HANFORD, CA - Federal inspectors found serious care deficiencies at Hanford Post Acute that contributed to multiple resident deaths, including fatal falls and a case of severe bowel impaction that required emergency surgery to remove more than two pounds of hardened stool.
The April 2025 inspection revealed systematic failures in fall prevention and basic medical monitoring that resulted in preventable deaths and life-threatening complications for vulnerable residents.
Fatal Fall Pattern Leads to Brain Injury Death
The most severe violation involved a 93-year-old male resident with dementia who experienced eight documented falls over six months before sustaining fatal injuries. Despite his cognitive impairment and history of impulsive behavior, the facility failed to implement adequate supervision measures.
The resident's final falls occurred on consecutive days in March 2025. On March 11, he was found bleeding on his room floor with a forehead laceration. After emergency treatment, he returned to the facility but fell again on March 12, reopening his head wound. CT scans revealed a subdural hematoma measuring 11 millimeters in thickness, along with additional brain bleeding.
"The resident was taking blood-thinning medication, which significantly increased his bleeding risk with any fall-related injuries," an Assistant Director of Nursing told inspectors. The resident passed away on March 17, 2025, from complications related to his fall injuries.
Previous Fall History Ignored
Medical records documented the resident's escalating fall pattern: - September 30, 2024: Found on floor next to bed - November 5, 2024: Found on floor next to bed - December 9, 2024: Found on floor next to bed - December 16, 2024: Found on floor next to bed - December 18, 2024: Found on floor next to bed - February 1, 2025: Found on floor, required emergency sutures for eyebrow laceration
Staff consistently described the resident as impulsive, confused, and unable to remember safety instructions. Multiple nursing assistants confirmed he would attempt to stand and walk without assistance despite being unsteady and at high risk for injury.
"Resident 1 was impulsive and needed one-on-one monitoring to keep him safe and prevent falls," a nursing assistant told inspectors. However, this level of supervision was never implemented.
Bowel Impaction Death Reveals Monitoring Failures
In a separate case highlighting inadequate medical oversight, a 78-year-old female resident died from complications related to severe fecal impaction after staff failed to monitor her bowel movements for nearly two weeks.
The resident, who had a documented history of constipation, consistently refused personal care from February 23 through March 6, 2025. Rather than implementing alternative monitoring strategies or seeking physician intervention, staff simply documented the refusals without assessing her condition.
On March 6, nursing staff found the resident unresponsive with dangerously low blood pressure (89/50) and altered mental status. Emergency department physicians discovered massive fecal impaction requiring immediate intervention.
Emergency Surgery Reveals Severity
Hospital records show the emergency physician performed digital removal of feces, extracting over 1,000 grams (2.2 pounds) of hardened stool. The procedure notes described "massive amounts of stool coming up the vagina and out of the rectum" and characterized the removed material as "hard rocky" feces.
Despite initial treatment efforts, the resident developed septic shock and passed away the same day under comfort care measures. The official cause of death was septic shock and colitis.
Staff Acknowledge System Failures
During interviews, multiple facility staff members acknowledged the preventable nature of these deaths. The Administrator admitted to inspectors: "We did not do enough fall interventions to keep Resident 1 safe from harm."
Regarding the bowel impaction case, nursing staff confirmed they could not accurately track the resident's condition because of documentation failures. "We did not know how often or how much the resident was having bowel movements," the Assistant Director of Nursing stated.
A Licensed Vocational Nurse involved in the second resident's care acknowledged: "It was important to notify the physician and document to keep the resident safe. Unfortunately, [the resident] chose not to receive care and refused to be checked."
Medical Standards Violated
Standard nursing protocols require comprehensive assessment of residents who refuse care, particularly those with known medical risks. When residents refuse essential care, facilities must implement alternative monitoring strategies and coordinate with physicians to prevent complications.
Fecal impaction represents a serious medical emergency in elderly populations, with studies showing mortality rates approaching 29% when complications develop. The condition requires early recognition and intervention to prevent life-threatening consequences including septic shock and organ failure.
Fall prevention protocols similarly mandate individualized interventions based on resident-specific risk factors. For residents with cognitive impairment and impulsive behaviors, standard interventions like call lights and bed alarms prove inadequate, requiring enhanced supervision measures.
Facility Policy Violations
The facility's own policies required comprehensive care planning within seven days of admission and mandated that fall prevention plans address specific resident risk factors. However, inspectors found care plans were either absent or inadequate for both residents' identified needs.
The facility's fall prevention policy specifically stated that residents should "not be left alone in room while out of bed" for high-risk individuals, yet this intervention was never implemented despite the resident's repeated falls.
Second Resident's Multiple Fall Pattern
The inspection also revealed concerning fall patterns for another resident who experienced eight falls within 30 days. This 68-year-old resident with brain injuries and cognitive impairment fell repeatedly despite being assessed as high-risk.
Staff described him as "very confused, difficult to communicate with and impulsive" with behaviors of "standing up suddenly and falling." Despite recognizing the need for constant supervision, the facility never implemented one-on-one monitoring.
The falls occurred in various locations including his bed, dining room, and near the nurses' station, indicating the resident's impulsive behaviors posed risks throughout the facility.
Regulatory Response
Federal inspectors cited the facility for multiple serious violations including failure to provide adequate supervision to prevent accidents and failure to ensure residents receive necessary treatment according to professional standards.
These citations carry significant penalties and require the facility to submit detailed correction plans addressing the identified deficiencies. The facility must demonstrate how it will prevent similar incidents through improved staffing, enhanced monitoring protocols, and comprehensive staff training.
The inspection findings highlight the critical importance of individualized care planning and proactive intervention for high-risk residents in nursing home settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hanford Post Acute from 2025-04-04 including all violations, facility responses, and corrective action plans.
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