Health inspection·March 18, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person centered care plan for one of six sampled residents (Resident 67) when there was no care plan to address Resident 67's refusal to accept laboratory blood draws ordered by the physician. This failure placed Resident 67 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure his well-being. Findings: During an observation on 3/12/19, at 8:30 a.m., in the resident's room, Resident 67 was lying in bed on his back asleep. During a review of the clinical record for Resident 67, the admission Record (document containing resident's personal information) dated 3/14/19, indicated Resident 67 was readmitted to the facility on [DATE]. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 8, on 3/13/19, at 2:32 p.m., LVN 8 reviewed Resident 67's Medication Review Report, dated 3/14/19, and stated Resident 67 physician gave orders on 11/27/18 for monthly lab draw for CBC (complete blood count) (a test that measures the cells that make up blood) and CMP (comprehensive metabolic panel) (a panel of tests that gives a healthcare provider important information about the current status of a person's metabolism). LVN 8 stated Resident 67's physician also gave orders for Hgb (hemoglobin) A1C test (blood test used to measure the average level of glucose (sugar) in the blood over a period of three months) to be drawn every three months. During an interview with LVN 8, on 3/13/19, at 2:48 p.m., she stated Resident 67 refused his laboratory monthly blood tests since September 2018. LVN 8 stated there were no laboratory test results to review. During a concurrent interview and clinical record review with the Director of Nursing (DON), on 3/13/19, at 3:14 p.m., she stated Resident 67 refused all laboratory blood tests ordered by the physician. The DON reviewed the care plan and stated a care plan problem and interventions were not developed for Resident 67's refusal of laboratory blood tests. The DON stated the nurses should have developed a care plan. The facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 12/16, indicated, .The comprehensive, person-centered care plan will .g. incorporate identified problem areas .j. Reflect the resident's expressed wishes regarding care and treatment goals .13 .care plans are revised as information about the residents and the residents' condition change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 2 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to provide services to attain or maintain the highest practical well-being for one of six sampled residents (Resident 67) when the facility failed to notify the physician of Resident 67's refusal of laboratory blood tests. Residents Affected - Few This failure had the potential risk of Resident 67 not receiving the appropriate care and possible adverse side effects to medications requiring routine laboratory monitoring. Findings: During on observation on 3/12/19, at 8:30 a.m., in the resident's room, Resident 67 was lying in bed on his back asleep. During a review of the clinical record for Resident 67, the admission Record, (document containing resident's personal information) indicated Resident 67 was readmitted to the facility on [DATE]. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 8, on 3/13/19, at 2:32 p.m., she reviewed Resident 67's Medication Review Report, dated 3/14/19, and stated Resident 67 had a physician's order dated 11/27/18 for CBC (complete blood count) (a test that measures the cells that make up blood) and CMP (comprehensive metabolic panel) (a panel of tests that gives a healthcare provider important information about the current status of a person's metabolism) monthly, and a HB (hemoglobin) A1C test (blood test used to measure the average level of glucose (sugar) in the blood over a period of three months) every three months. LVN 8 verified Resident 67 had a physician order dated 3/12/19 for CBC and CMP for one time. LVN 8 reviewed the clinical record and was unable to find documentation of the monthly lab results. During an interview with LVN 8, on 3/13/19, at 2:48 p.m., she stated Resident 67 refused his laboratory blood tests since September 2018 (past six months). During a concurrent interview and clinical record review with the Director of Nursing (DON), on 3/14/19, at 2:27 p.m., she stated Resident 67 was refusing laboratory blood tests. The DON reviewed the clinical record and was unable to find documentation the physician was notified of Resident 67's refusal of laboratory blood tests for the past six months. The DON stated the facility expectation was for the nurses to notify Resident 67's physician of blood test refusals and that did not occur. The facility policy and procedure titled, Change in Resident's Condition or Status dated 5/17, indicated, .1. the nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .f. refusal of treatment or medications two or more consecutive times) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 3 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to follow their Storage of Medication and Labeling of Medication Containers policy and procedure when three of three insulin solution pens (medication used to treat high blood sugar) were found expired and one vial of tuberculin solution (a protein derivative to test for tuberculosis, a bacterial infection affecting the lungs) was found with no expiration date in the medication storage room refrigerator. These failures had the potential to place Resident 55, 74 and 30 at risk of receiving expired insulin which could lead to ineffective control of blood sugar and place residents at risk of receiving expired tuberculin solution and have adverse reactions from the expired medication. Findings: 1. During a concurrent observation and interview with Registered Nurse (RN) 1, on 3/13/19, at 2:45 p.m., the [NAME] Wing medication cart had insulin Basaglar injection flex pen (insulin with injection device) labeled with an open date of 2/9/19 and expiration date of 3/11/19. RN 1 stated the insulin had expired two days prior. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 9, on 3/13/19, at 3:50 p.m., the medication room refrigerator on the [NAME] Wing nurses' station had a vial of tuberculin solution with an opened date of 2/7/19. The vial of tuberculin solution was not labeled with an expiration date. LVN 9 stated, It [Tuberculin solution] is good for 30 days once it is opened. This medication expired on 3/8/19. LVN 9 stated the facility had not admitted new residents after 3/6/19 and that was the reason the expired vial of tuberculin solution had been missed. LVN 9 stated, It [tuberculin solution] could have been given to residents when it was already expired and would have had inaccurate result. During a concurrent interview and record review with LVN 12, on 3/14/19, at 8:20 a.m., she stated insulin pens had to be labeled with the date opened and the expiration date. LVN 12 stated, Expired medications could be given to residents if the insulin pens were not labeled with expiration dates. During an interview with LVN 9, on 3/14/19, at 8:55 a.m., she stated, When a new medication like an insulin is brought out of the refrigerator, the licensed nurse had to label the medication with the date opened and the expiration date. During an interview with the Director of Staff Development (DSD), on 3/14/19, at 9:40 a.m., the DSD stated insulin pens had to be labeled with the date it was opened and the expired date. DSD stated, It (expired insulin) could be given to residents past the expiration date and create a problem. During a concurrent medication cart observation and interview with RN 1, on 3/18/19, at 10 a.m., she stated I don't check the expiration dates of the insulin pens in the cart. I trust the nurses are labeling with the correct dates. RN 1 checked the insulin medication pens in the medication cart and noticed an insulin pen labeled Basaglar Inj [injection] . The insulin pen was labeled with a hand written open date of 3/14/19 and discard date of 4/12/19. RN 1 stated the medication was for Resident 55. The pharmacy label indicated, .Discard 28 days after opened. RN 1 stated the expiration date on the label was wrong. RN 1 stated the discard date should have been 4/11/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 4 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent medication cart observation and interview with LVN 8, on 3/18/19, at 10:05 a.m., LVN 8 stated she did not check the insulin medication in her cart to verify expiration dates. LVN 8 checked the insulin pens in the medication cart and noticed an insulin pen labeled Lantus [long acting medication used to treat high blood sugar] . with hand written open date of 3/11/19 and discard date 4/10/19. LVN 8 stated the insulin medication was for Resident 74. The pharmacy label indicated, .Discard 28 days after opened. LVN 8 stated the expiration date on the label was wrong. During a concurrent medication cart observation and interview with LVN 11 on 3/18/19, at 10:25 a.m., LVN 11 stated I did not check the insulin pens in my medication cart to verify the expiration dates. LVN 11 8 checked the insulin pens in the medication cart and noticed an insulin pen labeled Tresiba [long acting medication used to treat high blood sugar] . with hand written open date of 3/14/19 and discard date 4/10/19. LVN 11 stated the medication was for Resident 30. The pharmacy label indicated, Discard 56 days after opened. The cart contained an insulin medication labeled Novolin R [medication used to treat high blood sugar] . with hand written open date label of 3/5/19 and discard date 4/1/19. LVN 11 stated the medication was for Resident 30. LVN 11 stated, We follow the facility policy of 28 days. LN 11 stated if the pharmacy label was followed then the discard dates were wrong. During an interview with the Director of Nursing (DON), on 3/18/19, at 10:20 a.m., the DON stated the facility did not have a policy for insulin vial or pens. The DON stated the facility followed the pharmacy label indications (28 days) for expiration dates. The facility pharmacy policy and procedure titled Medication ordering and receiving from pharmacy dated 2015, indicated Procedures . B. Each prescription medication label includes . 8) Expiration date of the effectiveness of the medication dispensed . The facility policy and procedure titled Storage of Medication dated April 2007, indicated .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . The facility policy and procedure titled Labeling of Medication Containers dated April 2007, indicated .3 .h. The expiration date when applicable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 5 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when: Residents Affected - Some 1. Dietary staff (DS) 1 failed to have a hair net covering which completely covered all hair while in the kitchen. 2. Certified Nurse Assistant (CNA) 3 touched the inside rim of a resident's cup while distributing a food tray. These failures had the potential to contaminate residents food and spread infection. Findings: 1. During a concurrent observation and interview with DS 1, on 3/13/19, at 8:55 a.m., in the kitchen, DS 1 had on a hair net which covered her hair bun and left approximately four inches of hair showing on all sides while working in the kitchen. DS 1 stated the facility did not have hair nets large enough to cover all her hair. DS 1 stated not having a hair net that covered all of her hair could lead to hair falling into residents' food and contaminating the food. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 3/13/19, at 8:55 a.m., in the kitchen, CDM confirmed DS 1 did not have on a hair net which covered all of her hair. CDM stated the facility did have larger hair nets. CDM provided DS 1 with a larger hair net and showed her where they were kept. CDM stated per facility policy, all hair must be covered by hair net. The facility food service policy and procedure titled Sanitation and Infection Control dated 2012, indicated, .A hair net and/or head covering which completely covers all hair should be worn during meal preparation and service . 2. During a concurrent dining observation and interview with CNA 3, on 3/12/19, at 12:31 p.m., CNA 3 touched the inside rim of a resident's cup with bare hands, poured milk into the cup, then gave the cup to the resident. CNA 3 admitted that she should have worn gloves or not touched the rim of the cup and could have spread infection. Food Code 2017 indicated, .Preventing Contamination by Employees .3-301.11 Preventing Contamination from Hands .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 6 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to create a facility assessment specific to the need of facility population and location as part of the required facility assessment, when the facility assessment did not include the required water management program. This practice failed to establish an individualized facility assessment to meet the requirement for a water management program. Findings: During an interview with the Maintenance Supervisor (MS), on 3/14/19, at 2 p.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature daily and emergency water supplies monthly for presence of minerals. MS stated he did not test for Legionella (disease is a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila found in both potable and non-potable water systems [showers, sinks and water fountains]). The MS stated, I do not have an emergency plan in placed if a water test comes out positive [for Legionella]. The MS stated, we [the facility] have one water fountain in the outdoor courtyard. The MS stated he was unaware if the water fountain was tested for waterborne bacteria. During an interview with the Administrator in training (AIT), on 3/14/19 at 3 p.m., AIT stated he was not sure if a water management program was part of the facility assessment. The AIT stated If it is not in the facility assessment binder, then it was not done. The AIT stated he was not aware of the AFL (all facilities letter) 18-39 regarding Reducing Legionella Risks in Health Care Facility Water System. The facility policy and procedure titled, [Facility name] Facility Assessment dated 1/22/19, indicated .Services waste management, hazardous waste management, telephone, HVAC, dental, barber/beauty, pharmacy . The facility assessment did not have information regarding the facility's need for a water management program. The facility policy and procedure titled, Facility Assessment dated 7/17, indicated, .3 .includes detailed review of the resident population . 4 .detailed review of the resources available to meet the needs of the resident population . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 7 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to provide accurate documentation for one of one sampled residents (Resident 74) when Licensed Vocational Nurses (LVNs) continued to document hearing aids being used after the hearing aids were reported missing. This failure had the potential to delay the replacement of Resident 74's lost hearing aids and potential risk of Resident 74 to experience isolation and depression from not being able to adequately hear. Findings: During a concurrent observation and interview with Family Member (FM) 1, on 3/12/19, at 9:06 a.m., in Resident 74's room, FM 1 stated the facility had lost Resident 74's hearing aids. Resident 74 was observed sitting in her wheel chair without her hearing aids. During a concurrent interview and record review with the Social Service Director (SSD), on 03/14/19, at 10:39 a.m., in the SSD office, she stated Resident 74's hearing aids went missing on 2/8/19. The SSD stated Resident 74 had an audiology appointment on 2/25/19 and a follow-up appointment was scheduled for 3/25/19 for new hearing aids. A document review of Resident 74's Report of Lost Property dated 2/8/19, indicated, Left and right hearing aids last seen on 2/7/19 AM. During a review of the clinical record for Resident 74, the Medication Administration Records (MAR) dated February 2019 and March 2019, indicated seven nurses (LVN 2, LVN 3, LVN 4, LVN 5, LVN 6, LVN 7, and LVN 8) documented they had either put the hearing aids in and made sure they were functioning or took hearing aids out and put them away 44 times on the MAR from 2/9/19 through 3/15/19. During a concurrent interview and record review with LVN 2, on 3/15/19, at 9:59 a.m., on the [NAME] Hall, LVN 2 stated she was unaware Resident 74 did not have hearing aids and did not know who was responsible for documenting hearing aids in on the MAR. LVN 2 reviewed the MAR and stated licensed nurses were responsible for documenting hearing aids accurately. LVN 2 stated she documented Resident 74's hearing aids were put in on 3/2/19, 3/4/19, and 3/5/19, and that was incorrect. LVN 2 stated she should have documented in the MAR notes that the hearing aids were missing. During a concurrent interview and record review with LVN 1, on 3/15/19, at 10:08 a.m., on the [NAME] Hall, LVN 1 stated Resident 74 was missing hearing aids in the morning on 2/9/19. LVN 1 informed the SSD and documented on the MAR notes unable to locate hearing aids. During a concurrent interview and record review with LVN 3, on 3/15/19, at 10:16 a.m., on the East Hall, LVN 3 stated she was aware Resident 74's hearing aids had been missing for a while. LVN 3 validated she documented that the hearing aids were in on 3/3/19. LVN 3 stated she did not know why she documented the hearing aids were in. During a concurrent interview and record review with the Director of Nursing (DON), on 3/15/19, at 10:44 a.m., in the DON's office, the DON reviewed the MAR for February 2019 and March 2019 and confirmed that LVNs inaccurately documented Resident 74's hearing aids being put in in the AM shift and returned in the PM shift, 44 times. The DON confirmed Resident 74's hearing aids had been missing since 2/9/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 8 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The facility policy and procedure titled Charting and Documentation dated July 2017, indicated, .Documentation in the medical record will be objective, complete, and accurate . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 9 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their Policy and Procedure on infectious diseases when they failed to have an infection control program that was effective in identification of infections and communicable diseases when: Residents Affected - Many 1. Twenty of 51 sampled residents (Resident 6, 16, 18, 21, 26, 27, 29, 30, 31, 50, 64, 67, 74, 282, 283, 287, 288, 289, 290, 291) received Tamiflu (an antiviral medication) prophylactically (preventive use) following one resident exhibiting symptoms of influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching) (flu) without documented surveillance and tracking. This resulted in the inadequate surveillance of 20 residents for flu like symptoms. 2. Nine of 9 sampled residents (Resident 18, 26, 31, 50, 286, 287, 288, 289 and 290) required hospitalization in a ten-day period for metapneumovirus (hMPV) (a respiratory virus that caused an upper respiratory infection and affected the nose, throat, and airways); there was no adequate survellance or tracking for infections. For Resident 286 and 289, this failure resulted in hospitalization with intubation (tube inserted through the nose or mouth into the trachea to help a person breathe) for respiratory failure and subsequent complications which led to their deaths. For Resident 18 and 31, this failure resulted in hospitalization for respiratory complications which subsequently lead to their deaths. For Resident 26, 50, 287, 288 and 290, this failure resulted in hospitalization for respiratory complications. 3. A facility water management plan was not created or implemented to reduce the risk of Legionella (a waterborne bacteria) and or other waterborne bacteria. This failure resulted in the facility not having a water management program which potentially exposed the vulnerable residents of the facility to Legionella and other harmful waterborne bacteria. Findings: 1. During an observation of Resident 64, on [DATE] at 8:07 a.m., Resident 64 was lying in bed and did not engage in conversation. During a review of the clinical record for Resident 64, the Nurses note dated [DATE], at 9:48 a.m., indicated, New order from [Medical Director] (MD) Tamiflu Capsule 75 mg [milligram, unit of measurement] .Give 1 capsule by mouth one time a day for Prophylaxis for 5 days . During a concurrent interview and record review of Resident 64's Nursing notes dated [DATE], with the assistant director of nursing (ADON), on [DATE], at 3:31 p.m., she stated there were residents who experienced flu like symptoms (fever, chills, muscle aches, cough, congestion, runny nose, headaches, and fatigue) in the facility in [DATE]. The ADON stated she could not recall which residents had flu like symptoms. The ADON stated the symptoms were suspected to be related to the flu, without laboratory confirmation. The ADON stated the medical director was notified regarding the residents who had flu like symptoms. The ADON stated the medical director ordered for all of the residents in the facility to receive Tamiflu prophylactically for five days. The ADON stated all the residents in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 10 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 the facility received Tamiflu on [DATE]. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and facility document review of the infection control surveillance logs with the Director of Staff Development (DSD), on [DATE], at 3:47 p.m., she stated she was the infection control nurse. The DSD stated she did not have an infection control surveillance program to track residents with symptoms of influenza and was not aware of residents affected with flu like symptoms in [DATE]. The DSD stated she did not know if there were residents tested for influenza during the suspected outbreak. The DSD stated 86 residents received Tamiflu without any documented tracking of symptoms prior to and during the Tamiflu administration. Residents Affected - Many During a review of the clinical record for Resident 64, the Nursing note dated [DATE], indicated, Resident received Tamiflu capsule 75 mg today. Resident tolerated well, no adverse reaction noted. The nursing notes did not reflect if Resident 64 experienced flu related symptoms prior to the start of the Tamiflu. During a concurrent interview with the Director of Nursing (DON) and facility document review the Physician Orders dated [DATE], indicated Resident's 6, 16, 18, 21, 26, 27, 29, 30, 31, 50, 64, 67, 74, 282, 283, 287, 288, 289, 290 and 291 received Tamiflu 75 mg 1 capsule by mouth. The DON stated the Tamiflu was given for 5 days to a total of 86 residents on [DATE]. During an interview with the DSD on [DATE], at 11:51 a.m., she stated, The [infection control for flu symptoms] surveillance log was not done [in [DATE]] because it was just one resident [Resident 291] who had symptoms [of influenza]. The DSD stated Tamiflu was given prophylactically for influenza. The DSD stated she was the infection control nurse. The DSD stated she did not complete the infection control surveillance, collect data or trend identification of residents who experienced coughs, fever, chills, body aches or other related flu like symptoms. The DSD stated the infection control surveillance consisted of listing residents who were on antibiotics for infections and the infection type. The DSD stated the information regarding the residents placed on antibiotics was collected after the antibiotic was ordered and did not have any type of monitoring prior to the initiation of antibiotic treatment. The DSD stated the infection control committee consisted of herself and the DON. The DSD stated a report of the number of residents placed on antibiotics and a report of the types of infections was presented on a quarterly basis to the quality assurance process improvement committee. The DSD stated she was not working on any current projects involving infection control. During a review of the clinical record for Resident 291, the Nursing notes dated [DATE] through [DATE] did not reflect monitoring of Resident 291's productive (expelling mucus) cough. During a review of the clinical record for Resident 291, the Nursing notes dated [DATE], indicated, Resident also on alert charting (a monitor placed to address any fever, cough or changes in condition) for a drop in her O2 sat (oxygen saturation) (level of oxygen carried by red blood cells through the arteries and delivered to internal organs) to 77 (A normal oxygen level is 95 to 100 percent oxygen) contacted doctor and obtained new order for (supplemental oxygen and chest x-ray) (photographic or digital image of the internal composition of a body part) .Resident has an occasional productive cough. During a review of the clinical record for Resident 291, the Nurses note dated [DATE], indicated, Received chest x ray results from [DATE] findings stated right hilar infiltrate (lung infection), edema (water or fluid collection), pneumonia .[doctor] made aware and notified and already ordered and administered the following Rocephin (antibiotic) solution .1 gram (gm) (unit of measure) .inject (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 11 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many intramuscularly (injection into the muscle) one time only for pneumonia. Azithromycin tablet (antibiotic) 500 mg give 500 mg by mouth one time only for pneumonia. Azithromycin tablet 250 mg give 250 mg by mouth one time per day for pneumonia for five days . The facility policy and procedure titled, Infection Prevention and Control Program dated [DATE], indicated, .The primary goal is to establish, maintain, and provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .GOALS .2. The facility performs an ongoing assessment to identify its risks for the acquisition and transmission of infectious agents. 3. The facility uses an epidemiological approach that consist of surveillance, data collection and trend identification. 4. The facility effectively implements infection prevention and control processes . The facility document titled, Job Description: Infection Control Nurse dated 9/18, indicated, .The primary purpose of your job position is to plan, organize, develop, coordinate, and direct our infection control program .Essential Duties .Participate in surveys of possible carriers among residents and personnel, and in tracking possible sources of infection within the facility .Report all reportable diseases to the county and state health departments . 2. During an interview with the DSD, on [DATE], at 3:51 p.m., she stated there were five to six residents who were hospitalized from [DATE] through [DATE], and tested positive for hMPV in the hospital. The DSD stated she did not know who were the residents hospitalized . The DSD stated she had not tracked any symptoms of influenza or respiratory infections prior to the notification from the local county health department (LCHD) on [DATE]. The DSD stated the DON had the information regarding the residents who tested positive for hMPV. The DSD stated the monitoring of influenza symptoms began on [DATE] one day after the notification to the facility about the hMPV outbreak. During an interview with the DON, on [DATE], at 4:21 p.m., she stated the following residents tested positive for hMPV: Resident 287, Resident 26, Resident 290, Resident 289, and Resident 288. The DON stated the facility began to track and monitor residents with respiratory symptoms and elevated temperatures on [DATE], after being notified of the outbreak by the LCHD. The DON stated she did not know she had to notify the California Department of Public Health (CDPH) Licensing and Certification (L&C) of the outbreak. During a concurrent interview and record review of Resident 287's Nursing notes with the DON, on [DATE], at 8:11 a.m., the DON stated Resident 287 was transferred to the General Acute Care Hospital (GACH) on [DATE] for shortness of breath (SOB) and rhonchi (continuous low pitched, rattling lung sounds that often resemble snoring). The DON stated Resident 287 complained of a sore throat after her return from the hospital on [DATE]. The DON stated there was no surveillance tracking implemented on [DATE] of residents in the facility exhibiting sore throats. The DON stated there was no surveillance tracking implemented on [DATE] of residents in the facility exhibiting shortness of breath or rhonchi. During a concurrent interview and record review of Resident 26's Nursing notes with the DON and the DSD, on [DATE], at 8:32 a.m., the DSD stated Resident 26 was sent to the hospital on [DATE], for an intermittent productive cough. The DON stated Resident 26 had SOB on [DATE]. The physician's assistant ordered a nebulizer treatment (aerosol medication inhaled to make breathing easier) and chest x-ray the same day which was not effective. The DON stated Resident 26 had not returned to the facility since her transfer to the GACH on [DATE]. The DON stated there was no infection surveillance to track additional residents for cough symptoms on [DATE]. The DON stated she did not believe the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 12 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many residents [Resident 18, 26, 31, 50, 286, 287, 288, 289 and 290] were hospitalized for infections but instead were due to complications of their chronic health conditions. The DON did not identify a possible pattern to the resident's symptoms in order to address an infection control problem. The DON stated Resident 26, 290, 288, 287, 286, 31, 289, 50, and 18's care plans identified chronic health conditions of CHF (congestive heart failure) and renal failure (failure of the kidneys) contributed to their hospitalization rather than acute infections. During a concurrent interview and record review of Resident 290's Nursing notes with the DON and the DSD, on [DATE], at 8:45 a.m., the DSD stated Resident 290 was transferred to the GACH on [DATE], and readmitted to the facility on [DATE]. The DSD reviewed Resident 290's nursing progress notes dated [DATE], and stated Resident 290 complained of congestion on [DATE] and was transferred to the GACH due to labored breathing. The DON stated there was no surveillance to track residents in the facility who experienced chest congestion on [DATE]. During a concurrent interview and record review of Resident 289's Nursing notes with the DON, on [DATE], at 8:56 a.m., she stated Resident 289 experienced intermittent coughing episodes on [DATE]. The DON stated Resident 289 was transferred to the GACH on [DATE] and had not returned to the facility. The DON stated there was no cough prior to Resident 289's transfer to the GACH. The DON stated there was no surveillance to track residents in the facility who experienced a cough on [DATE]. During a concurrent interview and record review of Resident 288's Nursing notes with the DON on [DATE], at 9:22 a.m., she stated Resident 288 was transferred to the GACH on [DATE] for altered mental status, cough and tachycardia (elevated heart rate above 60 beats per minute). The DON stated Resident 288 was readmitted to the facility on [DATE]. The DON stated there was no surveillance to track residents in the facility who experienced altered mental status, cough and tachycardia on [DATE]. During a concurrent interview and facility document review of the infection control surveillance for February or [DATE], with the DSD, on [DATE], at 10:18 a.m., she stated she did not start surveillance nor monitor residents with flu like and respiratory symptoms in the facility until after the notification from the LCHD was made [Residents 18, 26, 31, 50, 286, 287, 288, 289 and 290]. The DSD stated the public health nurse instructed the facility to initiate a facility wide surveillance of residents who experienced cough or fever on [DATE]. The DSD stated the surveillance and monitoring started on [DATE]. The DSD stated she did not have the lists of residents who were positive for hMPV. The DSD explained her process of infection tracking was from a generated computerized report of the antibiotics ordered on the previous day given to her by a medical records staff. The DSD stated she reviewed the antibiotics after the residents were started on them. The DSD stated the hMPV outbreak of five initial residents [Residents 286, 287, 288, 289 and 290] should have been reported to CDPH. During a telephone interview with the public health nurse (PHN) from the LCHD, on [DATE] at 11:01 a.m., she stated the GACH alerted the LCHD on [DATE] about the number of residents who tested positive for hMPV. The PHN stated the facility needed to monitor using a line listing to document all the residents' respiratory symptoms. The PHN stated there were a total of nine residents transferred from the facility to the GACH on [DATE] through [DATE]. She stated Resident 289 was hospitalized on [DATE], Resident 290 was hospitalized on [DATE], Resident 288 was hospitalized on [DATE], Resident 286 was hospitalized on [DATE], Resident 287 was hospitalized on [DATE], Resident 31 was hospitalized on [DATE], Resident 26 was hospitalized on [DATE], Resident 50 was hospitalized on [DATE] and Resident 18 was hospitalized on [DATE]. During an interview with the DON, on [DATE], at 2:14 p.m., the DON stated she did not believe the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 13 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility experienced an infection outbreak in [DATE] until the facility was informed by the LCHD on [DATE]. The DON stated the surveillance and monitoring for symptoms of cough and fever in the residents of the facility began on [DATE]. During an interview with the DON, on [DATE], at 3:52 p.m., the DON stated Resident 18 and Resident 286 expired in the hospital. During a telephone interview with the PHN, on [DATE], at 9 a.m., she stated three residents expired in the GACH. The PHN stated Resident 286 expired on [DATE] from acute hypoxic (tissues without oxygen) respiratory failure and chronic obstructive pulmonary disease (COPD). The PHN stated Resident 289 expired on [DATE] without a documented cause of death. The PHN stated Resident 18 expired on [DATE] from acute respiratory failure and hMPV. During a review of the clinical record for Resident 289, the admission Record dated [DATE], indicated she was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (abnormal metabolism of carbohydrates resulting in elevated blood sugar), heart failure, and end stage renal disease. Resident 289 was hospitalized on [DATE]. Review of the GACH clinical record for Resident 289, titled, History and Physical Examination dated [DATE], indicated, Chief Complaint Increasing shortness of breath increasing fluid retention for the past several days .Review of symptoms respiratory; shortness of breath, cough . Review of GACH clinical record for Resident 289, the Discharge Summary dated [DATE], indicated, Admit for observation for hemodialysis (a treatment to filter waste and water from blood the kidneys (vital organs) do not function), Nephrology (kidney specialist) consult .Patient developed a febrile illness after admission. Evaluation demonstrated a pneumonia primarily on the right. Microbiology (dealing with the structure and function of microscopic organisms) subsequently found metapneumo virus [hMPV], and blood cultures grew MRSA (methicillin resistant Staphylococcus aureus) (bacteria resistant to a type of antibiotic) from the blood. The patient developed increasing respiratory distress requiring intubation (tube placed into the airway to assist with or breathe for the patient) was transferred to the ICU (intensive care unit). In the ICU her pulmonary function continued to deteriorate requiring greater degrees of mechanical support, higher percentages of oxygen. She also developed frank hemoptysis (coughing up blood) .After discussion of the patient's condition and options [family] elected to withdraw care and initiate comfort care. Shortly after the patient was pulseless and apneic (stopped breathing) and was declared deceased at 4:40 p.m. During a review of the clinical record for Resident 290, the admission Record dated [DATE], indicated Resident 290 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus. During a review of the clinical record for Resident 290, the Nurses Note dated [DATE], indicated, Resident is sent out to the [Emergency Room] for labored [an abnormal respiration characterized by evidence of increased effort to breathe] breathing . Review of the GACH clinical record for Resident 290, the History and Physical Examination dated [DATE], indicated, CHIEF COMPLAINT: Shortness of breath and wheezing and productive cough. HISTORY OF PRESENT ILLNESS: .The patient was transferred from skilled nursing facility for shortness of breath, wheezing and productive cough for 3 days' duration. According to the son, the patient was noted to have significant bronchial wheezing and greenish phlegm with cough .PHYSICAL EXAMINATION .LUNGS: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 14 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Diffuse bilateral wheezing and basal crackles .ASSESSMENT AND PLAN: 1. Acute bronchitis [Inflammation of the lining of bronchial tubes, which carry air to and from the lungs] with bronchospasm [the muscles that line the airways of the lungs constrict or tighten]. 2. Leukocytosis [high level of white blood cells in the blood], likely due to acute bronchitis . Review of the GACH clinical record for Resident 290, the Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp [respiratory] Human Metapneun [metapneumovirus] .Detected . Review of GACH clinical record for Resident 290, the Discharge Summary dated [DATE], indicated, .Discharge dx [diagnoses] .Leukocytosis .Human metapneumovirus infection .Hospital course: [Resident 290] was admitted to the hospital with acute bronchitis. He continued to have increasing shortness of breath or wheeze. Pulmonary .was consulted, and his respiratory treatments were adjusted. Patient was found to be human metapneumovirus positive. He was placed on isolation [separating]. He continues treatment for COPD-like exacerbation [flare up] . During a review of the clinical record for Resident 288, the admission Record dated [DATE], indicated Resident 288 was admitted on [DATE] with diagnoses which included, diabetes mellitus, arteriosclerosis of the heart (hardening of the arteries), atrial fibrillation (irregular heart rhythm). During a review of the clinical record for Resident 288, the Nurses Note dated [DATE], indicated, Transfer out to hospital .due to altered mental status, cough and tachycardia. Review of the GACH clinical record for Resident 288, the History and Physical Examination dated [DATE], indicated, .HISTORY OF PRESENT ILLNESS .He describes fever and chills, some nausea. He was spiking a fever of 101 degrees at the nursing home .PLAN: The patient's picture is one of an infectious process. This could be pneumonia. This might just be a bad viral syndrome. Patient was spiking fevers in the ER last night . Review of the GACH clinical record for Resident 288, titled, Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp Human Metap .Detected . Review of the GACH clinical record for Resident 288, the Discharge Summary dated [DATE], indicated, .BRIEF HOSPITAL STAY: .Our workup shows metapneumovirus . During a review of the clinical record for Resident 286, the admission Record dated [DATE], indicated Resident 286 was admitted on [DATE] with diagnoses which included Parkinson disease (a nervous system disorder causing tremors and affecting the ability to walk) and chronic obstructive pulmonary disease (COPD, long term disease affecting the lungs). Review of the GACH clinical record for Resident 286, the History and Physical Examination dated [DATE], indicated, Chief Complaint .Cough .On arrival to [emergency department] patient was tachycardic [a person with fast heart beat], tachypnic [rapid breathing] and febrile .work up revealed [left lower lobe] infiltrate [build of fluid in the lung] on [chest x ray]. Review of the GACH clinical record for Resident 286, the Consultation dated [DATE], indicated, REASON FOR CONSULTATION; COPD exacerbation. Human [metapneumovirus] She was intubated for hypercapnic respiratory failure .Respiratory, human [metapneumovirus] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 15 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the GACH clinical record for Resident 286, the Discharge Summary dated [DATE], indicated, .female with .COPD presented with complaints of productive cough, wheezing and [shortness of breath]. Patient was a [Skilled Nursing Facility for rehab after being admitted with rib fracture and pneumonia five weeks ago .She was intubated and admitted to ICU [Intensive Care Unit] for COPD exacerbation and pneumonia. She was extubated (breathing tube removed) but continued to deteriorate after extubation .She continued to be in acute respiratory distress and was eventually started on comfort care on [DATE]. She passed away on [DATE] . During a review of the clinical record for Resident 287, the admission Record dated [DATE], indicated Resident was admitted to the facility on [DATE], with a diagnoses which included heart failure, end stage kidney disease, and diabetes. During a review of the clinical record for Resident 287, the Nurses Note dated [DATE], indicated, Resident complained of [shortness of breath] upon observation bilateral rhonchi present .sent to hospital for evaluation . Review of the GACH clinical record for Resident 287, the History and Physical Examination dated [DATE], indicated, .History of Present Illness . [Resident 287] with history of end-stage renal disease on dialysis who presented to the emergency department for palpitations and shortness of breath. The patient is now intubated .the patient presented with SVT (supraventricular tachycardia, faster than normal heart rate beginning above the heart's two lower chambers) of 180s [normal heart beat between 60 to 100 beats per minute] she converted with adenosine (medication to treat irregular heartbeats), became short of breath and desaturated (drop in oxygen saturation) into the 70s (normal blood oxygen saturation between 95 to 100 percent). At this time the emergency physician intubated the patient. Chest x-ray post intubation demonstrated a right lower lobe infiltrate consistent with pneumonia .Impression and Plan .respiratory failure: intubated for respiratory distress .pneumonia . Review of the GACH clinical record for Resident 287, the Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp Human Metapneum .Detected . Review of the GACH clinical record for Resident 287, the Discharge Summary dated [DATE], indicated, .Active Diagnoses .Healthcare-associated pneumonia .and human metapneumovirus pneumonia .Acute respiratory failure with hypoxia .requiring ventilator support .Summary: Patient admitted with shortness of breath and intubated in the emergency room due to hypoxia and respiratory distress .Infectious disease consultation was obtained and bio fire was positive for human parapneumo virus . During a review of the clinical record for Resident 31, the admission Record dated [DATE], indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of COPD, atrial fibrillation and anxiety. During a review of the clinical record for Resident 31, the Nurses Note dated [DATE], indicated, Resident noted to have labored breathing .sent to [general acute care hospital] .for respiratory distress. Review of the GACH clinical record for Resident 31, the History and Physical Examination dated [DATE], indicated, .Chief Complaint Shortness of breath, COPD .History of Present Illness .sent from [facility] nursing home because of shortness of breath . She is on oxygen .She is on nebulizer treatments. Her chest x-ray showed chronic changes with small pleural effusion .She is tachypneic and currently mouth breathing .Impression and Plan .Acute resp failure, hypoxia .COPD, bronchitis . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 16 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the GACH clinical record for Resident 31, the Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp Human Metapneu .Detected . Review of the GACH clinical record for Resident 31, the Death Summary dated [DATE], indicated, .No: response to verbal or tactile stimuli, spontaneous respiration, heart sounds, pulses or pupillary response . Residents Affected - Many During a review of the clinical record for Resident 26, titled, admission Record dated [DATE] indicated Resident 26 was admitted to the facility [DATE], with the diagnoses of COPD and end stage kidney disease. During a review of the clinical record for Resident 26, titled, Nurses Note dated [DATE], indicated, Sent to [general acute care hospital] for evaluation for [shortness of breath] . Review of GACH clinical record for Resident 26, the History and Physical Examination dated [DATE], indicated, .Chief Complaint: I couldn't get my breath .History of Present Illness .sent to the emergency room with shortness of breath and hypotension .chest x-ray in the emergency room showed diffuse interstitial processes. Patient is being admitted for acute exacerbation of chronic bronchitis . Review of GACH clinical record for Resident 26, titled, Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp Human Metap .Detected . During a review of the clinical record for Resident 50, the admission Record dated [DATE] indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of diabetes and atrial fibrillation. During a review of the clinical record for Resident 50, the Nurses Note dated [DATE], indicated, Sent to [general acute care hospital] for evaluation for cough and [shortness of breath]. Review of the GACH clinical record for Resident 50, the History and Physical Examination dated [DATE], indicated, .Chief Complaint cough w expectoration History of Present Illness . [Resident 50] bought to [GACH] for severe SOB going on for the last 1 month, off and on .Reports being sick w flu off and on but it got worse yesterday w excessive sputum production. In the ED, he was noted to have bilateral lower lobe infiltrates w trace pleural effusion, also had leukocytosis .Impression and Plan .Bilateral lower lobe pneumonia . Review of the GACH clinical record for Resident 50, the Flowsheet Print Request dated [DATE]-[DATE], indicated, .Immunology Results [DATE] .Resp Human Metapneun .Detected . Review of the GACH clinical record for Resident 50, the Discharge Summary dated [DATE], indicated, .Discharge dx .Bilateral lower lobe pneumonia .Human metapneumovirus infection .Hospital course .found to have bilateral pneumonia. He was started on IV antibiotics. Respiratory biofire [a laboratory test of 20 possible respiratory viruses and bacteria's] was positive for human med Pneumovirus . During a review of the clinical record for Resident 18, the admission Record dated [DATE], indicated Resident 18 was admitted to the facility on [DATE], with the diagnoses of heart failure, atrial fibrillation, and diabetes. Review of the GACH clinical record for Resident 18, the History and Physical Examination dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 17 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm [DATE], indicated, .Chief Complaint lethargy, weakness and shortness of breath x [for] 2 days .History of Present Illness .she was noted to be weak yesterday, and today she was more tired, she was breathing fast, cannot get comfortable and is restless, she has had similar presentation in the past and was diagnosed as pneumonia .patient work up in the ED shows tachycardia and tachypnea .[chest x-ray] shows pleural effusion, congestion . Residents Affected - Many Review of the GACH clinical record for Resident 18, the Progress Note dated [DATE], indicated, .Basic Information Still very short of breath, with distended neck veins. She is positive for metapneumovirus .Review of Systems Respiratory: Shortness of breath . Review of the GACH clinical record for Resident 18, the Consultation dated [DATE], indicated, .REASON FOR CONSULTATION: Human metapneumovirus .Chest x-ray demonstrated bilateral pleural effusions .Respiratory .positive for human metapneumovirus. I am asked to follow up this patient due to a cluster of cases, presenting from the same facility . Review of the GACH clinical record for Resident 18, the Death Summary dated [DATE], indicated, .No: response to verbal or tactile stimuli, spontaneous respiration, heart sounds, pulses or pupillary response . The facility policy and procedure titled, INFECTION PREVENTION AND CONTROL PROGRAM dated [DATE], indicated, .The Infection Control plan shall include: education, prevention, screening, surveillance, investigation, tracking, trending, reporting and performance improvement. The plan is an ongoing process designed to objectively and systematically monitor and evaluate the effectiveness of the infection control plan and practice. The primary goal is to establish, maintain, and provide a safe, sanitary, and comfortable environment [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 18 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively implement an antibiotic stewardship program when the Infection Preventionist (IP) failed to monitor and address the use of antibiotics when the resident's condition did not meet the facility McGeer Criteria (a program used to identify signs and symptoms with an aim to reduce unnecessary prescribing for the three infections where antibiotics are most frequently prescribed in nursing homes: urinary tract infections (UTIs), lower respiratory tract infections, and skin and soft tissue infections) and when the physician was not notified after the infection did not meet criteria for infection and use of antibiotic continued. Residents Affected - Some This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD), on 3/14/19, at 10 a.m., she reviewed the document titled, Infection Prevention and Control Surveillance Log dated 11/2018, and stated the document listed all facility residents who received physician ordered antibiotics for infections. The DSD stated the facility used McGeer's Criteria to evaluate if resident symptoms met the infection criteria for the use of prescribed antibiotics. The DSD stated licensed nurses and herself were educated on how to complete the McGeer's Criteria tool for infections. The DSD stated residents needed to meet McGeer's Criteria for infections to ensure antibiotic use was necessary. The DSD stated Mc Geer's Criteria was used to prevent the overutilization of antibiotics. During a review of the Infection Prevention and Surveillance Log dated 11/2018, the log indicated there were six residents who received antibiotics for a urinary tract infection (UTI) without meeting infection criteria. Two residents received antibiotics for pneumonia (infection of the lungs) without meeting criteria for infection. One resident received antibiotic for a respiratory tract infection without meeting criteria for infection. Three residents received antibiotics for cellulitis (infection beneath the skin) without meeting infection criteria. Three residents received antibiotics for wound infections without meeting criteria for infection. During a review of the Infection Prevention and Surveillance Log dated 12/2018, the log indicated 13 residents received antibiotics for UTI without meeting criteria for infection. Three residents received antibiotics for pneumonia without meeting criteria for infection. Four residents received antibiotics for wound infection without meeting criteria for infection. Two residents received antibiotics for eye infections without meeting criteria for infection. Two residents received antibiotics for cellulitis without meeting criteria for infection. One resident received antibiotic for dermatitis (infection of the skin) without meeting criteria for infection. One resident received antibiotic for respiratory infection without meeting criteria for infection. Six residents received antibiotics for Clostridium difficile (C.diff), UTI, eye infections, wound, and skin infections with or without evaluating if the use of the anitibiotic met the criteria for infection. During a review of the clinical record for Resident 283, the physician orders dated 11/18/18, indicated Resident 283 was prescribed an antibiotic, Macrobid 100 milligram (mg) (dry unit of measurement) by mouth (PO) twice a day (BID) for 10 days. Review of Resident 283's nursing notes from 11/15/18 to 11/18/18, indicated Resident 283 did not have a temperature, no hematuria (blood in the urine), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 19 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no dysuria (difficulty urinating), and no suprapubic pain (lower abdomen). The DSD stated use of the antibiotic did not meet McGeer Criteria. During a concurrent interview and record review with the DSD, on 3/14/19, at 10:10 a.m., she reviewed the surveillance log for November 2018 and stated Resident 283 received antibiotics to treat a UTI on 11/18/18. The DSD stated Macrobid (antibiotic used to treat infections) was ordered for Resident 283 on 11/18/18. The DSD stated Resident 283's symptoms and lab results did not meet McGeer's Criteria. The DSD stated the licensed nurses should have notified the physician when the resident did not meet McGeer's Criteria for the use of the antibiotic. During a review of the Infection Prevention and Surveillance Log dated 11/2018, indicated Resident 281 was prescribed an antibiotic, Macrobid 100 mg PO BID for seven days. Review of Resident 281's nursing notes dated 11/3/18, indicated the order date for Macrobid was 11/3/18. Review of Resident 281's nursing notes from 10/20/18 to 11/3/18, Resident 281 did not have a temperature, no hematuria, no dysuria, and no suprapubic pain. Review of laboratory report dated 11/6/18, indicated the final report for the urine culture collected on 11/3/18 grew 50,000 cfu/ml (colony-forming units per milliliter) Enterococcus faecalis (bacteria). The antibiotic was to treat a positive urine culture. The use of the antibiotic did not meet McGeer Criteria. During a concurrent interview and record review on 3/14/19 at 10:30 a.m., the DSD reviewed the surveillance log for November 2018 and stated Resident 281 had received antibiotics for an UTI during November 2018. The DSD stated the onset date was documented on 11/3/18. The DSD stated Macrobid was ordered for Resident 281 on 11/3/18. The DSD stated Resident 281's symptoms and lab results did not meet the McGeer Criteria. The DSD reviewed the nursing notes for 11/3/18 and stated there was no communication documented regarding notification to the physician that Resident 281 did not meet McGeer Criteria. During an interview on 3/14/19, at 10:39 a.m., the DSD stated the licensed nurses should have notified the physician regarding residents who did not meet the McGeer Criteria. The DSD stated there was no McGeer Criteria form that was filled out for the determination. The DSD provided a copy of a documented she used for McGeer Criteria titled Revised McGeer Criteria for LTC [long term care]. During a concurrent interview and record review on 3/14/19, at 10:44 a.m., the DSD stated there were seven residents who received antibiotics for a UTI during December 2018. The DSD reviewed the surveillance log for December 2018 and the residents did not meet the McGeer Criteria. The DSD stated she became aware of antibiotics after the residents were ordered the antibiotic to treat a suspected infection. The DSD stated she had different job titles and infection control was not the main task she completed. The DSD stated infection prevention should be the facility priority. The DSD stated she understood the importance of utilizing the McGeer Criteria and by using the McGeer Criteria to help lower the use of the antibiotics. The DSD stated some antibiotics may not be needed for the residents. During a review of the Infection Prevention and Surveillance Log dated December 2018, indicated Resident 282 was prescribed an antibiotic, Rocephin 1 gram (unit of measurement) IM (intramuscular) for one day. Review of Resident 282's nursing notes dated 12/20/18 at 11:54 a.m., indicated continue to monitor Resident 282 for new order of Rocephin given in the right buttock. Review of Resident 282's nursing notes dated 12/20/18 at 9:53 p.m., indicated lab results were received for the urinalysis completed on 12/19/18. The antibiotic was given before the lab results were completed and reviewed by the physician. Review of Resident 282's nursing notes from 12/1218 to 12/15/18, Resident 282 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 20 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not have a temperature, no hematuria, no dysuria, no change in cognition, and no suprapubic pain. The use of the antibiotic did not meet McGeer Criteria. During a review of the Infection Prevention and Surveillance Log dated December 2018, indicated Resident 26 was prescribed an antibiotic, Augmentin 875-125 mg PO BID for seven days. Review of Resident 26's nursing notes dated 12/4/18, indicated the order date for Augmentin was 12/4/18. The physician's order was changed to discontinue Augmentin to Rocephin 1 gram for three days. Review of Resident 26's nursing notes from 11/30/18 to 12/3/18, Resident 26 did not have a temperature, no hematuria, no dysuria, no change in cognition, and no suprapubic pain. The antibiotic was ordered after readmission from the GACH on 12/4/18. The use of the antibiotic did not meet McGeer Criteria. During a concurrent interview and record review on 3/14/19 at 10:50 a.m., the DSD reviewed the surveillance log for December 2018 and stated Resident 26 had received antibiotics for an UTI during December 2018. The DSD stated the onset date was documented on 12/4/18. The DSD stated Resident 26 was readmitted on [DATE] with orders for Augmentin. The DSD stated the PA changed the order to Rocephin for diagnoses of pneumonia and UTI. The DSD stated Resident 26's did not meet the McGeer Criteria. During a review of the Infection Prevention and Surveillance Log dated December 2018, indicated Resident 21 was prescribed two antibiotics, Cipro and Rocephin. Review of Resident 21's nursing notes dated 12/10/18, indicated the order date for Macrobid was 12/10/18. Review of Resident 21's nursing notes from 12/1/18 to 12/9/18, Resident 21 did not have a temperature, no hematuria, no dysuria, and no suprapubic pain. The antibiotic was to treat a positive urine culture. The use of the antibiotic did not meet McGeer Criteria. During a concurrent interview and record review on 3/14/19 at 10:55 a.m., the DSD reviewed the surveillance log for December 2018 and stated Resident 21 had received antibiotics for an UTI during December 2018. The DSD stated the onset date was documented on 12/10/18. The DSD stated Resident 21 did not meet the McGeer Criteria. During a review of the Infection Prevention and Surveillance Log dated December 2018, indicated Resident 30 was prescribed three antibiotics, Cipro, Rocephin, and Bactrim. Review of Resident 30's nursing notes dated 12/10/18, indicated the order date for Cipro and Rocephin was 12/10/18. Review of Resident 30's nursing notes from 12/1/18 to 12/8/18, Resident 30 did not have a temperature, no hematuria, no dysuria, and no suprapubic pain. Review of nursing note dated 12/12/18, indicated Resident 30's culture and sensitivity results received and the PA changed to order to Bactrim DS for 10 days. The antibiotics of Cipro and Rocephin were ordered before the culture and sensitivity was received. The antibiotics were to treat a positive urine culture. The use of the antibiotics did not meet McGeer Criteria. During a concurrent interview and record review on 3/14/19 at 11:01 a.m., the DSD reviewed the surveillance log for December 2018 and stated Resident 30 had received antibiotics for an UTI during December 2018. The DSD stated the onset date was documented on 12/10/18. The DSD stated Resident 30 did not meet the McGeer Criteria. During a review of the Infection Prevention and Surveillance Log dated December 2018, indicated Resident 284 was prescribed an antibiotic, Rocephin 1 gram IM once. Review of Resident 284's nursing notes dated 12/13/18, indicated the order date for Rocephin was 12/13/18. Review of Resident 284's nursing notes from 12/1/18 to 12/13/18, Resident 284 did not have a temperature, no hematuria, no dysuria, and no suprapubic pain. The antibiotic was to treat a positive urine culture. The use of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 21 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 antibiotic did not meet McGeer Criteria. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/14/19 at 11:08 a.m., the DSD reviewed the surveillance log for December 2018 and stated Resident 284 had received antibiotics for an UTI during December 2018. The DSD stated the onset date was documented on 12/13/18. The DSD stated Resident 284 did not meet the McGeer Criteria. Residents Affected - Some During an interview on 3/14/19, at 11:22 a.m., LVN 1 stated she had been working in the facility for six years. LVN 1 stated there was no standard tool used to monitor for signs and symptoms of UTI. LVN 1 stated the CNAs will notify the licensed nurses if there was something wrong with the residents. LVN 1 stated the licensed nurses then notify the physician of the change of condition. LVN 1 stated the physician will get new orders such as labs. LVN 1 stated she did not notify the physician if the resident did not meet any criteria for an infection. The facility policy and procedure titled Policy for Antibiotic Stewardship Program 2016 dated 10/1/16, indicated, Policy: It is the policy of [NAME] Post Acute to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use .Nursing home ASP activities should, at a minimum, include these basic elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improvement . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 22 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview the facility failed to provide the minimum square footage in four resident rooms (rooms 106, 108, 110 and 119) of at least 80 square feet per resident. Residents Affected - Some This failure had the potential to decrease resident freedom of mobility and could compromise provision of care. Findings: During an observation of the room and review with Maintenance Supervisor (MS), on 3/14/19, at 10:49 a.m., the MS measured Rooms 106, 108, 109 and 119. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and resident to ambulate. Wheelchairs and toilet facilities were accessible. The health and safety of the residents would not be adversely affected by this waiver. Room Square Footage No. of Beds 106 318.3 sq. ft. 4 108 295.1 sq. ft. 4 110 300.2 sq. ft. 4 119 317.0 sq. ft. 4 We recommend a room waiver. ______________________________________ Health Facilities Evaluator Supervisor II Date We request a room waiver. ______________________________________ Administrator Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056288 If continuation sheet Page 23 of 23