Health inspection·May 13, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure services provided met professional standards of quality for one of six sampled residents (Resident 4) when Resident 4 was administered 4.5 L/min (liters-unit of measurement)/min (minute) of oxygen via Nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 2L/min of oxygen per physician's order. Residents Affected - Few This failure had the potential to put Resident 4 at risk to oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; it can cause coughing and trouble breathing; in severe cases it can even cause death). Findings: During a Review of Resident 4's admission Record, (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/12/25, the AR indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Dyspnea (shortness of breath, difficulty breathing), and Asthma (a chronic lung condition making it difficult to breathe). During a concurrent observation and interview on 5/12/25 at 12:30 p.m., with the Infection Preventionist (IP), inside Resident 4's room, Resident 4 was lying in her bed, sleeping and with supplemental oxygen via nasal cannula receiving 4.5L/min. IP stated, she needs to check the physician order to verify if Resident 4 was supposed to receive 4.5L/min of supplemental oxygen. During a concurrent interview and record review on 5/12/25 at 12:45 p.m. with the IP, Resident 4's Physician Order Summary (POS) was reviewed. The POS indicated , . Oxygen 2LPM (liters per minute) via Nasal Cannula Continuously . Order Date 4/23/25 . The IP stated, Resident 4 current oxygen setting was incorrect and could potentially cause harm if not corrected immediately. The IP stated, the higher flow of oxygen could have a negative effect on Resident 4's overall health. The IP stated, she expect the licensed nurses to routinely check the oxygen setting during medication pass and as needed, and it was not done. During a concurrent interview and record review on 5/12/25 at 2:04 p.m. with the Minimum Data Set Nurse (MDSN), Resident 4's Progress Note (PN) was reviewed. The MDSN stated, she was unable to find any documentation indicating Resident 4 ' s oxygen level dropped below 90% (percent- unit of measurement) and a physician ' s order to increase the oxygen delivery from 2LPM to 4.5LPM. The MDSN stated, Resident 4 could get hurt from receiving too much oxygen. Page 1 of 5 056288 056288 05/13/2025 Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/12/25, at 2:13 p.m., with the Director of Nursing (DON), the DON stated oxygen was considered a medication and physician's order should be followed to prevent oxygen toxicity for Resident 4. During a review of the facility's policy and procedures (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated, .Verify that there is a physician's order .review the physician's orders or facility protocol for oxygen administration .after completing the oxygen setup or adjustment, the following information should be recorded .the rate of oxygen flow, route and rationale . During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders . 056288 Page 2 of 5 056288 05/13/2025 Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for three of six sampled residents (Residents 3, 5 and 6) when: Residents Affected - Some 1. Resident 5 ' s oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. 2. Resident 3 and Resident 6 ' s oxygen concentrator filters were covered with dust and lint. These failures placed Residents 3, 5 and 6 at an increased risk to develop respiratory and healthcare-associated infections. Findings: 1. During a review of Resident 5's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/12/25, the AR indicated, Resident 5 was admitted from an acute care hospital on 4/27/25 to the facility, with diagnoses that included Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), and Generalized Muscle Weakness. During a review of Resident 5's Order Summary Report (OSR), dated 5/12/25, the OSR indicated, . Order Summary . Oxygen at 2 LPM (liters per minute- unit of measurement) via nasal cannula (a device used to deliver supplemental oxygen) . Order Date 4/27/25 . During a review of Resident 5's Nursing Care Plan (CP), dated 5/8/25, the CP indicated, . [Resident 5] has COPD . Interventions/Tasks . Give oxygen therapy as ordered by the physician . Date Initiated: 4/27/25 . During an observation on 5/12/25, at 11:58 a.m., inside Resident 5 ' s room. Resident 5 was lying in bed, asleep and had an oxygen cannula connected to an oxygen concentrator. The oxygen was being given at 2L/min continuously. The oxygen concentrator filter was operating without the filter installed on the left side of the machine. During a concurrent observation and interview, on 5/12/25, at 12:35 p.m., inside Resident 5 ' s room with the Infection Preventionist (IP), the IP looked at Resident 5 ' s oxygen concentrator and stated the oxygen concentrator was operating without a dust filter and it should. The IP stated, Resident 5 ' s respiratory condition could worsen. The IP, stated maintaining the cleanliness of oxygen concentrator was the responsibility of the licensed nurses. During an interview on 5/12/25, at 2:13 p.m., with the Director of Nursing (DON), the DON stated using an oxygen concentrator without a filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated she expects the oxygen concentrator to be inspected and cleaned twice a week, and as needed for the safety and well-being of all residents receiving oxygen. The DON stated residents using dirty oxygen concentrators could have respiratory infection such as Pneumonia (lung infection caused by bacteria) and Bronchitis (inflammation of the airways). 056288 Page 3 of 5 056288 05/13/2025 Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders . Safety and Sanitation . Ensure that your unit ' s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's Policy and Procedure (P&P), titled, Oxygen Administration, dated 10/2010, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/2018, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation . 2. During a review of Resident 6's AR, dated 5/12/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/20/25 to the facility, with diagnoses that included COPD, Generalized Muscle Weakness, Hypertension, and Cerebral Infarction (stroke). During a review of Resident 5's OSR, dated 5/12/25, the OSR indicated, . Order Summary . Oxygen at 2 LPM via nasal cannula continuously . Order Date 2/20/25 . During a review of Resident 5's CP, dated 2/21/25, the CP indicated, . [Resident 6] has Oxygen Therapy r/t [related to] COPD . Interventions/Tasks . Oxygen 2LPM via nasal cannula continuously every shift . Date Initiated: 2/21/25 . During a review of Resident 3's AR, dated 5/12/25, the AR indicated, Resident 3 was admitted from an acute care hospital on 4/16/25 to the facility, with diagnoses that included COPD, Generalized Muscle Weakness, Hyperlipidemia (high cholesterol) and Morbid Obesity (overweight). During a review of Resident 3's OSR, dated 5/12/25, the OSR indicated, . Order Summary . Oxygen 2 LPM via nasal cannula every shift for SOB [shortness of breath] . Order Date 4/16/25 . During a review of Resident 3's CP, dated 2/21/25, the CP indicated, . [Resident 3] has COPD . Interventions/Tasks . Give oxygen therapy as ordered by the physician . Date Initiated: 4/17/25 . During a concurrent observation and interview, on 5/12/25, at 12:37 p.m., inside Resident 3 and Resident 6 ' s rooms, with the IP. Resident 3 and Resident 6 were in bed and being given oxygen through nasal cannulas connected to the oxygen concentrator. The IP looked at Resident 3 and Resident 6 ' s 056288 Page 4 of 5 056288 05/13/2025 Hanford Post Acute 1007 West Lacey Blvd Hanford, CA 93230

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oxygen concentrators and stated the oxygen concentrator filters were covered with dust and lint. The IP stated, using a dirty oxygen concentrator was not acceptable. The IP stated, Resident 3 and Resident 6 were not getting the full benefit of supplemental oxygen and their respiratory condition could worsen. The IP stated, residents receiving supplemental oxygen from oxygen concentrator with dirty filter could cause respiratory infections. The IP stated, the oxygen concentrator filters should be cleaned once a week and as needed. During an interview on 5/12/25, at 2:18 p.m., with the DON, the DON stated using a dirty oxygen concentrator was not acceptable and could potentially cause residents to become ill. The DON stated, the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated, residents using a dirty oxygen concentrator could have respiratory infection. The DON stated, she expects the oxygen concentrator to be cleaned twice a week and as needed by the licensed nurses for the safety and well-being of all residents receiving oxygen. During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders . Safety and Sanitation . Ensure that your unit ' s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's P&P titled, Oxygen Administration, dated 10/2010, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/2018, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation . 056288 Page 5 of 5