Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hansford Manor during CMS and state inspections, most recent first.
Food Items Improperly Stored, Labeled, and Dated: The kitchen had multiple food safety issues, including a large bag of French fries left open to air in the freezer, three unlabelled brown bags of food in the freezer, a bag of cheese left open to air in the cooler, and an expired container of parsley spice on the shelf. The DM and RD acknowledged the items were not stored per food safety standards, and the RD stated frozen items should be labeled and dated when removed from the box.
Incomplete DNR Form for a Cognitively Intact Resident: A resident with a DNR/DNI order had an OOH-DNR form in the chart that was missing the resident’s signature date. The resident was cognitively intact and had documented wishes to retain control over health care decisions, but staff gave conflicting views on whether the form was valid, with the LVN, DON, SW, and MR C each describing different interpretations of the incomplete DNR.
A resident with dementia, DM, CKD, and chronic ankle/foot wounds had active daily wound care orders and documented pressure ulcers and diabetic foot ulcers, but the care plan contained no wound, pressure ulcer, or diabetic foot ulcer interventions. The DON and MDS RN stated the wound care plan had been resolved/cancelled and never reentered, despite the resident’s ongoing wound history and recent MRSA in one wound.
A resident with COPD, chronic respiratory failure, dementia, and dependence on supplemental O2 had an active order for 2 L/NC, but surveyors observed the concentrator set above the ordered dose on multiple occasions. An LVN confirmed the order and found the resident was using about 3 L/min, stating the resident often adjusted the oxygen herself because she felt it helped her breathing. The DON and ADON acknowledged the resident was supposed to be on 2 L/min and that giving a resident medication at the ordered dose was an issue.
An Insulin Glargine pen in the Hall 2 med cart was found used but not labeled with the date it was opened or when it would expire. LVN A said she had not accessed the pen that shift, and the DON reported an agency nurse had used it the prior evening and failed to label it per facility policy requiring multi-dose vials to be marked with the date opened and nurse initials.
A resident's MDS assessment inaccurately recorded insulin injections, despite no orders or records supporting this. The resident, with conditions including type 2 diabetes, was actually on Ozempic. Staff interviews revealed the error was a typographical mistake by the MDS Coordinator, highlighting the importance of accurate documentation.
The facility failed to include bed rail use in the care plans of two residents with severe cognitive impairment and mobility issues. Despite orders for bed rails as enablers for bed mobility, the care plans did not reflect this, potentially placing residents at risk. Observations confirmed the use of bed rails, and interviews with staff highlighted a lapse in responsibility for updating care plans.
The facility failed to attempt appropriate alternatives before installing bed rails for two residents, risking entrapment or injury. One resident with neuropathy and bipolar disease, and another with dementia and muscle weakness, had bed rails installed upon admission without prior alternative interventions. Staff interviews revealed a lack of adherence to the facility's policy requiring informed consent after attempting alternatives.
Food Items Improperly Stored, Labeled, and Dated
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation and interview of the kitchen with the DM and RD, a large plastic bag of French fries was found open to air and not in its original box in the freezer, and three brown bags of a food item were also observed with no label and not in their original box. The DM stated the large bag of French fries should have been fastened and said she would throw it out. She stated the brown bags were French fries and that staff did not mark the bags because everyone knew what they were. The RD stated all frozen items should be labeled and dated when removed from the box and that the French fries should have been marked. In a later observation, a large container of parsley spice with an expiration date of July 2025 was found on the spice shelf, and a plastic bag of cheese was observed open to air in the cooler. The RD stated the cheese package should have been closed to air and acknowledged the parsley spice was expired and should have been thrown out. The facility policy stated food safety practices include labeling, dating, monitoring refrigerated foods, discarding expired items, and keeping foods covered in airtight containers.
Incomplete DNR Form for a Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that a resident’s advance directive was fully completed for Resident #25, whose record listed her as a DNR. Resident #25 was a [AGE]-year-old female admitted with diagnoses including idiopathic normal pressure hydrocephalus, chronic kidney disease, and peripheral vascular disease. Her most recent MDS quarterly assessment showed a BIMS of 15, indicating she was cognitively intact, and she was independent with most ADLs. Her care plan documented her desire to retain control and autonomy over her health care decisions and noted that she had an OOH-DNR. Record review showed an active DNR/DNI order and a DNR form signed by the physician, but the section for the adult person showed Resident #25’s signature without a date. During interview, the LVN responsible for the resident stated that the resident had not dated the DNR and initially said she would not start CPR because the resident was DNR, but then stated she would treat the resident as full code because the form was incomplete. The DON stated that if the person implementing the DNR did not date the form, the DNR was not valid and would not be carried out correctly. The SW stated she did not verify the DNR for Resident #25 and believed it was still valid because the doctor and two witnesses signed it. MR C also reviewed the form and acknowledged that Resident #25 did not date her signature, while stating she did not feel it was an issue because the witnesses and doctor signed the DNR.
Missing wound care plan for resident with chronic ankle and foot ulcers
Penalty
Summary
The facility failed to implement a comprehensive care plan for one resident that included measurable objectives and timeframes for his medical, nursing, mental, and psychosocial needs. Resident #1 was admitted with diagnoses including dementia, diabetes, chronic kidney disease, and pressure ulcer of the right ankle. His annual MDS showed a BIMS of 15, indicating he was cognitively intact, and he was independent with most ADLs. The record also showed one unhealed stage 3 pressure ulcer, one unstageable pressure ulcer, and diabetic foot ulcers, with active daily wound care orders for the right anterior ankle and right medial ankle. Review of the care plan, last revised on 8/13/25, showed no care plan for pressure ulcers, diabetic foot ulcers, or wound care. During interviews, the DON and ADON stated the resident had wounds to his ankles/feet for approximately a year, that the wounds had healed and worsened at different times, and that he recently had MRSA in one of the wounds. The DON reported the wound care had been resolved out of the care plan and had not been added back, and the MDS RN stated the wound care plans were resolved/cancelled on 4/23/25 and never reentered. The facility policy stated the IDT develops and implements a comprehensive, person-centered care plan based on the comprehensive assessment and that it describes the services to be furnished to attain or maintain the resident's highest practicable well-being.
Oxygen Not Kept at Ordered Dose
Penalty
Summary
Resident #12, a [AGE]-year-old female with COPD, chronic respiratory failure, dementia, and dependence on supplemental oxygen, was admitted to the facility on [DATE]. Her record showed an active order for oxygen at 2 L/NC continuous every morning and at bedtime related to COPD, and her care plan directed staff to give oxygen therapy as ordered by the physician. Her MDS indicated severe cognitive impairment with a BIMS score of 03 and that she was independent with most ADLs. During observation, Resident #12 was found sleeping in her recliner with oxygen via nasal cannula set at 4.5 L/min, and later her concentrator was observed set at 3.5 L/min. On interview, an LVN reviewed the order and confirmed the resident was supposed to be on 2 L/min, then checked the concentrator and found it was set at approximately 3 L/min. The LVN stated the resident often adjusted the oxygen herself because she felt it helped her breathing. The DON and ADON later stated the resident was supposed to have oxygen set at 2 L/min, that the resident often changed it, and that giving a resident medication at the ordered dose was an issue; the DON also stated that too much oxygen could compromise a resident with COPD. The facility policy review provided no information related to ensuring resident medication orders are implemented accurately.
Unlabeled Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to ensure that a medication was labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts reviewed. During an observation of the Hall 2 medication cart with LVN A present, an Insulin Glargine pen that had been used was found without a date showing when it was opened or when it should expire. LVN A stated the pen appeared to have been used and reported she had not used it that shift because it was a PM administration. During interview, LVN A reported she had been trained on insulin storage by the DON and that she marks all insulins when she opens or accesses them, but this pen was not opened or accessed by her. The DON later reported the facility determined an agency nurse had accessed the insulin pen the previous evening and was responsible for not marking it. Record review of the facility policy titled Usage, Storage, and Re-entry of Multi dose Vials stated that the product is to be disposed of within 28 days after initially opening and must be clearly labeled with the date opened and initials of the nurse who opened the product.
Inaccurate MDS Assessment for Resident's Medication
Penalty
Summary
The facility failed to complete an accurate assessment for a resident, identified as Resident #4, regarding her medication regimen. The resident's Minimum Data Set (MDS) assessment inaccurately indicated that she received insulin injections during the look-back period, despite no physician orders or documentation supporting this. The resident, a cognitively intact female with a BIMS score of 13, was admitted with conditions including hereditary motor and sensory neuropathy, bipolar disorder, type 2 diabetes mellitus, and chronic pain. Her care plan and medication administration records confirmed the absence of insulin administration, instead noting the use of Ozempic for diabetes management. Interviews with facility staff, including the Administrator (ADM), Director of Nursing (DON), and MDS Coordinator, revealed that the error was attributed to a typographical mistake by the MDS Coordinator. The staff acknowledged the potential implications of such inaccuracies, including incorrect care and reimbursement rates. The MDS Coordinator admitted to the error, emphasizing the importance of accurate data entry in the MDS assessment process. The deficiency was identified through a review of the resident's records and staff interviews, highlighting the need for precise documentation to ensure appropriate resident care and facility operations.
Failure to Include Bed Rail Use in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included the omission of bed rail use in their care plans. Resident #28, a male with severe cognitive impairment, dementia, anxiety disorder, osteoarthritis, muscle weakness, hallucinations, and a history of falls, was admitted with an order for bed rails as an enabler for bed mobility. Despite this, his care plan did not mention the use of bed rails, which were observed in use during multiple observations. Similarly, Resident #101, a male with severe cognitive impairment, dementia, insomnia, and muscle weakness, was admitted with an order for bed rails for bed mobility. His care plan also failed to include the use of bed rails, although they were observed in use during several observations. During an interview, Resident #101 acknowledged using the bed rails for mobility, indicating their importance in his care. Interviews with facility staff, including the MDS Coordinator and ADM, revealed that the responsibility for including bed rail use in care plans was acknowledged but not executed. The facility's policies on bed rail use and care planning emphasized the need for comprehensive care plans that include all necessary treatments and services, yet these were not adhered to, potentially placing residents at risk of harm due to incorrect care and lack of monitoring.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing bed rails for two residents, which could place them at risk of entrapment or injury. Resident #4, a female with hereditary motor and sensory neuropathy, bipolar disease, macular degeneration, and insomnia, was admitted with bed rails installed without prior alternative interventions. Her care plan indicated a moderate risk for falls and the use of side rails for safety and bed mobility. Despite having signed a consent form for side rails, there was no evidence of alternative measures being attempted before their installation. Resident #101, a male with dementia, insomnia, and muscle weakness, also had bed rails installed upon admission without exploring other options. His care plan noted limited physical mobility and the use of antianxiety medication. Although he signed a consent form for side rails, his family member did not recall providing consent. Observations showed that the resident used the bed rails, but there was no documentation of alternative interventions being considered prior to their use. Interviews with facility staff revealed that RNs were responsible for bed rail assessments at admission and monthly thereafter. Staff members stated that they educated families about the risks of bed rails and encouraged alternatives, but often followed family wishes. The facility's policy required informed consent after attempting alternatives, which was not adhered to in these cases. The Director of Nursing acknowledged the potential negative impacts of installing bed rails without trying alternatives, including limited mobility and risk of injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spearman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capstone Healthcare Of Perryton | 25.5 mi | ★★★★★ | 1 | 0 |
| Caprock Nursing & Rehabilitation | 38.5 mi | ★★★★★ | 2 | 0 |
| Avir At Borger | 38.8 mi | ★★★★★ | 17 | 0 |
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