three and a half feet in the air when she started leaning to the left and sliding down, legs first. CNA 2 stated she and CNA 1 lowered Resident 1 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the ground. CNA 2 stated, "We should have double checked the straps after the resident was elevated above the chair, before moving the chair. Tugging on the strap to ensure that the strap loop was seated and taunt [without slack] on the hook would have prevented the accident." Review of Resident 1's GACH X-Ray Final Report, dated 2/23/18 at 10:51 p.m., indicated, "There is severe osteopenia. Acute [new] displaced [end of the broken bone is separated] femoral fracture ...Acute fractures of the proximal and distal tib-fib [tibia and fibula]." Review of Resident 1's GACH History and Physical (H&P) Report, dated 2/24/18, page one of five indicated, "...Patient is a 92-year-old [y/o] white female with a history of osteopenia, multiple fractures, who has been essentially bedridden and wheelchair bound for the past 41/2 years... Patient has chronic (persisting for a long time or constantly recurring) pain. Patient was brought into the emergency room... for evaluation s/p [status post - meaning after) fall at SNF. X-ray of leg shows a fracture of the proximal fibula and tibia. Patient also has a rod [hardware used in the repair of a hip fracture] in her right mid femur and an artificial right hip. Because of this new fracture, patient is being referred for acute admission, orthopedic evaluation..." H&P page three of five indicated, "PAST MEDICAL HISTORY...her bones fracture easily. She had a left humerus [upper arm bone] fracture just by them moving her in a nursing home in the past..." page five of five of the H&P indicated, "...x-rays: multiple old fracture and osteopenia, new fracture prox [proximal] right tibia and fibular. Impression and Plan 92 y/o woman who non-ambulating [not walking] came from nursing home with history of fall from [mechanical lift] lift and sustained new fractures..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's GACH Discharge Summary Report, dated 2/28/18, indicated "...In the hospital, ortho (branch of medicine specializing the musculoskeletal system) consulted and felt surgery was not the best option for her. She ended up getting bilateral leg braces and is now stable for transport ..." Review of the facility copy of the manufacturer's user manual for the "Manual/Electric Mobile Patient Lift" dated 2013, indicated on page three, "DEALER: This manual MUST be given to the user of the product. USER: BEFORE using this product, read this manual and save for future reference ..." Page five of the manual indicated, "...Warnings: Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. See information below for definitions of the signal words. [The symbol of a triangle with an exclamation point inside it indicated Danger, Warning and Caution] DANGER: Danger indicates an imminently hazardous situation which, if not avoided, will result in death or serious injury. WARNING: Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. CAUTION: Caution indicates a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both." On page seven, the following was indicated beside the symbol of a triangle with an exclamation point inside it: "2. Safety: The Safety section contains important information for the safe operation and use of this product. 2.1 General Guidelines: WARNING DO NOT use this product or any available optional equipment without first completely reading and understanding these instructions... otherwise, injury or damage may occur..." On page nine, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the following was indicated beside the symbol of a triangle with an exclamation point inside it: "Using the sling: WARNING ...Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode)... Lifting the Patient [another symbol of a triangle with an exclamation point inside it] WARNING...When elevated a few inches of the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem ..." The warning verbiage for lifting the patient, as quoted above on page nine, was repeated on page 10, beside the symbol of a triangle with an exclamation point inside it, for transferring the patient as follows: "Transferring the Patient WARNING ...When elevated a few inches of the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem..." On page 30, the following was indicated beside the symbol of a triangle with an exclamation point inside it: "Lifting/Moving the Patient... WARNING: When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure the sling is properly connected to the hooks of the hanger bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem otherwise, injury or damage may occur..." This FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056288 (X3) DATE SURVEY COMPLETED 07/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HANFORD POST ACUTE 1007 W Lacey Blvd Hanford, CA 93230 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE warning was repeated beside the symbol of a triangle with an exclamation point inside it for Transferring the Patient on page 32, repeated again on page 35, and again on page 36. On 5/10/18, at 2:15 p.m., during an interview and concurrent record review with the Director of Staff Development (DSD), the facility's lift and sling manufacturer's user manual and the facility's undated Competency Evaluation Worksheet titled, "Transferring with a Mechanical Lift (2 person Assist)" were reviewed. The repeated warnings in the user manual were reviewed with the DSD. The DSD stated, "I taught the double checks after the incident [Resident 1's accident with injury on 2/23/18]... Double checking the loop [on the sling] is seated on the hook [of the lift] is necessary for safe operation of the lift." The DSD stated the double checking to make sure the sling is properly connected to the hooks on the lift should have been inserted after item 22 of the facility Competency Evaluation Worksheet, which speaks to raising the resident in the sling. The DSD stated, "It [the double checking the loop placement] is missing. It was omitted. It should be there." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C4G811 Facility ID: CA040000017 If continuation sheet 8 of 8