Oroville Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39942 Based on interview, and record review, the facility failed to fully implement their policy for the insertion of a Dobhoff tube (a small, flexible tube with a weighted tip, inserted through the nose into the stomach) for one patient (Patient 1), when nursing staff advanced this tube without waiting for the radiologist’s interpretation of x-ray to determine proper positioning. This failure may have contributed to Patient 1’s development of a pneumothorax (collapsed lung) after three attempts to place the tube which then required a chest tube (a tube placed through the chest wall to re-expand the lung). This caused Patient 1 to experience unnecessary pain and suffering and had the potential to threaten their health and well-being. Findings: The facility’s policy, titled, “Insertion of Tungsten (a type of metal) Weighted Enteral (intestinal) Feeding Tube,” dated 8/1/23, was reviewed. The policy indicated that the procedure may be performed by a Registered Nurse (RN). The responsibilities of the RN included ensuring proper insertion and placement of the tube. The insertion procedure involved placing the patient in an upright sitting position and measuring the length of the tube that would be inserted into the patient from the tip of their nose to their earlobe, and then to their xiphoid process (the pointed tip at the end of the sternum or breastbone). Reference marks on the tube facilitated measuring the length. The nurse was to determine the preferred nostril for insertion and lubricate the tip of the tube. The nurse was to have the patient swallow while the tube was advanced, and unless contraindicated (risk of causing harm), small sips of water may have been given to facilitate swallowing. The nurse should stop if the patient retched (gagged) or obstruction was encountered and never used force. Because the tube was soft, a metal stylet (guidewire) remained inside the tube during insertion. After insertion, the policy instructed the RN to check placement of the tube by auscultation (listening) over the stomach during injection of air using a syringe, aspiration (drawing out with a syringe) of gastric (stomach) contents, and by obtaining an x-ray to verify proper placement. After tube placement the stylet is removed, kept at the bedside, and never reinserted into the tube while it is in the patient. During a secure email communication, on 1/8/26 at 12:56 pm, with the Chief Nursing Officer (CNO), CNO explained the process of obtaining an x-ray for tube placement as stated in the above policy. CNO wrote that the policy directed staff to obtain an x-ray to verify placement, and the radiologist called or notified the staff regarding placement after they have had a chance to read the x-ray. The radiologist was the one who documents the findings, and the nurse had to wait for those findings to be documented in order to proceed with repositioning the tube, or instituting further orders. A review, of Patient 1’s clinical record indicated a medical history that included morbid obesity (overweight), chronic bronchitis (long-term inflammation of the airways), interstitial lung disease (inflammation and scarring of the lung tissue that affected oxygen absorption), hiatal hernia (upper part of the stomach pushed through a weakened diaphragm muscle) and gastroesophageal reflux disease (GERD-when stomach acid flowed back into the esophagus causing symptoms such as heartburn). Patient 1 underwent an elective abdominal surgery performed by Doctor of Osteopathy (DO) A on 5/7/25, recovered in hospital and discharged home on 5/14/25. On 5/15/25, eight days after the surgery, Patient 1 arrived at this facility’s Emergency Department via ambulance due to peritonitis (inflammation of the abdominal cavity), septic shock (life-threatening infection with low blood pressure), and respiratory failure (the lungs could not adequately transfer oxygen to the blood and remove carbon dioxide) related to a bowel leak from the internal surgical incisions. On that same date, Medical Doctor (MD) B performed an emergency surgery on Patient 1 to repair the areas that were leaking. Patient 1 required mechanical ventilation (a life support machine) with tracheostomy (a surgical opening in the neck to the windpipe) placement while recovering, in addition to intravenous (directly into a vein) nutrition and dialysis (treatment for kidney failure), as well as interventions for numerous infections. Patient 1’s health status deteriorated and their family agreed to implementing comfort measures. Patient 1 passed away in the hospital on 6/9/25. A review of a physician’s order placed by DO C, dated 5/31/25 (16 days after the emergency surgery by MD B), at 11:24 am, directed staff to place a Dobhoff tube via Patient 1’s nose. A review, of Patient 1’s Bronchoscopy (procedure to examine the airways and lungs) Procedure Note, dated 5/30/25 (one day before nursing placed the Dobhoff tube) at 8:45 am, by MD H, indicated a description of the procedure. MD H wrote, “The right upper lobe, lower lobe, and middle lobe were examined . . . and did not reveal any significant endobronchial (within the main airways) lesions (damaged tissue). The lower lobe had thick mucus which was removed after suctioning.” A review, of Patient 1’s Nursing Notes, dated 5/31/25 at 4:07 pm, by RN G, indicated a landmark tube length of 57 centimeters (cm -- a unit of measure, or 22 inches). A review, of Patient 1’s Nursing Notes, dated 5/31/25 at 4:15 pm by RN G, read, “X-ray at bedside for KUB (an image of the kidneys, ureters and bladder). Dobhoff not in stomach, reordered KUB after advancing [KUB] to 71 cm” (28 inches). A review, of Patient 1’s Nursing Notes, dated 5/31/25 at 5 pm, indicated, “X-ray at bedside for KUB. Readvanced Dobhoff and did another KUB for placement check. Dobhoff looks suspicious for not being in stomach, notified MD. MD ordered repeat KUB and frontal chest x-ray.” A review, of Patient 1’s Nursing Notes, dated 5/31/25 at 6:30 pm, by RN G, indicated, “KUB result showed Dobhoff in lung, MD aware, removed Dobhoff.” A record review, of three radiology reports related to x-rays taken during attempts to place the tube in Patient 1 on 5/31/25, indicated the documentation of interpretations made by the radiologist DO D. The results were posted between 6:17 pm, and 7:14 pm, on 5/31/25. The first image, obtained at 4:15 pm, indicated that the tube was in Patient 1’s trachea (windpipe) and through the right main bronchus (airway branching off from the trachea toward the lung). It was electronically signed at 6:17 pm, and confirmed reported to nursing staff at 6:23 pm. The second image, obtained at 5:17 pm (62 minutes later), indicated that the tube was in Patient 1’s trachea, through the right main bronchus and into the right lung. It was electronically signed at 7:08 pm. The third image, obtained at 5:26 pm (nine minutes later), indicated that the tube was through Patient 1’s trachea and in a different position in the right lung. It was electronically signed at 7:14 pm, and confirmed reported to nursing staff at 7:16 pm. A review, of an order, dated 5/31/25 at 5:49 pm, by DO C, indicated a KUB to evaluate a pneumothorax. A review, of a written order, dated 5/31/25 at 7:25 pm, by Nurse Practitioner (NP) E, showed a chest x-ray (CXR) for, “R/O (rule out) pneumothorax after multiple Dobhoff tube placement attempts.” A review, of a Nocturnist Hospitalist note, dated 5/31/25 at 10:39 pm, indicated that NP E entered DO D’s radiology report, “Significant Finding: pneumothorax on the right side of 20%. In addition, suspected evidence of parenchymal (functional lung tissue) injury represented by a 2.3 cm diameter area of airspace disease (cloudiness or haziness in the air sacs) in the posterior basal (back, base) segment of the right lower lobe.” A review, of Patient 1’s General Surgery Note, dated 5/31/25 at 8:29 pm, by MD K indicated, “Dobhoff attempted placement three times earlier today, unsuccessful each time. Follow up CXR shows moderate sized R PTX (right pneumothorax).” MD K described it as “iatrogenic” (caused by a medical procedure). MD K surgically placed a chest tube to re-expand Patient 1’s right lung which drained air and fluid from around the lung. During a telephone interview, on 1/7/26, at 2:30 pm, with RN G, RN G confirmed that they had attempted to insert a Dobhoff tube in Patient 1 on 5/31/25. RN G stated two other nurses (unidentified) helped with the tube placement because Patient 1 was not able to lift their head up, or participate. Patient 1 was not able to follow directions, and was not able to swallow. RN G confirmed the initial length of the tube they measured, and documented was 57 cm. When asked what the term “readvanced,” meant in their notes, RN G stated advanced meant moved forward. RN G confirmed they made three total attempts to place the tube. RN G stated they left the stylet inside the tube in place. RN G stated no staff saw the radiologist’s reports that showed the tube was in the trachea, right main stem, and lung while attempting placement, they came later. RN G stated, that they remembered DO C looked at one of the x-rays. During a telephone interview, on 1/7/26, at 2:54 pm, RN G stated that during the attempts to place the Dobhoff tube, the tube was never taken out and reinserted, just advanced. RN G stated they could not hear any air bolus injected, and did not aspirate any stomach contents. Nurses (unidentified) looked at the x-ray, said it was suspicious for not being in the stomach. They had called DO C to look at the image.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 17065 Based on dietetic services document review and dietetic services management interview, the hospital failed to ensure patient menus met the current standard of practice when the non-select patient menu did not meet the Dietary Reference Intakes (DRIs - a set of recommended daily nutrient levels designed to maintain health consisting of the Recommended Dietary Allowance, Adequate Intake, and Estimated Average Requirement) recommended by the Institute of Medicine. Findings: DRIs are scientifically developed, quantitative nutrient reference values for healthy populations in the US and Canada. They are used to plan and assess diets, ensuring adequate intake and reducing disease risk (Institute of Medicine). On 1/29/26 beginning at 3:50 p.m., the hospital presented the menu’s nutritional analysis of the hospital’s most commonly ordered diets. Except for liquid diets, the commonly ordered diets included regular, carbohydrate consistent (CCHO, a diet used to treat diabetes-low, standard and high levels), mechanical soft, cardiac (a diet used to treat heart disease) 4 gram (a metric unit of measure - a sodium-restricted diet), and pureed diets. A random review of the nutritional analysis revealed the regular diet was consistently low on Vitamins D and E. Additionally, the regular diet was low in folate on three of seven days. Review of the low CCHO diet revealed suboptimal values in fiber, magnesium, potassium, Vitamins C, D and E, zinc, and folate. The nutritional adequacy of the diets reviewed ranged from 44 to 81 percent depending on the day and diet. Vitamin D is important in maintaining bones and teeth; Vitamin E helps protect cells from damage and is important in immune function; Vitamin C supports immune function, brain and heart health and helps absorb iron; folate is important in healthy cell growth; magnesium contributes to energy production and nerve and muscle function; potassium maintains the fluid balance in cells, and nerve and muscle function; zinc is essential for immune and skin health and hormone production. During an interview on 1/28/26 beginning at 1:20 p.m., the Director of Nutrition Services (DNS) and Chief Clinical Dietitian (CNM) indicated the hospital goal was for the menus to meet the DRI. They also indicated while they were aware the diets were low in Vitamin D, they had not recently reviewed the full analysis to identify any additional shortcomings. Review of All Facilities Letter 14-32 issued by the California Department of Public Health, dated 12/4/14, indicated the nutritional needs of patients must be met through menu development in accordance with the physician ordered diets. For menus that do not meet the RDA’s, there must be an established system that addresses any nutritional inadequacy of the diet.”

“LEADERSHIP RESPONSIBILITIES CFR(s): Standard: Leadership responsibilities (1) The governing body must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 40358 Based on interview and record review, the governing body failed to ensure the administration had qualified/certified staff in leadership positions for infection control, high-level disinfection areas, and environmental services according to the hospital’s job descriptions and national standards for five sampled staff in leadership positions. These failures resulted in an infection prevention and control program that did not provide a sanitary environment (Refer to A-750). Findings: During an interview on 1/27/26 at 10:15 am, during an interview with the Infection Prevention Registered Nurse (IPRN), she stated she had been in the IP role a “little over a year” and prior to that she was in an interim IP role. The IPRN stated she did not have infection control certification and was not a member of a national infection control organization. The IPRN stated she was registered to take the national certification exam but did not have a test date yet. Requested a copy of the infection control certification application receipt. A review of the job description titled “Director of Employee Health Services/Infection Control/Workers Compensation,” dated 9/2025, indicated, “Professional Certification in Infection Control Foundations (such as STRIVE or a-IPC) within 6 months of hire. Certification in Infection Control Advanced (such as CIC) within 6 months of eligibility.” During an interview with the Director of Perioperative Services (DPS) on 1/27/26 at 10:25 am, he stated the hospital followed AORN and AAMI national standards. During an interview on 1/27/26 at 10:30 am in the perioperative area with the Surgical Services Supervisor (SSS), the SSS stated his role included oversight for the Central Processing Department, but he was not a certified sterile processing technician (SPT). On 1/27/26 at 3:00 pm, the team requested a meeting with the Administrator/Chief Operating Officer (ADM) to review and clarify the plan of correction for infection control. Staff informed the team that the ADM was off campus and unavailable. During an interview on 1/28/26 at 9:28 am in the ADM’s office, the ADM was unable to answer questions about the plan of correction for infection control. The ADM stated the IPRN was “brand new” and not certified, and she was taking the certification exam “soon”. The ADM validated that the IPRN did not meet national standards or the hospital’s own job description requiring infection control certification. During an interview on 1/28/26 at 9:28 am with the Chief Nursing Officer CNO, the CNO stated the hospital followed AAMI national standards and was not aware that standards required the sterilized processing department supervisor be certified. The CNO stated the SSS reported to the DPS, the DPS reported to the CEO, and the IPRN reported to the ADM. Requested a copy of the organization chart for a second time and the ADM’s job description. During an interview on 1/28/26 at 9:50 am in the CNO office with the DPS, the DPS stated he was not aware that AAMI national standards required the sterilized processing department supervisor to be certified. The DPS stated the SSS was not certified for sterilized processing and did not meet the AAMI standards. A review of the document titled “[name of corporation/hospital] organizational chart,” (undated), indicated “ ...Environmental Services, Infection Control, Surgery Services report directly to the Administrator/Chief Operating Officer, who reports to the President/Chief Executive Officer, who reports to the Board of Trustees.” The organizational chart validated interview with CNO. A review of the document titled “Job Description for Chief Operating Officer,” dated 8/2017, indicated “...The Chief Operation Officer provides leadership... to ensure that the organization has the proper operational controls, administrative and reporting procedures, and people systems in place... recruit and retain required members of the management team... Organizational Expectations:... Maintains hospital standards for a clean and quiet patient environment... Adheres to infection-control policies and protocols... Maintains compliance with organization’s policies as well as established practices, protocols, and procedures of the position, department, and applicable professional standards...” During an interview on 1/28/26 at 3:15 pm with Environmental Services Supervisor (EVSS) 2, he stated surgical services staff cleaned the perioperative area, and the EVS department leadership was not involved with perioperative services cleaning and did not provide oversight for the staff who cleaned perioperative services. During an interview on 1/29/26 at 9:10 am with the IPRN, she stated she looked for the certification application receipt and had not received one. The IPRN stated she looked further and had submitted her application to the finance office to pay for the application fee, and they had not followed through until 1/27/26. Requested a copy of the receipt. A review of a document titled “CBIC Certification Center,” dated 1/27/26 (provided 1/29/26 at 4:30 pm), indicated, “My applications” IPRN, “Application Type: CIC... Submitted date 1/27/2026.” During a concurrent interview and record review on 1/29/26 at 11:20 am with the Human Resources Recruiting Coordinator (HRRC), the Director of Education (DOE), the IPRN, and the Learning Management Specialist (LMS), employee files were reviewed. The following concerns with job description requirements, actual qualifications, leadership competencies, and delinquent performance reviews after promotion were identified: -Reviewed SSS’s employee file that indicated a promotion on 2/8/24 into the supervisory role. The most recent completed performance evaluation was dated 2022, prior to promotion to current role. The HRRC stated it was an expectation that all employees have a current annual evaluation on file by 12/31. The HRRC and DOE stated they would expect an evaluation to be completed “after someone is promoted” within a year “to evaluate performance in their new role.” The HRRC validated the performance evaluation was past due. -Reviewed of the job description titled “Surgical Services Supervisor,” dated 7/2019, indicated, “... Reports to Director Perioperative Surgical Services, Job Summary: The Surgical Services Supervisor ...assesses, plans, organizes, directs, and evaluates activities and personnel in the Sterile Processing Department... Assess the knowledge, competency, and performance of Sterile Processing Technicians... Responsibilities: Supervises the Sterile processing, surgical/OR Technologist staff, assists in training, evaluations the performance of staff... Ensures proper care and handling of instrumentation received through decontamination area. Monitors the use of proper techniques through the instrumentation process, preparation and packaging areas, sterilization and Quality Assurance areas... Ensures sterilization activities are properly documented, and participates in the maintenance of department records... Qualifications... Certification in Sterile Processing and Surgical Technology within the first year of the job...”. The HRRC validated that the job requirements for the role were “not met.” Requested leadership training documentation for the SSS. The DOE stated there was no documented formalized training for the leadership position when staff promoted to leadership roles. During a concurrent interview and record review on 1/29/26 at 2:20 pm with the HRRC, the DOE, the IPRN, and the LMS, employee file review continued as follows: -Reviewed the DPS’s employee file that indicated a 2/27/23 promotion date into the Director role. The most recent documented completed performance evaluation was in 2024. - Reviewed the document titled “Job Description for the Director of Perioperative Services,” dated 1/2022, indicated, “Reports to Vice President of Nursing, Job Summary, The Director of Perioperative Services is responsible for planning, organizing, implementing, and evaluating activities of the Operating Room, Central Sterile... Duties... 5. Ensures that staff skills, competencies and educational needs are met. 6. Ensures that infection prevention procedures are utilized to maintain safe and quality care of the surgical patients... 9. Evaluates physical facilities, equipment and supplies to ensure safe nursing care... Requirements... 3. CNOR - Certified Perioperative Nurse preferred at hire, expected within one year of hire...”. The HRRC validated the job requirements for the role were “not met.” The HRRC and DOE confirmed that no formal leadership training was completed for current role. -Reviewed EVSS 2’s employee file that indicated a 4/11/22 hire date and 7/21/23 promotion to the EVSS role. -Reviewed the document titled “Job Description for the Environmental Services Supervisor,” dated 1/2020,which indicated Reports Director Environmental Services Job Summary: Directs and administers the housekeeping program to maintain the hospital environment in a sanitary, attractive, and orderly condition. Duties... Inspects and evaluates the physical condition of the hospital and all outside account areas; recommends painting, repairs, furnishing and refurnishing, relocation of equipment, and reallocation of space to improve sanitation, appearance, and efficiency... Is responsible for maintaining the records of the Environmental Services Department...Qualifications:... Minimum of 5 years’ experience in a hospital setting and knowledge of basic cleaning procedures... Organizational Expectations:... Adheres to infection-control policies and procedures. Maintains compliance with organization’s polices, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards...”. The HRRC could not validate that EVSS 2 met the qualifications for “five years of experience in a hospital setting” for the current role. Review of the document titled “Job Description for Chief Operating Officer,” dated 8/2017, indicated, “Reports to Chief Executive Officer/President... Duties:... Provide mentoring and guidance. Responsible for the measurement and effectiveness of all processes internal and external... Foster a success-oriented, accountable environment within the organization... Organizational Expectations:... Promotes culture of safety for patients and employees... Maintains hospital standards for a clean and quiet patient environment... Adheres to infection-control policies and procedures... Maintains compliance with organization’s policies, as well as established practices, protocols and procedures of the position, department, and applicable professional standards... Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements.” During an interview on 1/30/26 at 9:17 am with the Corporate Compliance Officer (CCO) and the CNO, the CCO stated they relied on managers to ensure daily tasks are completed and job descriptions followed. The CCO stated the hospital did not have a proactive plan in place for leadership development or any supervisor development programs or anything in place when there was a lapse in leadership. During a phone interview on 1/30/26 at 9:46 am with the Director of Human Resources (DHR), the DHR stated the annual evaluations were due by 12/31 each year, and when an employee was in a new role, a 90-day or six-month probationary evaluation was done. The DHR was not aware that the SSS had not had a documented evaluation since 2022. The DHR stated that this delayed evaluation “should not take place.” The DHR stated that if there was a job description requirement with a timeline, the requirement must be completed by the timeline. The DHR was not aware the SSS and DPS did not meet the job requirements. During an interview and record review on 1/30/26 at 11:07 am with the CNO, hospital and surgical services organization charts were reviewed. The CNO validated the DPS and surgery service reported to the ADM. The CNO also reported there was a dotted line connecting the DPS to her. The CNO stated she was aware the IPRN was not certified according to the hospital’s job descriptions but was not aware the DPS and SSS were not certified for their roles and in compliance with their job descriptions and national standards. A review of ANSI/AAMI “ST79: 2017 - Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities” indicated, “4.2 Qualifications, 4.2.1 Supervisory personnel: All preparation and sterilization activities, including decontamination, inspection, preparation, packaging, sterilization, storage, and distribution, should be supervised by competent, qualified personnel. Personnel assigned to supervisory functions should be prepared for this responsibility by education, training, and experience. Minimum recommended qualifications include a) successful completion of a sterile processing management certification examination...” 49418 Review of the Joint Commission (an independent organization that sets standards for quality improvement and patient safety in healthcare) website titled “National Performance Goal #5: Preventing and Controlling Infection,” dated 2026, indicated infection prevention and control practices focused on (a) annual infection risk assessment, to include identifying and prioritizing risks for infection, contamination, and exposure risks to patients and staff and (b) preparedness for infectious diseases. The site indicated protocols must address ensuring training and competencies for staff. During an interview with the ADM on 1/29/26 at 11:05 am, ADM stated the DPO was currently acting as the interim Director of Environmental Services (EVS). ADM stated the DPO was responsible for the Environmental Services “crew,” who were to maintain a clean and sanitary environment. ADM stated the IPRN was the head of the Infection Control Program, adding, “but we all have a responsibility for infection control.” ADM stated Directors and Managers should be doing Environment of Care (EOC) rounds (visual inspections to identify safety hazards and infection control issues) with their staff and added, “Ultimately, I’m responsible” for the cleanliness of the facility.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a plan that failed to address the patient population and the types of services the facility would provide during an emergency. This affected 106 of 106 patients and could result in a delayed response to an emergency. Findings: During record review and interview with Staff, the emergency preparedness plan was reviewed. On 8/26/25 at 9:46 a.m., the facility’s EPP failed to address the patient population and the type of services the facility has the ability to provide in an emergency. Upon interview, Staff 4 acknowledged that patient population and the type of services the facility has the ability to provide were not in the EPP.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a plan that failed to include a system to track staff and patients during an emergency. This affected 106 of 106 patients and could result in an ineffective emergency preparedness plan for tracking patients and staff during an emergency evacuation. Findings: During record review and interview with Staff, the emergency preparedness plan was reviewed. On 8/26/25 at 10:17 a.m., the facility’s emergency plan failed to include a system to track the location of on-duty staff and patients in the event they are relocated during an emergency. Upon interview, Staff 4 acknowledged that they did not have a policy or procedure for staff and patient tracking during an emergency.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the ceilings and walls. This affected three of 26 smoke compartments and could result in the spread of smoke in the event of a fire. Findings: During a tour of the facility and interview with Staff, the walls and ceilings were observed. 1. On 8/25/25 at 10:28 a.m., an approximately two-inch round penetration was observed in the ceiling of the soft water closet, on the exterior of the building near the Lab. A white plastic pipe was running through the penetration into the attic. Upon interview, Staff 2 acknowledged the penetration. 46858 2. On 8/25/25 at 1:50 p.m., a penetration was observed on the west wall of the Storage Room by the Nurse Station in the Unit 6 Nurse Station. The wall penetration measured approximately two by six inches. During a concurrent interview, Staff 3 confirmed the finding and stated that the penetration was likely created by the doorknob colliding with the adjacent wall when being opened. 3. On 8/25/25 at 3:21 p.m., two ceiling penetrations were observed along the northwest and southeast ends of the Phone Room in the Lobby/Registration Area. The northwest penetration measured approximately seven by seven inches and contained black tubing and a water line. The southeast penetration measured approximately three by eight inches and contained electrical conduit. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure how the penetrations were created.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by minimized egress corridors. This could result in a delay of egress in the event of an evacuation. This affected one of 26 smoke compartments. NFPA 101: Life Safety Code, 2012 Edition 19.2.3.4 * Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width Findings: During a tour of the facility and interview with the staff, the egress corridors were observed. On 8/25/25 at 1:19 p.m., the 8 feet egress corridor outside of the Respiratory Therapy Room in the Emergency Unit was observed minimized by approximately five wheelchairs and three waiting room chairs. The corridor was observed to be minimized down to approximately 36 inches. During a concurrent interview, Staff 3 confirmed the finding and stated the according corridor was only used by visitors and patients after 8 p.m.. Staff 3 stated the corridor was used as storage when it was not in use.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the emergency lighting system. This was evidenced by operating rooms missing emergency lighting. This could result in a delay in egress in the event of a power outage. This affected one of 26 smoke compartments. NFPA 101: Life Safety Code, 2012 Edition 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 7.9.2.3 * The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities 7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NEC 70: National Electrical Code, 2011 edition 517.63 Grounded Power Systems in Anesthetizing Locations. 517.63(A) Battery-Powered Lighting Units. One or more battery-powered lighting units shall be provided and shall be permitted to be wired to the critical lighting circuit in the area and connected ahead of any local switches. Findings: During a tour of the facility and interview with the staff, the emergency lighting system was observed. 1. On 8/26/25 at 9:11 a.m., the procedure room labeled “Endo 1” in the ambulatory care unit was observed missing battery-back up emergency lighting. During a concurrent interview, Staff 1 confirmed the finding and stated that he was unsure if the primary lighting system in the operating room was connected to the facility’s emergency power supply system. 2. On 8/26/25 at 9:13 a.m., the procedure room labeled “Endo 2” in the ambulatory care unit was observed missing battery-back up emergency lighting. During a concurrent interview, Staff 1 confirmed the finding and stated he was not sure if the primary lighting system in the operating room was connected to the facility’s emergency power supply system.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by a self-closing door to a hazardous area that failed to latch. This could result in the passage of smoke and fire in the event of a fire originating from a hazardous area. This affected one of 26 smoke compartments. Findings: During a tour of the facility and interview with staff, the facility’s hazardous area enclosures were observed. On 8/25/25 at 11:55 a.m., the door to the Oxygen Storage Closet in the Emergency Room Unit failed to latch when tested for closure. Storage closet was observed storing approximately 15 full E tanks and ice machine components. The door was tested for closure approximately three times. The door was observed missing latching hardware. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure why the door was missing latching hardware.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to mark the batteries in the fire alarm control panel cabinet with the date of manufacture. This affected 26 of 26 smoke compartments and could result in the batteries not being replaced at required intervals. NFPA 101: Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition 10.5.9 * Storage Batteries. 10.5.9.1 Marking. 10.5.9.1.1 Batteries shall be marked with the month and year of manufacture using the month/year format. 10.5.9.1.2 Where the battery is not marked with the month/year by the manufacturer, the installer shall obtain the date-code and mark the battery with the month/year of battery manufacture. Findings: During a tour of the facility and interview with the Staff, the fire alarm system was observed. On 8/25/25 at 10:12 a.m., the two sealed lead acid batteries in the fire alarm control unit cabinet were observed. Both batteries were missing a date of manufacture marking. Upon interview, Staff 2 acknowledged that the manufacture date was missing on the batteries.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing signage for the post indicator valve (PIV) and fire department connections (FDC). This affected 26 of 26 smoke compartments and could result in delay and confusion of identifying the fire sprinkler valve and FDC that serves the facility. NFPA 101: Life Safety Code, 2012 Edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 6.7.4 * Identification of Valves. 6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means. 6.7.4.3 The control valve sign shall identify the portion of the building served. 8.17.2.4.5 Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served. Findings: During a tour of the facility and interview with Staff, the fire sprinkler system was observed. 1. On 8/25/25 at 10:20 a.m., the FDC near the main entrance was observed. The FDC was missing a sign identifying which portion of the building it served. Upon interview, Staff 2 acknowledged that the FDC was missing identification signage. 2. On 8/25/25 at 10:21 a.m., the PIV for the original portion of the hospital was observed missing an identification sign. The PIV was located near the main entrance to the building and was missing a sign that indicated which portion of the building it served. Upon interview, Staff 2 acknowledged that the PIV was missing an identification sign. 3. On 8/25/25 at 10:32 a.m., the Fire Department Connection on the East side of the building near Radiology was observed. The Fire Department Connection was missing a sign identifying which portion of the building it served. Upon interview, Staff 2 acknowledged that the FDC was missing identification signage.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to maintain the sprinkler system components. This could result in a malfunction of the automatic sprinkler system in the event of a fire. This affected three of 26 smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13, Standard for the Installation of Sprinkler System, 2010 Edition 8.6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). 8.6.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition 5.2.1.1.1 * Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer Findings: During a tour of the facility and interview with the staff, the sprinkler system components were observed. 1. On 8/25/25 at 10:25 a.m., one of 12 sidewall fire sprinklers protecting the overhang outside the main entrance on the exterior of the building was observed with green corrosion on the deflector and rivet. Upon interview, Staff 2 acknowledged that the sprinkler deflector was corroded. 2. On 8/25/25 at 11:28 a.m., one of four sprinklers protecting the Lab in the Hematology Department was observed with dust debris along the body and deflector. During a concurrent interview, Staff 3 confirmed the finding and stated that the airflow created by the medical equipment in the Lab likely caused the sprinkler to be covered in debris. 3. On 8/25/25 at 1:11 p.m., one of two sprinklers protecting Room 3H in the Emergency Department was observed with dust and cobweb debris along the body and deflector. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unaware of the condition of the sprinkler. 4. On 8/25/25 at 1:52 p.m., the sprinkler protecting the Clean Linen Closet by Room 602 was observed obstructed by approximately six blankets and two pillows. The blankets and pillows were observed being stored approximately nine inches away from the sprinkler pendant. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure how long the items had been stored in that position.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by obstructed and non-latching corridor doors. This can increase the passage of smoke through smoke compartments. This affected six of 26 smoke compartments. Findings: During a tour of the facility and interview with the staff, the corridor doors were observed. 1. On 8/25/25 at 10:42 a.m., the corridor door to the Delivery Room at the end of the corridor of the Obstetrics Unit was observed with a self-closing mechanism. The corridor door was observed obstructed from closure by a metal stool. The stool was observed at the base of the door, obstructing it from closure. During a concurrent interview, Staff 3 confirmed the finding and stated that the stool was likely placed in that location when the patient’s bed was being moved. 2. On 8/25/25 at 10:47 a.m., the corridor door to the Staff Room by the Front Nurse Station in the Obstetrics Unit was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door was tested for closure approximately two times. During a concurrent interview, Staff 3 confirmed the finding and stated that the door’s unadjusted self-closing mechanism likely prevented the door from fully latching. 3. On 8/25/25 at 11:34 a.m., the corridor door to the Lab Registration Room in the Laboratory Unit was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door’s latching hardware was observed covered with tape, preventing it from extending. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure how the tape appeared on the latching hardware. 4. On 8/25/25 at 11:38 a.m., the corridor door to the Specimen Processing Room in the Laboratory Unit was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door’s latching hardware was observed covered with tape, preventing it from extending. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure how the tape appeared on the latching hardware. 5. On 8/25/25 at 1:16 p.m., the corridor door to Room 4I in the Emergency Care Unit failed to latch when tested for closure. The door’s latching hardware was observed failing to fully extend, preventing it from closure. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unaware of the condition of the latching hardware. 6. On 8/25/25 at 1:42 p.m., the corridor door to the Cafeteria was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door was tested for closure approximately two times. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure why the door had failed to latch. 7. On 8/25/25 at 2:49 p.m., the corridor door to the Dark Room in the Ambulatory Care Unit was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door handle was observed damaged, preventing the latching hardware to actuate. During a concurrent interview, Staff 3 confirmed the finding and stated that he would need Maintenance Staff to inspect the door handle.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke and fire in the event of a fire. This affected three of 26 smoke compartments. NAPA 101, Life Safety Code, 2012 Edition 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac). (B) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. 8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. Findings: During a tour of the facility and interview with the staff, the smoke barrier walls were observed. 1. On 8/26/25 at 9:47 a.m., the smoke barrier wall above the cross-corridor doors labeled “4-22” and “4-23” was observed with a penetration. The penetration measured approximately two by two inches and contained low voltage cable running through it. During a concurrent interview, Staff 3 confirmed the finding and stated that the penetration should have been sealed. 2. On 8/26/25 at 10:20 a.m., the smoke barrier wall above the cross-corridor doors labeled “26-11” was observed with a penetration. The penetration measured approximately three inches in diameter and contained low voltage cable running through it. During a concurrent interview, Staff 3 confirmed the finding and stated that Maintenance Staff were in the process of sealing all penetrations. 3. On 8/26/25 at 10:28 a.m., the smoke barrier wall above the cross-corridor doors by the Cafeteria’s Serving Area was observed with a penetration. The penetration measured approximately an inch and a half in diameter and contained low voltage cable and metal conduit running through it. During a concurrent interview, Staff 3 confirmed the finding and stated that Maintenance Staff were in the process of sealing all penetrations.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the elevators. This was evidenced by missing monthly testing documentation. This affected 26 of 26 smoke compartments and could result in the malfunction of the elevators. Findings: During record review and interview with staff, the elevators maintenance records requested. On 8/25/25 at 1:51 p.m., the written records of monthly Firefighter’s Service tests for elevators one and two were reviewed. The firefighter Service was not tested for the months of June and July 2025. Upon interview, Staff 1 stated that their elevator vendor conducts those monthly tests.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 43380 Based on record review, and interview the facility failed to vary the times they conducted fire drills on each shift. This was evidenced by fire drills that were conducted at the same time on each shift. This affected 26 of 26 smoke compartments and could result in staff being untrained and unaware of their roles and responsibilities in the event of a fire. NFPA 101, Life Safety Code 2012 Edition 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Findings: During record review and interview with Staff, the fire drill records were reviewed. On 8/25/25 at 10:51 a.m., the facility’s fire drill records were reviewed. The fire drill records indicated four of four AM shift fire drills and four of four PM shift fire drills were conducted at the same time during the last four quarters. The AM shift drills on 7/31/24, 10/30/24, 1/28/25, and 4/30/25 were conducted at 1300 hours. The PM shift fire drills on 8/29/24, 11/27/24, 2/27/25, and 5/28/25 were conducted at 1730 hours. Upon interview Staff 1 and Staff 2 acknowledged that the fire drills were not varied throughout the AM and PM shifts.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the medical gas and vacuum system. This was evidenced by the failure to provide a documented maintenance program. This affected the 26 of 26 smoke compartments and could result in the failure of the medical gas and vacuum system. Findings: During record review, and interview with staff, the facility’s medical gas and vacuum system maintenance records were requested. On 8/25/25 at 1:45 p.m., the facility failed to provide a documented maintenance program that included an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets and a maintenance schedule that was established through a risk assessment considering manufacturer recommendations. The facility provided certificates for five Engineering Staff members that indicated they were certified to maintain the medical gas and vacuum system per AASE 6040 requirements. Upon interview, Staff 2 stated that they document when the system was repaired but don’t have a maintenance program or schedule based on a risk assessment.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the oxygen supply system. This was evidenced by unlabeled oxygen supply valves. This affected one of 26 smoke compartments. NFPA 99: Health Care Facilities Code, 2012 Edition 5.1.3.1.9 Locations containing central supply systems or cylinders containing only oxygen or medical air shall have their door(s) labeled as follows: Medical Gases NO Smoking or Open Flame 5.1.11.2 Shutoff Valves. 5.1.11.2.1 Shutoff valves shall be identified with the following: (1) Name or chemical symbol for the specific medical gas or vacuum system (2) Room or areas served (3) Caution to not close or open the valve except in emergency Findings: During a tour of the facility and interview with the staff, the oxygen supply system was observed. On 8/25/25 at 10:36 a.m., the oxygen supply valve on the corridor wall by the Front Nurse Station in the Obstetrics Unit was observed missing labeling to identify what rooms the valves service. During a concurrent interview, Staff 3 confirmed the finding and stated he was unaware the valves were not identified.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 46858 Based on document review and interview, the facility failed to maintain the electrical system components. This was evidenced by the failure to provide a wet procedure risk assessment. This could result in an electrical fire. This affected one of 26 smoke compartments. Findings: During document review, and interview with staff, the facility’s electrical system components were observed, and maintenance records were requested. On 8/26/25 at 2:30 p.m., the facility failed to provide documentation to show the Operating Rooms in the Ambulatory Care Unit were deemed a wet procedure or not a wet location. There was not sufficient evidence to show the two operating rooms were protected by ground-fault circuit interrupters or an isolated power supply system. During a concurrent interview, Staff 1 stated that Staff only conducted endoscopic procedures in the operating rooms. Staff 4 stated that the facility used monitored sedated anesthesia care when operating. Staff 4 stated they would search for a risk assessment to show the operating rooms were not considered wet-procedure locations. The facility was given until 10 a.m. on 8/27/25 to submit the according risk assessment record. No risk assessment record was received.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the line isolation monitor (LIM) electrical system. This was evidenced by the failure to provide testing records. This affected Operating Rooms one through four and could result in the malfunction of the LIM system. Findings: During a tour of the facility, record review, and interview with staff, the facility’s LIM system was observed, and maintenance records were requested. On 8/25/25 at 3:12 p.m., the facility was observed with a LIM outside of each of the four Operating Rooms. The facility failed to provide records that the LIM systems were tested by actuating the LIM test switch, which activates both visual and audible alarm at intervals of less than or equal to 1 month. Upon interview Staff 2 acknowledged that they were not testing the LIM systems for Operating Rooms one through four.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 43380 Based on observation, record review, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by missing records of monthly battery testing on the sealed lead acid generator batteries. This affected 26 of 26 smoke compartments and could result in a loss of power due to a generator malfunction during an emergency power outage. NFPA 99, Health Care Facilities Code, 2012 Edition. 6.4 Essential Electrical System Requirements - Type 1. 6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition. 8.1* General. 8.1.1 The routine maintenance and operational testing program shall be based on all of the following: (1) Manufacturer’s recommendations (2) Instruction manuals (3) Minimum requirements of this chapter (4) The authority having jurisdiction 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8.3.4.1 The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. Findings: During a tour of the facility, record review, and interview with staff, the EPSS was observed, and records were reviewed. 1. On 8/25/25 at 11:52 a.m., testing records for the facility’s 500-kilowatt diesel fueled back-up generator were requested. The facility failed to provide 12 of 12 battery conductance testing records for the generator’s sealed lead acid batteries. Upon interview, Staff 2 acknowledged that they were not testing the generator batteries for conductance. 2. On 8/25/25 at 1:19 p.m., testing records for the facility’s 230-kilowatt diesel fueled back-up generator were requested. The facility failed to provide 12 of 12 battery conductance testing records for the generator’s sealed lead acid batteries. Upon interview, Staff 2 acknowledged that they were not testing the generator batteries for conductance.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by exposed opening in an electrical panels and missing identifications. This could result in an electrical fire. This affected four of 26 smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.5.1.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, National Electrical Code, 2011 Edition 408.4 Field Identification Required. 408.4(A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. 408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure. Findings: During a tour of the facility and interview with the staff, the electrical equipment was observed. 1. On 8/25/25 at 11:11 a.m., the electrical panel along the south wall of the Med Surge Area in Unit 1 was observed with an exposed opening in one of the breaker space. The breaker space 27 was observed missing a spare cap. During a concurrent interview, Staff 3 confirmed the finding and stated he was not aware the panel contained an exposed opening. 2. On 8/25/25 at 1:57 p.m., the electrical panel labeled “Panel A” by the Janitorial Closet in the Lobby/Registration Area was observed with exposed openings in two of the breaker spaces. The breaker spaces 16 and 42 were observed missing spare caps. During a concurrent interview, Staff 3 confirmed the finding and stated he was not aware the panel contained exposed openings. 3. On 8/25/25 at 2:38 p.m., the electrical panel labeled “L2A Section 1” by Room 206 in Unit 2 was observed with an exposed opening in one of the breaker space. The breaker space 20 was observed missing a spare cap. During a concurrent interview, Staff 3 confirmed the finding and stated the Maintenance Staff were in the process of covering exposed openings throughout the facility. 4. On 8/25/25 at 3:10 p.m., the Line Isolation Monitor for Operating Room 1 was observed with eight sets of electrical breakers and a main electrical breaker rated for 60 amperes. The only electrical breaker that was identified was breaker 3. None of the rest of the breakers were identified. Upon interview, Staff 1 acknowledged that the breakers were not identified. 5. On 8/25/25 at 3:11 p.m., the Line Isolation Monitor for Operating Room 2 was observed with eight sets of electrical breakers and a main electrical breaker rated for 60 amperes. None of the breakers were identified. Upon interview, Staff 1 acknowledged that the breakers were not identified.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of extension cords and by daisy chained and suspended power strips. This could result in an electrical fire. This affected four of 26 smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, National Electrical Code, 2011 Edition 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable. 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals. Findings: During a tour of the facility and interview with the staff, the electrical equipment was observed. 1. On 8/25/25 at 10:16 a.m., a yellow extension cord was observed extending from the northwest to northeast wall of Lower-Level Social Services Office. The extension cord was observed powering computer components. During a concurrent interview, Staff 3 confirmed the finding and stated he was unsure how long the extension cord had been in use. 2. On 8/25/25 at 10:22 a.m., a power strip was observed suspended and daisy chained to an extension cord along the southwest wall of the Lower-Level Linen Room. The power strip was observed suspended approximately 36 inches from the floor on a chain-linked fence. The power strip was observed powering a temperature control system component. During a concurrent interview, Staff 3 confirmed the finding and stated he was unaware the extension cord was being used. 3. On 8/25/25 at 11 a.m., a red extension cord was observed connected to a power strip along the south wall of the Nursing Director’s Office. The extension cord was observed powering printer components. During a concurrent interview, Staff 3 confirmed the finding and stated he was unaware the extension cord was being used. 4. On 8/25/25 at 2:32 p.m., a power strip connected to the southwest wall of the Unit 2 Break Room was observed suspended under a table. The power strip was observed suspended approximately six inches above the floor. The power strip was observed powering coffee maker and microwave components. During a concurrent interview, Staff 3 confirmed the finding and stated that he was not aware the power strip was in a suspended position. 5. On 8/25/25 at 3:21 p.m., a power strip was observed suspended in the Dictation Room across the Emergency Unit Break Room. The power strip was observed suspended approximately four inches from the floor and powering computer components. During a concurrent interview, Staff 3 confirmed the finding and stated that the power strip should not have been in that position.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the oxygen supply system. This was evidenced by unlabeled oxygen storage rooms/doors. This affected three of 26 smoke compartments. Findings: During a tour of the facility and interview with the staff, the oxygen rooms/doors were observed. 1. On 8/25/25 at 11:53 a.m., the Oxygen Storage Closet in the Emergency Room Unit was observed without labels to identify it as an oxygen storage room/door. The closet was observed storing approximately 15 full oxygen E tanks. During a concurrent interview, Staff 3 confirmed the finding and stated that he was unsure why the room was not labeled. 2. On 8/25/25 at 2:44 p.m., the Medication and Ice Machine Room near Room 810 was observed without labels to identify it as an oxygen storage room/door. The room was observed storing approximately three empty oxygen E tanks. During a concurrent interview, Staff 3 confirmed the finding and stated that the room should have been identified as an oxygen storage area. 3. On 8/26/25 at 9:15 a.m., the Oxygen Storage Room in the Ambulatory Care Unit by the Nurse Station was observed without labels to identify it as an oxygen storage room/door. The room was observed storing approximately eight full oxygen E tanks. During a concurrent interview, Staff 3 confirmed the finding and stated that they had just noticed the lack of signage.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 51253 The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.23 Nursing Care Services as evidenced by the following: 1. Based on interview and record review, the acute care facility failed to address the severe pain and repeated nausea/vomiting for one of 33 sampled patients (Patient 18) during the night shift on 8/6/25 - 8/7/25. This failure resulted in the severe pain and repeated nausea/vomiting of one patient. (Refer to A-396) 2. Based on observation, interview and hospital document review the hospital failed to ensure all patient care related activities were delivered by licensed or certified nursing staff when housekeeping staff assumed the responsibility of meal delivery to one patient (Patient 29) who was in an isolation room. (Refer to A-0397) 3. Based on observation, interview and record review, the hospital failed; 1. to ensure duplicate as-needed orders were clarified with the physician and IV (intravenous, administered into the vein) heparin (a medication that reduces the blood’s ability to clot and prevent new clot formation or the enlargement of existing clots) was administered in accordance with hospital protocol. (Refer to A-0405, finding 1) 2. to document an open date on a container of blood-glucose test strips for one of 33 sampled patients (Patient 12). (Refer to A-0405, finding 2) 3. to remove the opened sterile water (water that has been purified and is free from microbial contamination) container per the manufacturer’s guidelines on one of 33 sampled patients (Patient 12). (Refer to A-0405, finding 3) These failures had the potential for patients to receive unnecessary medication, inadequate treatment, or the use of expired blood glucose test strips leading to exposure to unwanted side effects, worsening of their medical conditions, resulting potential for incorrect results for blood glucose levels, and for the potential use of contaminate the sterile water used for Patient 12’s tracheostomy (opening in the neck and windpipe to allow a tube to be inserted to provide breathing support) care. Contamination has the potential to introduce infection into Patient 12’s lungs The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in compliance with the Condition of Participation for Nursing Services.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 49418 Based on observation, interview, and record review, the hospital failed to ensure that the Conditions of Participation for Physical Environment were met when they failed to maintain a sanitary and safe environment throughout the hospital as evidenced by: 1. The Level 1 bathroom (BR 1) nearest the entrance to Unit 1 was in general disrepair (Refer to A-0701, Finding 1). 2. Facility door frames were gouged and damaged with missing paint, and walls beneath hand sanitizer dispensers showed bubbling paint (Refer to A-0701, Finding 2). 3. The Unit 6 Shower Room (SR 6) was “out of order,” with the shower head capped and unavailable for patient use for 77 days (Refer to A-0701, Finding 3). 4. Food and Nutrition Services Department (FNSD) walls and trim throughout the kitchen had holes and damaged or missing paint, rendering them uncleanable (Refer to A-0701, Finding 4). 5. FNSD equipment was not well-maintained (Refer to A-0701, Finding 5). 6. Three out of seven observed ice machines were not clean, chemicals used did not meet manufacturer’s specifications, and air gaps were not in place to meet regulatory requirements. (Refer to A-0701, Finding 6). 7. FNSD flooring was damaged, and covering was separated from the wall (Refer to A-0701, Finding 7). 8. Nursing unit food pantry counters were damaged and uncleanable. Three of six pantry refrigerators had cracked gaskets. The air gap for the ice machine on Unit 1 did not meet regulatory requirements (Refer to A-0701, Finding 8). Conclusion: The cumulative effects of these systemic problems resulted in the facility’s inability to ensure the Conditions of Participation for Physical Environment were met.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 49418 Based on observation, interview, and record review, the hospital failed to ensure an effective, active, system-wide infection control program as evidenced by: 1. The Governing Body appointed a Director of Infection Prevention (DIP) who lacked the required certifications specified in the facility’s job description for the position (Refer to A-0748.) 2. Failure to follow the facility’s Water Management Plan (WMP) policy to inhibit growth of Legionella (bacteria that causes severe pneumonia) and other waterborne pathogens (microorganisms in water that cause harmful effects) in the water system (Refer to A-0750, Finding 1.) 3. Seven of 10 employee files had missing or incomplete immunization documentation (Refer to A-0750, Finding 2). 4. The facility failed to maintain sufficient infection control processes and surveillance to ensure a clean and sanitary environment, prevent potential sources and transmission of infections, and reduce the risk of food- and waterborne illness when: A. The facility’s nursing unit food pantries were not clean (Refer to A-0750, Finding 3). B. Bathroom (BR) 1 was in disrepair and was not clean (Refer to A-0750, Finding 4). C. Upper- and lower-level stairway doors (SD) had dark discolorations at hand and foot levels that appeared to be smudged hand- and footprints (Refer to A-0750, Finding 5). D. The stove hood was not clean and was dripping with grease, a sanitation issue and potential fire hazard (Refer to A-0750, Finding 6). E. The kitchen was not maintained by the Plant Operations Department in a manner that met professional standards of practice to ensure food safety and sanitation in a hospital kitchen (Refer to A-0750, Finding 7). F. Kitchen sanitation tasks assigned and budgeted to the Environmental Services Department were not regularly completed in a manner that met professional standards of practice to ensure food safety and sanitation in a hospital kitchen (Refer to A-0750, Finding 8). G. Kitchen work areas and food production equipment were not clean (Refer to A-0750, Finding 9). H. Food was not stored in a sanitary manner (Refer to A-0750, Finding 10). I. Nutrition Services staff did not follow professional standards of practice to minimize the risk of cross-contamination (unintentional transfer of microorganisms with harmful effect) in the kitchen (Refer to A-0750, Finding 11). J. Nutrition Services staff and Environmental Services staff did not follow manufacturers’ instructions for cleaning fixed equipment (equipment that cannot be put through a dishwasher or 3-compartment sink such as counters, cabinets, carts, small appliances) (Refer to A-0750, Finding 12). K. Nursing staff did not follow professional standards of practice for use of Personal Protective Equipment (PPE) when delivering meals to patients (Refer to A-0750, Finding 13). L. Nutrition Services staff did not follow professional standards of practice to monitor and document ambient food cooling (Refer to A-0750, Finding 14). M. The facility’s ice machines were not clean (Refer to A-0750, Finding 15). N. The cafeteria beverage dispensing machine tubing was not routinely flushed to prevent microbial growth (Refer to A-0750, Finding 16). O. The breast milk refrigerator in the Obstetrics Department was not certified by the National Sanitation Foundation (NSF), and staff did not use food-safe chemicals to clean bins that separated and stored patient’s breast milk (Refer to A-0750, Finding 17). Conclusion: The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure an effective system-wide infection control program that provided a safe environment free of transmission sources of infection and communicable disease to be in compliance with the Condition of Participation for Infection Control.”

“MEDICAL STAFF RESPONSIBILITIES - UPDATE CFR(s): 482.22(c)(5) [The bylaws must:] [Include a requirement that --] (ii) An updated examination of the patient, including any changes in the patient’s condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration, and except as provided under paragraph (c)(5)(iii) of this section. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 27519 Based on Interview and record review the facility failed to ensure that the current Medical Staff By-Laws included the requirement that an updated patient examination was documented in the in the patient’s medical record within 24 hours but, before surgery when the History and Physical examination was completed within 30 days of admission. This failure had the potential for the medical team to be unaware of new or recent changes in the health condition of the patient prior to having a surgical procedure which could result in poor quality of care and/or a poor outcome for the patient. Findings: During a review of the facility’s Medical Staff By-Laws dated 7/29/25, it was found that there was no provision requiring a physician or qualified licensed practitioner to document an update to a physical examination in a patient’s medical record within 24 hours or prior to a surgical procedure when a History and Physical examination (a physician’s assessment of a resident that contains information about a patient’s medical history and exam findings at the time of admission to the facility) had been completed within the previous 30 days. During an interview on 8/12/25 at 9:40 AM, the Director of Medical Staff stated that the language for the updated examination was not carried forward from the previous version of the Medical Staff By-laws. She indicated that this omission was an error due to the revised statement not being included.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51253 Based on interview and record review, the acute care facility failed to address the severe pain and repeated nausea/vomiting for one of 33 sampled patients (Patient 18) during the night shift on 8/6/25 - 8/7/25. This failure resulted in the severe pain and repeated nausea/vomiting of one patient. A record review of Emergency Room (ER) Nurse Note on 8/6/25 at 1:06 pm, signed by Registered Nurse (RN) Q, indicated Patient 18, a 17 year old male, presented to the Emergency Room (ER) on 8/6/25 at 12:57 pm. Patient 18 presented with lower abdominal (stomach) pain for the past three days. He went to a clinic and was diagnosed with constipation (unable to have a bowel movement). He was instructed to go to the ER. Initial vital signs showed a heart rate of 52 (beats per minute) and bilateral lower quadrant (BLQ) abdominal pain 8/10 (severe pain). A record review of policy titled, “Pain Management” with a Review Date of 8/2023 indicated that the “Pain intensity scale will be zero to ten. Ten being the worst pain and zero being no pain. The A-B-C-D-E approach to managing pain will be used. A- Ask about pain every four hours. Assess pain systematically. Reassess. B- Believe that patient and family in their reports of pain and what relieves it. C- Choose pain control options appropriate for the patient, family, and setting. D- Deliver interventions in a timely, logical, and coordinated fashion. E- Empower patients and their families. Enable patients to control their court to the greatest extent possible. -Pain assessments should be documented in the Electronic Health Record (EMR) every four hours. Reassessments of pain need to be timely and performed in a manner that is comprehensive and appropriate to the circumstances to ensure safety and efficacy. -If the pain medication is not adequate call the physician. If the physician does not respond, call the (Chief of Hospital Operations) CHO or the Nurse Manager.” A record review of policy titled, “Standards of Care for Medical Surgical Units” with a Review Date of 8/2023 indicated, “Initiate appropriate assessments and interventions to support patient needs. Consider: Pain ... Assess the patient’s pain/discomfort status at least every four hours and as needed (PRN).” This policy also indicated, “Standard of care is for comfort: The patient will have minimized pain/discomfort. Evaluate the effectiveness of the intervention every shift and notify the physician if ordered medications are ineffective. Revise plan of care.” A record review on 8/6/25 at 9:44 pm of Plan of Care Order Details signed by Medical Doctor (MD) F, the plan of care was “To assess patient vitals and for the presence of clinical pain.” Plan Orders also indicated, “to assess for potential anxiety or pain. Notify provider of abnormal assessment.” A record review of PT 18’s initial ER Laboratory results dated 8/6/25 at 5:27 pm, indicated the following: -Potassium at 3.1 mmol/L (Normal range is 3.4 - 5.1) millimole per liter (A vital mineral and electrolyte that plays a crucial role in various bodily functions. It helps maintain proper nerve and muscle function, regulates heartbeat, and aids in the movement of nutrients into and out of cells) This is a very sensitive electrolyte and even if slightly too high or too low out of range, it will affect the heart rhythm. -White Blood Cell Count (WBC) at 15.1 K/uL - thousands per microliter. Normal range is 3.8 - 10.6)) This level indicated an infection. -CPK at 926 U/L - Units per liter (Normal range is 43 - 310) This indicated measures the amount of this enzyme in your blood to check for muscle, heart, or brain damage or injury. -AST at 61 U/L (Normal range is <59) This is a liver enzyme, and when elevated, it indicated a problem with the liver. -ALT at 34 (Normal range is <34) This is a liver enzyme, and when elevated, it indicated a problem with the liver. A record review of PT 18’s computed tomography (CT- uses a series of X-ray images and a computer to create detailed cross-sectional pictures of the inside of your body) scan note dated 8/6/25 at 7:10 pm, by signed by a MD G, a indicated, “Fluid filled colon may indicate colitis. Trace free fluid in the pelvis, water density 20 HU (a quantitative measure of radiodensity used in CT scans. They represent the amount of X-ray attenuation (absorption) of a tissue relative to water -Hounsfield Units {HU}). 18 cm of hepatomegaly (enlarged liver).” A record review a of Nursing Note signed by RN R dated on 8/6/25 at 8:15 pm, indicated, “[Family Member (FM) 18] wondering if PT 18 can have more pain medications, MD E notified.” A record review a of Nursing Note signed by RN R dated 8/6/25 at 9:55 pm, indicated, “[FM 18]wanting orders for promethazine (medication given for severe nausea and vomiting, stronger medication than Zofran that was already received yet in ER) ...” A record review of MD E, ER orders dated 8/6/25, indicated Patient 18 received the following for pain in the ER: -Morphine (medication for severe pain) injections 4 mg (milligram) injection; two injections received. -Toradol (medication to treat severe pain and inflammation) injections 15 mg by injection; two injections received. A record review of Progress Note by RN R dated 8/6/25 at 10:40 pm, indicated, indicated Patient 18 was admitted to Unit 1 (medical surgical unit- Med-Surge) in room 110A. The “ER Physician/Mid-Level, clinical impression 1 ER, chief compliant was Abdominal Pain, Nausea, and Vomiting (MD E).” ER Nurse Note Patient Statement of Chief Complaint was “Abdominal Pain and Constipation (RN R).” A record review of an Admission Note by RN F, the NOC shift nurse (8/6/25 - 8/7/25 nocturnal or overnight shift), dated 8/6/25 at 11:41 pm, indicated RN R gave report to RN F, Unit 1 in Med-Surge unit. At time of admission, Patient 18’s heart rate was bradycardic (low heart rate) at 44 beats per minute. FM 18 was present at bedside and in report, RN F stated, “RLQ (right lower quadrant) abdominal Pain,” then immediately after Note indicated, “Patient 18 denies pain at this time because the “Toradol (pain medication for severe pain received in the ER) seemed to help.” Note went on to indicate, Patient 18 had “Nausea/Vomiting” and “Constipation with altered bowel elimination.” The Admission Note indicated that interventions would be “NPO (not eating by mouth), Zofran (medication for mild nausea and vomiting) as needed and Tylenol (medication for fever or mild pain.).” A record review of Doctor’s Admission Orders dated 8/6/25 at 9:49 pm, indicated orders for Patient 18, MD F placed order for Zofran 4 mg/ml PRN (as needed) for nausea/vomiting. Document also indicated Tylenol PO (given orally) 650 mg PRN for mild pain or temperature. Patient was NPO (nothing by mouth) at this time, but doctor ordered a PO medication. During an interview on 8/11/25 at 10:30 am, with FM 18, FM 18 was crying. FM 18 stated that she was very frustrated with the care PT 18 had received. FM 18 Stated they came to the ER on 8/6/25. PT 18 was vomiting and he had severe pain. The ED had first given PT 18 Zofran for the vomiting, but it did not work. FM 18 and Patient 18 repeatedly stated “Zofran did not work and Patient 18 did not stop the vomiting.” Next, the ER gave Patient 18 Phenergan (promethazine) for nausea/vomiting. This medication worked. It stopped the vomiting. The ER had first given Patient 18 Morphine for pain. This did work, but it did not last long, FM 18 stated. FM 18 also stated that the ER gave Patient 18 Toradol after the Morphine, and this worked great. They were transferred to the hospital at about 11:30 pm. Their “overnight nurse” was RN F. FM 18 stated sometime “a little past midnight,” the pain and the vomiting started back again. FM 18 asked RN F if Patient 18 could be given the same medications Patient 18 received in the ER because they worked and stabilized him. RN F stated to FM 18 that she was trying to reach a doctor, to get the orders for Patient 18, but RN F stated to FM 18 she could not get a hold of anyone for orders. FM 18 stated Patient 18’s condition became very dire as time went on. Patient 18 was in so much pain, Patient 18 was hitting his head up against the wall. FM 18 also stated Patient 18 was also vomiting “about every 15 minutes.” FM 18 stated she felt very desperate, because she had never seen Patient 18 in so much pain. FM 18 stated she begged nurse RN F for help. RN F told FM 18 that she was messaging through the “backline” [is the hospital’s internal phone messaging texting system] to Nurse Practitioner (NP) A, but still was unable to get the orders Patient 18 had in the ER, but she would “keep trying.” FM 18 stated they were given Zofran by RN F sometime around 2:00 am and FM 18 stated she told RN F that “Zofran does not work and they already tried that in the ER.” FM 18 stated that RN F told her she was unable to get orders and that was all she could give Patient 18. FM 18 stated that when the day shift nurse came on, Patient 18 was able to finally get some help from RN G (day shift 8/7/25). Patient 18 was finally able to get medication orders to stop his pain and vomiting. During an interview on 8/11/25 at 11:00 am, Patient 18 stated he remembered his first night at the hospital. Patient 18 was in 10/10 pain for almost all of the night and he vomited several times throughout the night. He felt better in the ER, but when put in the hospital, all of his symptoms returned. He could not get help until the daytime nurse came in. Patient 18 stated, “It was a long night.” RN F stated to him that she could not get a hold of any doctors to give the orders he needed. RN F told him that she keeps trying the “backline, but no one is answering.” Patient 18 stated he was finally able to get some help from the day shift nurse, RN G. A record review of RN F’s narrative written note dated 8/6/25 at 11:17 pm, indicated, “This RN backline NP about potassium chloride riders.” RN F was texting NP A, who was on duty that NOC shift. RN F asked NP A for potassium riders. Record review of RN F Narrative Note dated 8/7/25 at 12:43 pm, indicated she contacted NP A about “pt’s HR (Patient 18’s Heart Rate) being in the “40’s (normal range is 60-100 beats per minute).” A record review of Pain Assessments for Patient 18, dated 8/7/25 at 4:25 am, indicated RN F assessed Patient 18 at a “99- Unresponsive sleeping.” There was no other pain evaluation by RN F noted during the entire NOC shift in Patient 18’s medical record. A record review of a study by PubMed cited as, Afenigus AD. Evaluating pain in non-verbal critical care patients: a narrative review of the critical care pain observation tool and Its clinical applications. Front Pain Res (Lausanne). 2024 Oct 15;5:1481085. doi: 10.3389/fpain.2024.1481085. PMID: 39474515; PMCID: PMC11518793, indicated Scale of “99 Unresponsive” is not a valid pain scale to use for a patient who is sleeping. If a patient is unresponsive, then they should refer to another pain scale. A patient who is sleeping is not unresponsive. “In healthcare, assessing pain in patients who are unable to respond verbally (due to intubation, advanced dementia, or cognitive impairment) is a significant challenge. Several tools and strategies can be used to assess pain in non-verbal patients.” During an interview on 8/11/25 at 1:20 pm, Director of ICU and HAMS (DIH), was asked what a 99 meant on pain scale and showed him RN F’s documentation on the Patient 18’s pain. DIH stated, “I have no idea what that means. I had never seen that before. Maybe she meant to put a 9 as in a 9/10 pain scale.” During an interview on 8/18/25 at 10 am, RN H, Med Surge nurse, was asked if a patient was sleeping in one of her assigned rooms, what pain scale would she assign to them? RN H stated, a “0/10.” During an interview on 8/18/25 at 10:06 am, RN J, Med-Surge nurse, was asked if a patient was sleeping in one of her assigned rooms, what pain scale would she assign to them? RN J stated, a “0/10.” During an interview on 8/18/25 at 10:11 am, RN K, Med Surge nurse, was asked if a patient was sleeping in one of her assigned rooms, what pain scale would she assign to them? RN K stated, a “0/10.” A record review of the Nursing Narrative: “Report from Charge Nurse dated 8/7/25 at 1:30 am, indicated that pt (patient) vomited with a total of 75 (cubic centimeter of unit volume, same as ml- cc) with green color.”When RN F went on break, the charge nurse measured and reported on PT 18’s vomit, or emesis. RN F stated in this note that she gave Zofran 4 mg to treat this vomiting. A record review of the Omnicell (secure automated medication cabinets on nursing units used to store and dispense medications and supplies) record dated 8/7/25 at 1:55 am, indicated nurse RN F pulled Zofran 4 mg for Patient 18. A record review of the Omnicell record dated 8/7/25 at 3:00 am, indicated RN F gave Patient 18 Omirfev (Tylenol 1,000 mg) for the indication of Fever. A record review of the internal messaging dialogue from RN F to NP A dated 8/7/25 at 5:27 am, indicated, “Hey NP A, I have Zofran at 1:58 am, Patient 18’s nausea and vomiting has not subsided. Patient 18 has had a total of 135 cc emesis (vomit) since patient has been here. Is there something you can order for this patient? Thank you.” A record review of RN F’s documentation of PT 18’s Emesis Output Report for the NOC shift (8/6/25 - 8/7/25) indicated 110 cc. A record review of the “Med Admin Log,” dated 8/7/25 at 3:14 am, RN F indicated the effectiveness of Zofran as “effective.” But soon after, RN F indicated, “nausea and vomiting has not subsided.” A record review of messaging conversation from NP A to RN F in reply, dated 8/7/25 at 5:36 am indicated, “will place fluid bolus.” During an interview on 8/13/25 at 4:40 pm, RN F was asked what she remembered about Patient 18? Stated she remembered 17 year old Patient 18’s FM 18 was there staying with Patient 18. RN F stated she remembered that throughout the night, FM 18 and patient 18 were asking for the same pain medications and the same antinausea/vomiting medications Patient 18 received in the ER. FM 18 and patient 18 told RN F that patient 18’s pain and nausea/vomiting were stabilized well in the ER and FM 18 and patient 18 wanted those same medications. RN F stated she remembered the FM 18 telling her they gave Zofran in ER and it did not work. RN F was asked if she asked any doctor or NP for any of these medications (medications received in the ER such as Toradol and Phenergan) for pain and nausea FM 18 was requesting? RN F stated, “No.” She was asked “Why?” RN F stated, “I cannot recall.” RN F was asked how often she conducted a pain evaluation on Patient 18? RN F stated every two hours. She was asked if Patient 18 was in pain during her shift? RN F stated, “I cannot recall.” RN F was asked if Patient 18 was vomiting all night? RN F stated, “I cannot recall.” She was asked what the “backline” was? RN F stated an internal messaging system on phone. She was asked who the NP was on duty that night? RN F stated, NP A. RN F was asked if she contacted a doctor or the NP for any kind of pain or antinausea/vomiting medications? RN F stated, “I cannot recall.” RN F also stated, “I was worried about Patient 18’s low heart rate and I do remember Patient 18 had a fever.” Stated, “I did give the patient Ofirmev (injectable acetaminophen (Tylenol) medication used for the management of pain and fever) for his fever.” She was asked, “You do remember he had a fever and a low heart rate, but you do not remember if he was in pain or vomiting all night?” RN F stated, “I only remember he had a fever and low heart rate. I cannot recall if he had pain or vomiting.” During an interview on 8/14/25 at 1:45 pm, RN G stated she checked on PT 18 and FM 18 on 8/7/25 at 7:20 am. Both were sleeping at this time and Patient 18 briefly woke up. RN G stated, in the change of shift report RN F told ,her that she (RN F) tried to get orders for PT 18 via the “backline,” but was unable. RN G told RN F that she should have contacted the ER doctor for orders. RN G stated, when they woke up, both Patient 18 and FM 18 told RN G that Patient 18 was in severe pain all night and vomiting all night. RN G stated that both FM 18 and Patient 18 had asked RN F for the same pain and anti-vomit medications Patient 18 received in the ER, because “they worked.” RN G stated, both FM 18 and Patient 18 reported to her they did not get help for pain or vomiting from night RN F. RNG was asked what time did both FM 18 and Patient 18 report this to RN G? RN G stated, the all night pain and nausea was reported to her before 9:26 am when she pulled the Zofran and the Ofirmev from the Omnicell. RN G also had contacted MD E for “appropriate” orders as well. RN G tried to give the Zofran and Ofirmev to Patient 18, but FM 18 refused them because she stated, “Those don’t work. I want what was given in the ER, because those work.” RN G stated she responded to FM 18 by stating she wanted to give the Zofran and Ofirmev now and she will get the “ER medications” when she was able to get orders from doctor. RN G stated at least Patient 18 will have something in the meantime. Patient 18 and FM 18 stated that they were afraid they would not receive the stronger pain and nausea medications if Patient 18 takes the medications that do not work now. RN G stated she had to return these medications. RN G stated she contacted the doctor to ask for the ER medication orders for severe pain and nausea, stronger pain and nausea medications. Before pulling the Zofran and Ofirmev from the Omnicell, she contacted MD E. She was asked about her charting note where she wrote at 9:45 am that she contacted MD E? RN G stated that her note stating she contacted MD E at 9:45 am was just an estimate. (The Omnicell documentation showed the Zofran and Ofirmev was pulled at 9:26 am). RN G stated MD E told her via phone conversation he had to review Patient 18’s laboratory results before he puts in the orders for the pain and nausea medications. MD E had put in the orders for these medications at 9:47 am. These were the medications FM 18 and Patient 18 had been asking for “all night” and when they woke up in the morning. Patient 18’s pain scale went from a 10/10 severe pain, to complete pain control, 0/10 on RN G shift. A record review of the Pain Assessments for Patient 18, dated 8/7/25 at 10:06 am, by RN G assessed him at a “10/10- Most severe pain rating.” This pain was re-assessed at 10:55 am by RN G as a “0/10” after getting appropriate pain medication orders and then administering pain medication. A record review of MD E’s Orders, dated 8/7/25 at 9:47 am, MD E put in Toradol Injection 15 mg for pain and at same time put in orders for Phenergan 25 mg for Nausea/vomiting. These were the medications Patient 18 received in the ER that controlled his pain and nausea/vomiting. During an interview on 8/14/25 10:50 am Director of Med-Surge (DMS), was asked if she could present any evidence that RN F addressed Patient 18’s severe pain and repeated nausea/vomiting that lasted throughout RN F’s NOC shift between 8/6/25 - 8/7/25. DMS looked up the internal conversations that took place between RN F and the facility. DMS stated that Patient 18’s pain was addressed by RN F, Patient 18 was not in pain, a pain of “99- Unresponsive sleeping” is a qualified pain scale and acceptable to the acute care facility, and Patient 18’s nausea and vomiting was addressed appropriately. DMS also stated she “felt like the nurse (RN F) did what she was supposed to be doing.” No evidence was presented to indicate that RN F addressed the severe pain and nausea/vomiting according to the acute care facility’s policy and/or federal and state guidelines.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 17065 Based on observation, interview and hospital document review the hospital failed to ensure all patient care related activities were delivered by licensed or certified nursing staff when housekeeping staff assumed the responsibility of meal delivery to one patient (Patient 29) who was in an isolation room. Findings: Patient care activities in a licensed health facility fall under the responsibilities of the Registered Nurse (California Nurse Practice Act). A Registered nurse may assign unlicensed personnel, such as a nursing assistant, to perform patient care duties within a limited scope, the supervision and responsibility for the delegation of tasks continue to fall under the clinical supervision of the Registered Nurse. A nursing assistant helps the nursing team within a limited scope of care duties and responsibilities under a licensed nurse’s supervision (PracticalNursing.Org, 2020). As a multifaceted allied healthcare worker, a nursing assistant is allowed to perform a variety of tasks and duties such as answering patient call lights; serving and feeding patient meals and reporting changes in condition to nursing staff among other tasks. Nursing assistants may not, in turn, delegate assigned tasks to other unlicensed or uncertified personnel. A patient meal delivery observation was conducted on 8/12/25 beginning at 12:35 p.m., at Unit 2. A meal delivery cart was transported to the unit after which nursing staff were notified of its presence. It was also noted one of the rooms was designated as having “contact precautions” (precautions used in healthcare setting to prevent the spread of germs by direct contact). In a concurrent interview, nursing staff identified herself as a Patient Care Technician (PCT) PCT 1 also indicated she was a certified nursing assistant. PCT 1 confirmed she was getting ready to pass the noon meal trays. The continuing observation noted Environmental Staff 1 (EVS) had just exited the patient’s room and was removing personal protective equipment (PPE). On the wall adjacent to the room was a poster labeled “contact precautions”. EVS 1 removed a yellow paper gown, however she kept on her gloves. PCT 1 lifted the meal tray in EVS 1’s direction. There was no verbal communication. EVS 1 put on a fresh gown and placed a second pair of gloves over her existing gloves. EVS 1 then entered the patient’s room, placed the meal tray on the overbed table and proceeded to enter the room and close the door. In an interview on 8/13/24 at 8:30 a.m., the Chief Nursing Officer acknowledged certified nursing staff were not authorized to delegate any patient care activities to unlicensed/uncertified personnel. In an interview on 8/13/25 beginning at 9:30 a.m., Environmental Supervisors (EVSS) 1 and 2 the surveyor described the observations. EVSS 1 indicated housekeeping staff were advised not to undertake any patient care related activities. They also stated if asked to complete patient related activities they should decline. Review of hospital document titled “PCT [Patient Care Technician] Orientation Medical Surgical Units” dated 11/23/19 revealed PCT 1 was deemed competent in multiple areas including: complying with all federal, state and regulatory agency requirements; a review of all isolation policies; personal protective equipment; practices within scope; understanding of role as a nursing team member and in collaboration with the registered nurse and family assists in implementing a patient’s plan of care. The hospital also submitted an untitled, undated document describing the certified nursing courses PCT 1 completed from 8/23/20-8/18/23. While there were multiple training courses none focused on CNA scope of practice or complying with federal, state or regulatory agency requirements. Review of training received by EVS 1 it was noted in 2018 she participated in the “Safe Patient Handling Skills Fair Checklist”. It was also noted the employee completed 10 of 11 stations, except for assisting patients into a vehicle. It was also noted the exception of Station 2, which was a healthcare violence prevention and safety awareness training, the remaining stations all focused on direct patient care activities such as bed positioning, transferring a stroke patient and using a fall recovery device. None of these tasks would be within the scope of work of an environmental services staff member. Review of position description titled “Environmentalist” dated 8/2012, listed the position summary as “ ...in charge of maintaining and clean and satisfying environment ...” Hospital policy titled “Standards of Care for Medical Surgical Units” dated 8/23 describes that it is the responsibility of the “ ...nurse to assign or delegate tasks ...based on the knowledge and skills of the provider selected ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 43258 Based on observation, interview and record review, the hospital failed; 1. to ensure that orders for duplicate anti-nausea medication were clarified with the physician. 2. to ensure duplicate as-needed orders were clarified with the physician and IV (intravenous, administered into the vein) heparin (a medication that reduces the blood’s ability to clot and prevent new clot formation or the enlargement of existing clots) was administered in accordance with hospital protocol. 3. to document an open date on a container of blood-glucose test strips for one of 33 sampled patients (Patient 12). 4. to remove the opened sterile water (water that has been purified and is free from microbial contamination) container per the manufacturer’s guidelines on one of 33 sampled patients (Patient 12). These failures had the potential for patients to receive unnecessary medication, inadequate treatment, or the use of expired blood glucose test strips leading to exposure to unwanted side effects, worsening of their medical conditions, resulting potential for incorrect results for blood glucose levels, and for the potential use of contaminate the sterile water used for Patient 12’s tracheostomy (opening in the neck and windpipe to allow a tube to be inserted to provide breathing support) care. Contamination has the potential to introduce infection into Patient 12’s lungs Findings: 1. A review of Patient 18’s History & Physical (H&P, comprehensive patient assessment) indicated he presented to the Emergency Department (ED) on 8/6/25 with complaints of nausea, vomiting and abdominal pain. The Plan indicated, “ ...IV fluids, IV antiemetics (medications to treat nausea and vomiting), IV pain meds ...” During a medication pass observation on 8/12/25 at 8:53 a.m. with Registered Nurse M (RN M) in the High Acuity Medical Surgical (HAMS) Unit, RN M was observed preparing to administer ondansetron (a medication to treat nausea and vomiting) 4 milligrams/2 milliliters (mg/ml, a unit of measurement) intravenous (IV, administered into the vein) to Patient 18 (Pt 18). Pt 18’s mother stated the ondansetron was not effective for treating the nausea and vomiting and wanted the promethazine (a medication to treat nausea and vomiting) instead. RN M returned the ondansetron to the medication room, removed the promethazine from the automated dispensing cabinet, prepared then administered it to Patient 18. A review of Patient 18’s medical record indicated physician’s orders for the following: - Promethazine 25 mg/ml injectable: intravenous every 6 hours as needed for nausea, ordered 8/7/25 - Ondansetron 4 mg/2ml injectable: IV push (a method of administering medication directly into a patient’s bloodstream) every 6 hours as needed for nausea/vomiting, ordered 8/6/25 During a concurrent interview and record review on 8/12/25 at 11:37 a.m. with Director of Pharmacy (DOP), Pt 18’s physician’s orders for promethazine and ondansetron were reviewed. DOP stated it would be expected to see more information in the orders regarding the timing of administration for each medication to direct nursing staff as to when to give each medication. She stated pharmacy and nursing staff should have clarified the order with the physician since both were as-needed for the same indication. During a concurrent interview and record review on 8/13/25 at 3:43 p.m. with RN A in the HAMS Unit, Pt 18’s physician’s orders and directions for promethazine and ondansetron were reviewed. RN A stated if the patient needed a medication to treat nausea and/or vomiting she would choose ondansetron first based upon the fact that it had less side effects associated with it. During a concurrent interview and record review on 8/13/25 at 3:52 p.m. with RN B in the HAMS Unit, Pt 18’s physician’s orders and directions for promethazine and ondansetron were reviewed. RN B confirmed the orders did not indicate which to administer first if Pt 18 had nausea and/or vomiting. She stated whenever a patient had multiple as-needed medications prescribed to treat the same condition there were parameters included in the order to direct staff as to when to administer each. She stated if parameters were not included in the order, she would reach out to the physician to clarify the order. During a concurrent interview and record review on 8/13/25 at 3:58 p.m. with RN C in the HAMS Unit, Pt 18’s physician’s orders and directions for promethazine and ondansetron were reviewed. RN C stated if a patient was experiencing nausea and/or vomiting, he stated usually elderly patients had reactions to promethazine so that was why he would administer ondansetron first. RN C stated he usually administered ondansetron first and if it was not effective he would check with the physician to see if it was appropriate to administer the promethazine. During a review of the hospitals policy and procedure (P&P) titled, “Bar Code Medication Administration (BCMA),” dated 4/2023, the P&P indicated, “Procedure ... C. Duplicate PRN medications ordered for the same indication ... 2. Any PRN medications ordered for the same indication needs to be clarified by the physician.” 2. A review of Pt 21’s H&P indicated he presented to the ED on 7/25/25 with complaint of shortness of breath. The Plan indicated there was concern for NSTEMI (Non-ST-Elevation Myocardial Infarction, a type of heart attack where a blood clot partially blocks a coronary artery, reducing blood flow to the heart muscle) and Pt 21 was to be started on IV heparin. A review of Pt 21’s medical record indicated a physician’s order for heparin 25,000 units/D5W (dextrose 5% in water) IV, give 80 units/kilogram (kg, a unit of measurement) to a max of 10,000 units then start infusion of 18 units/kg/hour (max of 2000 units/hour) to achieve a goal of aPTT (activated partial thromboplastin time, a test that indicates the amount of time it takes for the blood to form a clot) 50-70 seconds, ordered 7/28/25 (renewed order, originally 7/25/25). During a concurrent interview and record review on 8/14/25 at 10 a.m. with the Director of Intensive Care Unit/HAMS (DIH), Pt 21’s IV Heparin Infusion Flow Sheet and physician notifications were reviewed. DIH confirmed Pt 21’s flow sheet indicated on 7/26/25 at 2:30 a.m. that Pt 21’s aPTT was greater than 200. DIH confirmed the heparin protocol indicated, “Hold infusion 1 ½ hours & inform provider.” DIH confirmed that the physician should have been contacted by the nurse and that documentation of the contact should have been made. DIH reviewed Pt 21’s medical record and confirmed there was no documentation that the physician had been contacted. During a review of the facility’s P&P titled, “Medication Administration,” dated 8/2023, the P&P indicated, “Purpose: To ensure that medications are administered by the nursing personnel in an accurate, consistent, and efficient manner, in compliance with a physician’s order. Procedure: 1. Medications are to be administered only with orders from a physician/provider.” 51253 2. During an observation on 8/11/25 of Patient 12’s patient room, observed an open container of blood glucose test strips on Patient 12’s side table without labled open date on the bottle. During an interview and concurrent record review, on 8/11/25 at 11:00 am, reviewed the blood glucose test strips manufacturer’s guidelines with RN E, Charge Nurse for HAMS. Brand name of the blood glucose test strips was StatStrip and Reference number was 42214. Manufacturer’s instructions indicated, “Open test strips are stable for up to six months or the expiration date, whichever comes first.” RN E reviewed the manufacturer’s instructions and confirmed there was no way of knowing when the six months are due and the test strips could be expired. RN E took the test strips out of use. During an interview and concurrent record review with Chief Nursing Officer (CNO), CNO was shown the pictures of the container of test strips and CNO confirmed there was no open date on the container. CNO confirmed there is no way of knowing if the blood glucose test strips were expired or not. 3. During an observation on 8/11/25 at 10:40 am, at the bedside table of tracheostomy Patient 12, there was one opened container of sterile water that had been opened and dated three days prior. The sterile water container had writing on the front in black ink that read, “Trach.” There was a second container of sterile water that was opened and not dated. A record review of the manufacturer’s guidelines of this brand of sterile water by AirLife Vyaire Sterile Water, Lot Number 1049725 for “Inhalation” indicated, “Discard unused portion.” There is also an icon on the manufacturer guidelines that indicated, “Do not re-use.” During an interview on 8/11/25 at 10:00 am, RT A, Respiratory Therapist for Patient 12 in 225B, stated the expiration date of Sterile Water once opened is three days. During an interview on 8/11/25 at10 20 am, RT B, Respiratory Therapist for Unit 2, stated the expiration date for Sterile water was 24 hours.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 43258 Based on observation and interview, the hospital failed to store Omnipaque (a medical imaging contrast agent) in a safe manner separate from other chemicals and maintain emergency drug supply in a sealed container in accordance with California State law. These failures had the potential for patients to receive unsafe or altered medications from exposure to chemicals and for patients to not receive emergency medications timely in order to prevent injury or death. Findings: 1. During a concurrent inspection and interview on 8/13/25 at 8 a.m. with Director of Pharmacy (DOP) and Director of Interventional Services (DIS) in the Cardiac Catheterization Laboratory (a specialized room in a hospital equipped for performing minimally invasive procedures on the heart and blood vessels), multiple bottles of 10% Neutral Buffered Formalin (formaldehyde, a hazardous chemical used to preserve tissue samples by preventing breakdown for laboratory analysis) were observed co-mingled with Omnipaque 9 milligram/milliliter (mg/ml, a unit of measurement) oral solution. DIS confirmed the Formalin should have been stored separately from the Omnipaque. A review of the Safety Data Sheet (SDS, a document that provides information about a hazardous chemical or substance, including potential hazards, safe handling procedures, and emergency response measures for 10% Neutral Buffered Formalin , revised 10/21/14, the SDS indicated, “Hazard Statement(s) ... Harmful if inhaled. Causes skin irritation. Causes serious eye damage. May cause allergy or asthma symptoms or breathing difficulties if inhaled. May cause an allergic skin reaction. May cause genetic defects. May cause cancer. May cause damage to organs (lungs, nose). May cause damage to organs (lungs, nose) through prolonged or repeated exposure.” During a review of the hospital’s document titled, “Chemical Hygiene Plan for [name of hospital] Laboratory,” dated 9/22/94, the plan indicated, “Chemical Storage Safety Rules ... 4. Cabinets and specially monitored refrigerators are used for chemical storage only.” In accordance with California Code of Regulations Title 22 for General Acute Care Hospitals regulations for Pharmaceutical Service General Requirements, the regulation 70263 (q)(4) states, “Test agents, germicides, disinfectants and other household substances shall be stored separately from drugs.” 2. During a concurrent inspection and interview on 8/13/25 at 9:53 a.m. with DOP and Director of Perioperative Services (DPS) in the Post Anesthesia Care Unit (PACU, a recovery room for patients waking up from surgery or procedures where they received anesthesia), a locked Malignant Hypothermia Cart (MH Cart, a mobile cart containing emergency medications for the rapid treatment of a rare but life-threatening reaction to certain anesthesia drugs) was observed. A refrigerator, embedded in the MH Cart was sealed with a red plastic tie. The DPS was alerted by staff standing nearby that the key to unlock the top drawers of the MH Cart was contained inside the refrigerator. DOP and DPS acknowledged and confirmed the MH Cart was locked in addition to being sealed. During a review of the facility’s P&P titled, “Emergency Medicine: Crash Carts,” dated 4/2023, the P&P indicated, “Policy ... The emergency drug supply shall remain inside the cart, sealed, at all times when not in use. The seals shall be broken only when an emergency situation arises ...” In accordance with California Code of Regulations Title 22 for General Acute Care Hospitals regulations for Pharmaceutical Service General Requirements, the regulation 70263 (f)(2) states, “The emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist in such a manner that a seal must be broken to gain access to the drugs ...””

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 42448 Based on observation, interview and departmental and administrative document review, the hospital failed to ensure adequate organization and resources for the Food and Nutrition Services Department when: *1. Multiple departments were budgeted to share responsibility for sanitation and maintenance of the kitchen; there was no evidence of oversight by the management of departments involved to ensure their staff completed those responsibilities properly and timely; and the kitchen wasn’t sanitary or maintained in good condition (Cross Reference A-619, A-701). *2. The hospital failed to plan for adequate quantities of food supplies to meet the nutritional needs of patients and staff in the event of a widespread disaster. These failures had the potential to result in fire, early failure of expensive equipment, microbial growth, the attraction of disease-carrying insects and rodents, foodborne illness and death for patients and staff consuming food from the Food and Nutrition Services Department. Failure to ensure the nutritional needs of patients and staff may result in affecting the medical status of patients and compromise the ability of staff to care for the medical needs of inpatients. Findings: *1. Multiple departments were budgeted to share responsibility for sanitation and maintenance of the kitchen; there was no evidence of oversight by the management of departments involved to ensure their staff completed those responsibilities properly and timely; and the kitchen wasn’t sanitary or maintained in good condition (Cross Reference A-619, A-701). Review of a policy titled “Infection Control Procedures; Dietary Service Section,” reviewed 11/21, showed “Procedures in the Dietary Department are established to eliminate the possibility of contamination and cross-infection for the safety of all patients and personnel.” “Food Service is an important factor within the hospital, contributing to patient and employee morale, as well as to health maintenance. Unsanitary food service can play a significant role in disease transmission. Maintenance of sanitation standards is of paramount importance in medical-care facilities.” During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am the hood was dripping with grease. Multiple walls, ceilings and cabinets throughout the food services areas were soiled and had holes, missing paint, worn finishes, and were uncleanable. Flooring was damaged and there were gaps between floor coving and walls that could harbor grime and pests. There was ice on the ceiling and condenser fan of the walk-in freezer. One refrigerator had rusted shelves, rusted wire protector over the condenser fan, condensation and mold around both doors. Multiple surfaces had an accumulation of grease, grime and dust on the physical plant and on kitchen large and small equipment. Trash cans were thick with grime and food debris on the lids and handles throughout the survey. Utility food carts were soiled. Dry food storage areas and bins were not clean. Review of the undated owner’s manual for the hood, titled “Hoodmart Commercial Kitchen Hoods Installation, Operation, and Maintenance Manual” showed “According to NFPA (National Fire Protection Association), dirty hoods are the major cause of fire in commercial kitchens.” Review of a policy titled Infection Control Practices - Responsibilities,” reviewed 11/21, showed “These guidelines are established to minimize the risk of disease transmission in hospital related, public eating places.” It delineated these responsibilities regarding sanitation and maintenance: The Food Service Director was to “ensure proper maintenance and cleaning of all equipment and submit policies and procedures related to infection hazard to the Infection Control Committee.” The Infection Control Nurse was to act as a resource person, review policies, “periodically make rounds through the food service department to assess the infection control practices,” and investigate any food-borne illnesses. The Infection Control Committee was to review and approve policies, and review infection data in the public food department “to detect and deal with hazardous practices.” “Dietary, Environmental Service and Engineering: 1. Maintains ice machine in a clean and sanitary condition. 2. Provides for the removal and proper disposal of garbage from the kitchen. 3. Provides for continuing preventive maintenance of equipment.” Review of a document titled “Orohealth Corporation/ Oroville Hospital Organizational Chart,” dated January 2025, showed the Directors of the Nutrition Services Department, Environmental Services Department and Plant Operations Department, and Employee Health reported to the hospital’s Chief Operating Officer. The Director of Infection Prevention was not found on the Chart unless it was lumped with Employee Health. *1A. Food and Nutrition Services Department (FANS) Role in Sanitation in Food Services: Review of a document titled Job Description for Director of Nutrition Services, updated 9/17, showed duties did not list responsibility for the sanitation of Food and Nutrition Services (FANS). During an interview with the Director of Nutrition Services (DNS) on 8/11/25 at 10:20 am, she was asked about the sanitation and maintenance in her department. She stated Environmental Services (EVS) came into the department each night to clean, and were responsible for the trash, trash cans, walls, vents, floors, floor drains, hood filters, and loading dock. The DNS stated she called maintenance (Plant Operations) when she needed them, and they were responsible for the sprinkler heads, ice machine, refrigeration and any out-of-range temps in the temperature control system. During an interview with the Food Production Manager (FPM) on 8/12/25 at 9:25 am, she was asked about staffs’ cleaning assignments, and she replied, staff had difficulty getting everything done in the time they were allotted. During an interview with DNS on 8/12/25 at 10:35 am, she was asked if the FANS Department had adequate staff. She stated she needed a cleaning budget where she could schedule a cleaning team to come in at least weekly. She stated her department staff were pressed for time, they were not allowed to have overtime, and she needed to spend more time training and monitoring staff in cleaning. She stated she and Administration had discussed providing more hours for her department’s budget for cleaning, but the budgeted cleaning hours remained with EVS. During an interview with DNS on 8/12/25 at 2:30 pm, she stated neither she nor her team did any formal inspections of the kitchen. They did informal walk-throughs and observations, but it was not documented. During an interview with the FPM on 8/12/25 at 11:25 am, she stated they recently had staffing position reductions that required them to change their menu. They lost two positions and could no longer complete all the work. They incorporated some of the tasks from the eliminated positions into the cook and #14 positions, plus the menu changes, and that was how they were able to absorb the staffing cuts. In a concurrent interview with the DFS, she stated, “Technically we are fully staffed now.” Review of Food and Nutrition Services cleaning logs dated July and August 2025, reviewed from dates 7/1/25 through 8/11/25 showed: The “Dietary Department Cafeteria Weekend Cleaning Checklist,” had 22 weekly tasks assigned, with 132 out of 132 assignments signed off as completed. It included tasks such as cleaning cafeteria cabinets, tray line lowerators (spring- loaded carts designed to hold plates, cups, etc for tray line) and carts, refrigerators, fan, doctor’s lounge refrigerator, café serving line, sneeze guards, salad bar, toaster, and coffee urns. The “Dietary Department Weekly Cleaning Tasks,” had 13 assignments spread over three days, with 76 out of 90 assignments signed off as completed. It included tasks such as cleaning the spice rack, reach-in refrigerators, sinks and sink drains, coffee urns, drawers under cook’s table, clean and disinfect cabinets, and clean tray line area. The “Dietary Department Daily Dishwashing Cleaning Checklist #7, #10, #13, Clean/Sanitize” showed 50 tasks assigned among three positions daily, with 167 out of 175 tasks signed off as completed. It included tasks such as cleaning racks in the walk-in refrigerator, prep area tables, equipment storage racks, clean and de-scale dishwasher, all mobile hand carts, mixer table, “Call Maintenance to clean box fans.” During an interview with DNS on 8/14/25 at 1:20 pm regarding Quality Assurance/Performance Improvement (QAPI) efforts, she stated the department had no kitchen QAPI activities in 2024, but in January 2025 the kitchen started a focus on cleaning list completion. Review of a document titled “CQI Data Collection Form,” dated 7/15/25, showed Nutrition Services Problem Statement “Cleaning and sanitation duties are not always being completed as assigned, particularly with newly hired staff,” and project goals: “To reduce incidents of non-compliance; Improvement of kitchen cleanliness scores from internal audits and health inspections; Cleaning and sanitation tasks will be completed 95% of the time.” The data summary showed percentage of tasks successfully (signed off as) completed in Q1 (first quarter) 2025 was 94.3%, and in Q2 98.7%. Yet the kitchen remained unsanitary. While QAPI data regarding dietary staff sign-off of cleaning assignments was being collected and reported by the dietary department, it didn’t fully reflect the depth and scope of the department, nor the true extent of the lack of sanitation and maintenance found in that department. *1B. Environmental Services (EVS) Role in Sanitation in Food Services: Review of a document titled “Job Description for Director Environmental Services,” updated 1/25, showed “The Director of Environmental Services is responsible for maintaining a safe and sanitary environment. The Director of Environmental Services will review productivity, quality control, and operating efficiency throughout the facility.” During an interview and concurrent document review with Environmental Services Supervisors 1 (EVSS1) and 2 (EVSS2), and with the Director of Plant Operations (DPO) on 8/11/25 at 4:00 pm, they stated the Director of Environmental Services resigned the previous week. EVSS1 provided an undated document titled “NOC Dietary Work Order” and stated it reflected the responsibilities completed by EVS staff in the kitchen each night. The form showed EVS staff were assigned to complete the following tasks: Daily: pull all trash/chairs up; clean coffee var thoroughly and hose (floor) mats; dust mop whole floor/under vending machines; wipe tables/chairs/drinking fountain; clean windows inside and out; sweep/mop; take all mats and trashcans outside/ move food carts into hall; empty all trashes then spray all mats; sweep and mop kitchen; clean and stock bathroom; stock all paper products in kitchen; clean all stainless steel with correct cleaner. Weekly: wipe down vents; use flat mop on walls and ceilings; wipe down pot and pan rack; wipe down salad bar; dust bread rack; scrub floors; scrub stove hoods. Monthly: Lights/food carts. When asked if EVS leadership ever followed up to ensure EVS staff completed the work in Dietary properly and timely, EVSS1 responded supervisors did “weekly check-ins with EVS staff.” He stated the facility also tried to do Environment of Care Rounds (EOC) in the kitchen yearly. The EVSS1 and EVSS2 supervisors were asked to provide documentation of staff completion of the daily NOC Dietary Work Orders for the past 2 weeks, and to provide any documentation of EVS management oversight/check-ins regarding their staff’s work. No documentation was provided by end of survey. During an interview with the Food Production Manager (FPM) on 8/12/25 at 9:50 am, she stated she did not think EVS cleaned the walls, not even occasionally. She stated EVS emptied the trash every night, but it did not appear they washed the trash cans. She stated they did a good job cleaning the floors and floor mats. During an interview with Environmental Services Supervisor 1 (EVSS1) and Environmental Services Lead (EVSL) on 8/14/25 at 3:25 pm, the process and timelines described for EVS to clean the hood and filters in between professional cleaning events did not match the guidelines provided in the undated owner’s manual for the hood, titled “Hoodmart Commercial Kitchen Hoods Installation, Operation, and Maintenance Manual.” During further interview with EVSS1 and EVSL on 8/14/25 at 3:25 pm, they stated EVS staff worked in the Dietary department from about 10:00 pm until about 1:00 am nightly, and then they had to start taking calls for service to other areas. EVSL stated the staff did Dietary first, for about 2 ½ hours before other areas started calling. If staff didn’t get called, they could work in Dietary longer. Further review of the undated “NOC Dietary Work Order” form showed the EVS staff were to work in Dietary from 10:00 pm to 2:00 am (four hours) daily, and in other areas of the hospital from 2:00 am to 6:30 am (4 ½ hours). Review of an EVS policy titled “Dietary Work Schedule “D”,” reviewed 10/23, showed EVS staff were to work an eight-hour shift in Dietary, with twelve areas of responsibility in the department, and 27 tasks that required completion daily including but not limited to cleaning the floors, the hoods, walls, vents, multiple pieces of food production and cafeteria equipment, and trash can lids. During continued interview with EVSS1 and EVSL on 8/14/25 at 3:25 pm, the surveyor stated it looked like tasks in the kitchen weren’t being done, or were not done correctly. EVSS1 and EVSL replied “There is so much to do, and then staff start getting calls” that pulled them to work in other areas of the hospital. When asked how long it would take to do the assigned work in dietary correctly and completely, they replied probably five to six hours daily. During an interview and concurrent document review with Environmental Services Supervisors 1 (EVSS1) and 2 (EVSS2), and with the Director of Plant Operations (DPO) on 8/11/25 at 4:00 pm, EVSS1 and EVSS2 were asked to provide documentation of staff completion of the daily NOC Dietary Work Orders for the past 2 weeks, and to provide any documentation of EVS management oversight/check-ins regarding their staff’s work. No documentation was provided by the end of the survey. *1C. Plant Operations Role in Sanitation and Maintenance in Food Services: Review of a policy titled Utilities Management Program, reviewed 2/2023, showed the program included preventive maintenance, repair, assessment/evaluation, replacement/installation of equipment and follow-up. “All equipment used in the care of patients, used by visitors, staff/employees must be evaluated ...to insure that all equipment is safe for its intended use and is adequately maintained to keep it in proper operating condition.” Review of a document titled Job Description for Director of Plant Operations (DPO), updated 1/23, showed duties included “Establishes and administers preventative maintenance program. Periodically inspects buildings and utility systems to determine need of alterations and repairs.” During an interview with DPO on 8/11/25 at 3:05 pm, he stated, Plant Operations responsibilities in the kitchen included equipment maintenance (or they called a repairman); wall maintenance including paint, finish on wood cabinets, holes in walls; cleaning ice machines. During an interview with DPO on 8/13/25 at 9:00 am, he stated they had maintenance staffing 24 hours a day, 7 days a week. The NOC (night) shift did the repairs in the kitchen and had a work order and equipment checklist to go through in the kitchen monthly. He stated he assumed EVS was cleaning the hoods, so the hoods were not on Plant Ops Dietary monthly PMs list. When asked about the Dietary flooring and coving in disrepair, the DPO stated it was everyone’s responsibility to notice and report concerns, and Plant Op did not have a PM (preventative maintenance task) on flooring and coving. When asked why EVS cleaned the kitchen instead of Dietary staff, he replied “It’s always been that way” for the 36 years he had worked there. *1D. Infection Prevention/ Environment of Care (EOC) Rounds Role in Sanitation: During an interview with the Infection Preventionist Nurse (IPRN) on 8/13/25 at 8:30 am, she stated Food and Nutrition Services (FANS) was not included in the hospital’s EOC surveillance program. “I do walk-throughs, but I don’t document it in any way.” “If there is a big issue, I send an email to (DFS) to address it. I don’t address it formally in any way.” When asked if she would think FANS had any kind of role in infection control in the hospital, she replied the kitchen was a place where there were all kinds of potential for food borne illness in relation to food handling, food storage, and food preparation. She stated patients and employees would be at risk if something went wrong. When asked why, in light of her statements, FANS wasn’t included in EOC rounds she stated she still needed to pull FANS and Pharmacy into EOC Rounds, but DFS or FANS staff did participate in infection control meetings. *2. The hospital failed to ensure adequate food supplies to ensure the nutritional needs of patients and staff were met in the event of a widespread disaster. In a food storage observation on 8/13/25 beginning at 3:30 p.m., the hospitals’ disaster preparedness feeding plan was reviewed with the Food Production Manager (FPM) and Dietary Supervisor (DS). It was noted the hospital developed a menu which included shelf stable items such as canned chicken or turkey, corned beef hash, chili, canned green bean salad as well as bread, canned fruits and evaporated milk. In a concurrent interview, the FPM and DS were asked to describe the number of meals that would be available to patients and staff. They indicated the inventory would be adequate for 660 meals per day intended for patients and staff. This meal total would equate to 133 meals for patients, as determined by the licensed bed count and 87 meals for staff required to care for patients. The surveyor asked how the daily meal count and staffing levels were determined. Neither the FPM or DS were sure of how that number was determined. They also stated it was likely determined by the Director of Environmental Services who was fulfilling the role of Emergency Preparedness Coordinator, a position that was currently vacant. The surveyor requested the hospital to determine the typical number of staff that would be working on a routine day shift during the week. The hospital presented a document dated 8/14/25 which indicated there would be approximately 270 staff during a typical weekday shift. It was also noted that the same 660 number was utilized to evaluate the need for patient and staff meals as well as hydration. Review of a hospital document titled “Emergency Operations Plan Policies and Procedures” dated 4/29/25 and reviewed by hospital leadership staff also used the 660 number in development of the disaster preparedness plan.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 42448 Based on observations, interviews and record reviews, the hospital failed to ensure staff were competent in their respective duties when: *1. Staff did not follow professional standards of practice or manufacturer’s instructions when cleaning fixed equipment (equipment such as carts and counters that cannot go through the dishwasher or 3-compartment sink). *2. Staff did not consistently perform cooling log processes for ambient foods such as egg salad, tuna salad and chicken salad. *3. Staff did not have standardized recipes for pureed foods, and did not puree foods in a manner to conserve nutritive value and be visually appealing for patients. These failures had the potential to provide textures to patients that could cause them to choke, be visually and flavorfully unattractive resulting in decreased meal intakes and decline; contribute to a lack of sanitation in the department, resulting in foodborne illness or death for patients and staff consuming food from the hospital food services. Findings: Review of a hospital policy titled “Staff Competency,” reviewed 4/25, showed “It is the policy of Oroville Hospital to hire and retain staff that is competent to do the jobs for which they are hired.” “Each employee will receive a performance evaluation at least annually to ensure continued competence in job-related knowledge and skills. Employees who demonstrate weakness in any area will receive training and/or continuing education as needed to regain and maintain competence.” *1. Staff did not follow professional standards of practice or manufacturer’s instructions when cleaning fixed equipment (equipment such as carts and counters that cannot go through the dishwasher or 3-compartment sink) (Cross Reference A-0619, A-750). Review of a Dietary Department policy titled “In-service Program,” reviewed 5/22 showed in-service classes would be held on a regular basis and based on need for all kitchen employees, and a record would be kept for all employees attended. “Minimally, annually, dietary staff will be tested on hospital wide policies. The following classes may be given but not limited to ...” Sanitation, Food Storage and Cleaning Procedures (policy listed ten topics). Review of the 2022 FDA Food Code showed: §4-202.16 Nonfood-Contact Surfaces: “Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.” §4-601.11 showed (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 1A. Nutrition Services staff cleaning (Cross Reference A-750, A-619): During the initial tour on 8/11/25, beginning at 9:40 am, the kitchen in general was unsanitary, including both large and small equipment. Review of a policy titled “Procedures for Cleaning & Sanitizing Equipment,” revised 3/25, explained the process to clean equipment as: wash with detergent and water, rinse with potable water, sanitize and air dry. Review of the manufacturer’s instructions for Quat II Sanitizer directed equipment to be washed with detergent and water, rinsed with potable water, sanitized and remain wet for 60 seconds, and air dry for cleaning equipment. Review of the manufacturer’s instructions for Betco Citrus Chisel Cleaner/Degreaser directed that food contact surfaces be rinsed with potable water after use of the degreaser. During an interview with FSW1 in the cook’s area on 8/12/25 at 10:00 am, she was asked about sanitation of the counter-mounted can opener. She stated she tried to “wipe it down” after each use, but it was the PM Cook’s job to clean it and run it through the dish washer at the end of each shift. During an interview with FSW7 on 8/12/25 at 9:50 a.m., she described the cleaning process for patient meal carts as cleaning the inside and outside with auto-dispensed sanitizer. It did not include a wash or rinse process, or wet time for sanitizer. During an interview with FSW 5 on 8/12/25 at 4:20 pm, he stated he used sanitizer and a cloth to clean equipment. He stated he didn’t regularly use soapy water to clean equipment in his work area, but used degreaser if equipment was greasy. He stated he did not rinse the equipment after using degreaser. Review of the curriculum for an undated in-service titled “In-service: Chemical Sanitizers in the Kitchen” showed steps for cleaning food-contact work surfaces included washing and sanitizing. It did not include rinsing, or air dry. It directed staff to “sanitize” counters, food carts, the meat slicer, blender, Robocoup (food processor) and can opener after each use. There were no directives to clean the equipment with soapy water, and rinse with potable water before applying sanitizer. Review of the curriculum for an undated in-service titled “In-service: Kitchen Sanitation” directed staff “All utensils, counters, shelves and equipment shall be kept clean, maintained and in good repair.” “When cleaning/sanitizing patient carts after each meal service, santitize all outside and inside surfaces, including the inside top.” There were no directives to clean the equipment with soapy water, and rinse with potable water before applying sanitizer. Review of staff training and competency records for Food Service Worker 1 (FSW1), FSW3, and FSW5, provided by Human Resources and DNS showed: FSW1’s education records began in 2011. FSW3’s education records began in 2015. FSW5’s education records began in 2017. The Healthstream (software) education tracking summaries showed completed in-services included (but were not limited to): OH Dietary - Kitchen Sanitation and Updated Cleaning Schedules, completed by FSW1 1/30/25, FSW3 1/14/25, FSW5 1/20/25. OH Dietary - Kitchen Sanitation In-service, completed by FSW1 12/10/24, FSW3 12/12/24, FSW5 12/11/24. Records included a post-test regarding kitchen sanitation, but the test did not include any questions regarding the process for cleaning equipment. OH Dietary - Food Safety and Sanitation Inservice completed by FSW1 1/16/24, FSW3 1/15/24, FSW5 12/04/23. OH Dietary - Food Safety Preventing Food-Borne Illness completed by FSW1 10/30/25, FSW3 10/30/25, FSW5 11/02/23. Review of a document from FSW1’s file, titled “Oroville Hospital Introductory Departmental Guide Skills Checklist, signed by FSW1 and the manager/supervisor on 2/2/23, showed “Cleans up work area does assigned cleaning, using a germicide,” but did not list any competencies related to the process of cleaning equipment. The files for FSW 3 and FSW 5 did not contain a skills competency checklist, and FSW1 had no skills checklist completed any more recently than 2023. 1B. Environmental Services (EVS) staff cleaning: During the initial tour on 8/11/25, beginning at 9:40 am, the hood, trash cans, vents, walls, ceilings and other tasks included on the NOC Dietary Work Order had grime, dust, dripping grease or other unsanitary conditions. It appeared they weren’t being done or were not being done properly (Cross Reference A-0619, A-0750). During an interview with EVSS1 and Environmental Services Lead (EVSL) on 8/14/25 at 3:25 pm, EVSL stated when EVS staff cleaned the hood filters, they used a ladder, took the filters to the “corral” outside, and sprayed them with water and degreaser until clean. He stated the hood filters should be cleaned by EVS staff twice a week. Review of the undated owner’s manual for the hood, titled “Hoodmart Commercial Kitchen Hoods Installation, Operation, and Maintenance Manual” showed the hood grease filters should be washed in the dishwasher or sink with mild detergent weekly, or more frequently in a heavy grease-producing environment. “Clean entire interior of the hood prior to replacing the baffle filters. Use mild detergent if necessary; do not use abrasive cleaners or cloths.” EVSL stated they used auto-dispensed Citrus Chisel degreaser and yellow rags to wipe down the dining tables and chairs in the cafeteria. He stated there were no additional steps or rinsing. During continued interview, EVSS1 and EVSL were asked how they would define the terms used in the directions on their “NOC Dietary Work Order” form they replied: “Wipe down” meant use a cloth to wipe surface with a chemical appropriate for the job “Dust” meant use a cloth to remove dust “Scrub” meant clean using some sort of abrasion, a scrub brush or abrasion pads “Clean” meant using a yellow rag and appropriate chemical. Some chemicals needed to be wiped off, or wiped down with a clean water cloth. EVSS 1 stated he didn’t know if the chemicals EVS staff used in the kitchen needed to be rinsed off. No processes for the wash with detergent, rinse with potable water, sanitize and air dry were described as processes used by EVS staff in the kitchen. Environmental Services Worker 9 (EVSW9), EVSW10, and EVSW11 were identified by Administration as the EVS staff who had worked cleaning the Dietary Department the nights of 8/10/25 and 8/11/25 (the night prior to survey start/initial tour of the kitchen, and first night of survey). Staff training and competency records for EVSW9, EVSW10, and EVSW11, were provided by Human Resources and the DNS, and showed: EVSW9’s education records began in 2023 EVSW10’s education records began in 2018 EVSW11’s education records began in 2022. The Healthstream (software) education tracking summaries showed no in-services regarding the food safety requirements or processes for kitchen sanitation, cleaning hoods, or other equipment in Nutrition Services were completed by EVSW9, EVSW10, or EVSW11. Further review of the EVS staff training and competency files showed the completion of “Oroville Hospital Introductory Departmental Guide Skills Checklist” for EVSW10 (signed 11/18/18) and EVSW11 (signed 8/13/25 - during the survey). There was no checklist in place for EVSW9. The Departmental Guide Skills Checklists listed “Clean and service hospital buildings ...as assigned,” cleaning and sanitizing various patient room/bathroom areas; cleaning labor and delivery rooms, nurseries and operating rooms as assigned; however, there were no competencies specific to cleaning the kitchen and using chemicals in compliance with food safety standards of practice, or for cleaning the hood per manufacturer’s instructions. *2. Staff did not consistently perform cooling log processes for ambient foods such as egg salad, tuna salad and chicken salad. Review of a policy titled Cooling of Food, reviewed 12/24, addressed cooling hot food, but did not address cooling ambient temperature food. Review of the 2022 Food and Drug Administration (FDA) Food Code, §3-501.14 Cooling, showed “Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.” 2022 FDA Food Code Annex 3, 3-501.16 indicated, “Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature “Danger Zone” of 41 degrees F to 135 degrees F for too long.” Observations of refrigerators in the kitchen identified egg salad, chicken salad (both dated 8/11 on 8/11/25 at 10:20 am), and tuna salad prepared (undated, observed 8/12/25 at 10:00 am) by Nutrition Services staff. During an observation of the posted “Cool Down Log” on 8/12/25 at 9:45 am, it showed food cooling monitoring from what appeared to maybe be 8/2/25 to 8/12/25 at 10:30 am. Much of the writing of dates and foods on the log was illegible or poorly legible and the data would be difficult to use if there was ever an outbreak of foodborne illness. The posted log contained one entry for egg salad on 8/12/25, and no entries for chicken salad or tuna salad. Further review of documents titled “Cool Down Log” dated 6/14/25 through 8/12/25 showed no cooling log entries for egg salad, tuna salad or chicken salad until 8/12/25, during the survey, when egg salad was documented, and it was documented on a hot food cooling log, not an ambient food cooling log. Review of food temperature log documents titled “Quality Assurance HACCP Report - Patient,” dated 7/1/25 through 8/11/25 showed Cold Salads (egg, tuna, turkey, chicken) were prepared and served for patients 40 times during that time span. During an interview with DNS on 8/14/25 at 1:20 pm, she stated she never thought of doing ambient cooling logs for tuna salad, egg salad, chicken salad because their ingredients were refrigerated. Review of the hospital’s undated recipes titled “Recipe: Chicken Salad,” “Recipe: Egg Salad,” and “Recipe: Tuna Salad” showed they each listed the amounts of each ingredient to use, the temperature needed to be 40° F (degrees Fahrenheit - a measure of temperature). The portion size was listed as “3- 2 inch 1/6 pans” which was not clear as to what the serving size would be for a patient or customer, or how many servings would be expected from one recipe. The directions showed “Combine and mix.” There was no prompt to check the temperature of the finished product to ensure it hadn’t reached temperatures above 40° F during the preparation process, or to start an ambient food cooling log if the finished product was above 40° F. Review of staff training and competency records provided by Human Resources and DNS showed OH Dietary Cooling and Reheating Foods In-Service was completed by FSW1 and FSW3 on 11/20/24, and was completed by FSW5 on 11/21/24. The curriculum for this in-service is unknown. Review of a document for FSW5 titled “Post Test Cooling and Reheating Potentially Hazardous foods” contained questions related to hot food cooling procedures, but ambient food cooling was not addressed. *3. Staff did not have standardized recipes for pureed foods, and did not puree foods in a manner that created a smooth, soft, mounded consistency or conserved nutritive value and visual appeal for patients. Review of the “Oroville Hospital Diet Manual,” “Puree Diet” section, revised 1/24, showed purpose: “To provide foods that can be successfully and safely swallowed without chewing. The diet consists of foods that are easy to swallow because they are blended, whipped or mashed until they are a smooth texture.” While it provided lists of foods allowed, foods to avoid, and a sample menu, it did not provide any further guidance as to what the consistency of pureed diets should be like. Review of the Nutrition Care Manual from the Academy of Nutrition and Dietetics, accessed 8/24/25, described the desired characteristics of a pureed diet: “Foods in this diet should not require chewing ...These foods are easy to swallow because they are pureed smooth and free of lumps.” Food should stay mounded on a fork with very little or no flow through, to ensure it is not too thin. It should slide easily off a spoon, to ensure it is not too thick. During an observation of lunch tray line (patient meal assembly process) on 8/11/25 at 12:00 pm, three meal trays had pureed diets, and the divided plates held pureed chicken, mashed potatoes and gravy, and pureed broccoli. The pureed chicken and pureed broccoli did not form a soft mound and spread across the plate in a thick liquid-like mass. Review of a report titled Diet Orders, dated 8/11/25 at 11:18 am, showed the diet orders of all patients in the facility, with three out of 99 patients on a pureed diet (excluding patients in the Emergency Department, Same Day Services, Obstetrics, Nursery, and patients with Nothing by Mouth (NPO) or without diet orders). During an observation in the cook’s area on 8/11/25 at 12:00 pm, Food Service Worker 1 (FSW1) stated she was preparing pureed rice. She stated she used a Cream of Rice product and mixed it with water. She stated the process for pureeing was to use either water or vegetable broth. The product she was working with resembled a milkshake consistency. She stated she would like it to be a pudding consistency, and added 2 pumps of “simply thickener” and stirred it with a whisk. The thickener didn’t seem to make much difference in the consistency. At that point the Director of Nutrition Services (DNS) intervened and took over, continuing to thicken the product. Review of staff training and competency records provided by Human Resources and DNS showed an in-service titled “OH Dietary Puree Diets and Utilizing Kitchen Equipment” was completed by FSW1 on 8/26/24, by FSW 3 on 7/25/24, and by FSW5 on 7/30/24. The curriculum for this in-service and whether there was a written or demonstration competency post-test is unknown. Review of a document for FSW1 titled Oroville Hospital Introductory Departmental Guide Skills Check List, signed by FSW1 and the supervisor/manager on 2/2/23 showed FSW1 “Prepares, seasons and cooks food for hospital patients, employees and visitors,” but the document did not include a section/topic for evaluation of competency regarding texture modified diets. During an observation of lunch tray line on 8/12/25 beginning at 11:55 am, one patient received a pureed diet. The divided plate held pureed hamburger, pureed rice with gravy, and pureed beets. Everything on the plate looked brown and white, and the pureed rice and pureed beets ran across the plate in a thick, liquid-like mass. During an interview with the Dietary Supervisor (DS) on 8/12/25 at 4:20 pm, she stated they had a 7-day menu cycle, the recipes were from long ago, and she was not sure where the recipes originated from. When asked if the pureed rice served at lunch was made with Cream of Rice, DS stated “The cooks should only be using Cream of Rice at breakfast. That’s not pureed rice.” In a concurrent observation and interview, FSW 1 provided their recipe binder and showed that all of their pureed recipes were in the back of the binder. The DS was asked to provide copies of all of their pureed recipes. Review of untitled Cook’s Menu Extension Spreadsheets (a tool listing portion sizes and foods to be served for each diet order, each meal, each day), for the 7-day menu cycle showed patients on pureed diets were served pureed entrees including Spaghetti with Meat Sauce, Hamburger Patty with mashed potatoes and gravy, Italian Breaded Chicken, Cheese Enchiladas, Chicken Cordon Bleu, Stuffed Shells with Marinara Sauce, Meatloaf, Foccacia Chicken, Macaroni and Cheese, Pork Carnitas, Garden Chili, Chicken Breast with Grill Marks, and Pot Roast. Review of nine undated pureed recipes provided by the DS on 8/12/25 at 4:20 pm showed they were titled Puree Enchilada Recipe, Puree Italian Breaded Chicken Recipe, Puree Rice Recipe, Puree Pork Chop Recipe, Puree Focaccia Chicken Recipe, Puree Chicken Cordon Blue Recipe, Puree Spaghetti Sauce Recipe, Puree Meatloaf Recipe, and Recipe: Cream of Rice. There were no pureed recipes for pasta, pureed hamburger patty, Stuffed Shells with Marinara Sauce, Macaroni and Cheese, Pork Carnitas, Garden Chili, Chicken Breast with Grill Marks, and Pot Roast, pureed vegetables of any kind, pureed fruit of any kind, or pureed refried beans. Further review of the puree recipes showed the extent of instructions included “Blend to a puree consistency,” with no further guidance as to what the end consistency should be like. Eight out of nine puree recipes did not provide a portion size. Six out of nine puree recipes did not include the yield. Review of a policy titled Food Preparation, revised 4/25, showed “Standardized recipes adjusted to appropriate yield, shall be used when preparing food in large quantity in order to achieve uniformity and predetermined results.” International Dysphagia Diet Standardization Initiative (IDDSI): Review of the Nutrition Care Manual of the Academy of Nutrition and Dietetics, accessed 8/24/25, reflected the current standard of practice for texture-modified diets was adoption of the International Dysphagia Diet Standardization Initiative (IDDSI). Review of the IDDSI website https://www.iddsi.org showed IDDSI is a global framework that provides standardized terminology, definitions, and testing methods for texture-modified foods and thickened liquids to improve safety for individuals with dysphagia (difficulty swallowing). It creates a common language across cultures and care settings for healthcare professionals, caregivers, and patients, reducing confusion and improving patient outcomes, quality of life, and safety during eating and drinking. During an interview with the Speech Therapist (ST) on 8/13/25 at 12:30 pm she was asked what percentage of the patients she saw in the hospital were appropriate for the IDDSI framework. She stated if the case load was 40, 25 patients would be on a special (texture modified) diet. She explained that chewing was a component of the pharyngeal phase of swallowing, so patients with chewing difficulty would also be included. When asked how the hospital planned to move forward with the IDDSI framework, ST stated the plan was to initiate it with the hospital’s Tower expansion, but staff have been told it was going to expand for 5 years now. She explained her understanding from the Nutrition Services Department was, the kitchen in its current state could not accommodate the change to IDDSI, and she didn’t see IDDSI happening any time soon. ST stated she didn’t see what it was in the kitchen that was hindering them from the change now. ST stated many other facilities removed the IDDSI dysphagia diet titles on diets to ease the transition to IDDSI. When asked if the point of IDDSI was to get everyone on the same page with texture-modified diets, to speak the same language and consistently provide the same textures/consistencies in food, ST agreed the facility’s use of the IDDSI standardized language would be important for getting food consistencies right, and for everyone to know exactly what the patient was to receive. ST stated IDDSI was a big project, and at this point, Administration was the hindrance if, in fact, there wasn’t the space in the kitchen to implement it, and if procurement of equipment was required that may not be in the capital expenditure budget. Discussed the types of equipment for IDDSI that have demonstrated to be effective, all of which have a relatively nominal cost.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 42448 Based on observation, interview and record review, the facility failed to ensure their therapeutic diet manual provided comprehensive information regarding renal diets for reference by providers, nursing, dietitians and other staff. This failure had the potential to result in the diet not being ordered appropriately for patients, and for food and beverages to be provided to patients that could compromise their health. Findings: Review of facility lunch meal tray tickets dated 8/12/25 showed paper tickets with preprinted lists of diet orders, lists “special items” such as nutrition supplements, and open spaces where patient food likes and dislikes could be handwritten in. The names and room numbers of patients were handwritten on the tray tickets, the ordered diet or combination diets were circled, and special items or needs were circled or handwritten in. A notable printed diet order choice was written Renal / Non-Dialysis. For patients on renal diets, staff circled “Renal,” and then would circle either “Dialysis” to indicate the Renal/Dialysis diet or would circle all of “Non-Dialysis.” Six out of six patients on renal diets no indicators of any specific protein, sodium, potassium or phosphorus levels ordered by the provider included on their lunch tray tickets. Review of the “Oroville Hospital Diet Manual,” “Renal Diet Therapy” section, revised 5/24, showed the purpose of the renal diet was to address the kidney’s decreased ability to remove waste products from the body for patients with kidney disease or kidney injury. Renal diets often restrict protein, sodium, potassium, and/or phosphorus, and the Renal Diet Therapy section provided examples of those foods, their nutrient content, as well as a sample menu. “The type of renal diet and level of dietary restrictions imposed depend upon the extent of the kidney injury or stage of chronic kidney disease and whether or not the patient requires dialysis ...”. There was no indication of what the hospital’s default/ standard diet parameters were when a provider ordered a Renal Non-Dialysis or Renal Dialysis diet. During an interview with the Chief Clinical Dietitian (CNM) on 8/14/25 at 9:00 am, and concurrent record review of a document titled “Oroville Hospital Diet Manual,” it was noted the Renal Dialysis Therapy section, revised 5/24, did not contain information specific to the facility’s Renal Non-Dialysis diet. The CNM agreed it was not explained in the document. The CNM later returned with a document titled “Clarification of Diet Orders,” revised 11/23, that defined the Renal Dialysis diet as 85 grams protein, 2 grams potassium, 2 grams sodium, and 1 gram phosphorus. The Renal Non-Dialysis diet was defined as 70-75 grams protein, 2 grams potassium, 2 grams sodium, 1 gram phosphorus, but none of this information was provided in the renal diet section for provider or nursing reference. Review of a report titled Diet Orders, dated 8/12/25 at 10:31 am, showed the diet orders of all patients in the facility, with six out of 88 patients on a Renal/Dialysis diet, and one out of 88 patients on a Renal/ Non-Dialysis diet (excluding patients in the Emergency Room, Obstetrics, Nursery, Same Day Services, and patients with no diet order or an order for nothing by mouth (NPO)).”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, the hospital failed to maintain the physical plant and overall hospital environment when: 1. The Level 1 bathroom (BR 1) nearest the entrance to Unit 1 was in general disrepair. 2. Facility door frames were gouged and damaged with missing paint, and walls beneath hand sanitizer dispensers showed bubbling paint. 3. The Unit 6 Shower Room (SR 6) was “out of order” with the shower head “capped” and unavailable for patient use for 77 days. 4. Food and Nutrition Services Department (FNSD) walls and trim throughout the kitchen had holes and damaged missing paint, rendering them uncleanable. 5. FNSD equipment was not well-maintained. 6. Three out of seven observed ice machines were not clean, chemicals used did not meet manufacturer’s specifications, and air gaps were not in place to meet regulatory requirements. 7. FNSD flooring was damaged, and covering was separated from the wall. 8. Nursing unit food pantry counters were damaged and uncleanable. Three of six pantry refrigerators had cracked gaskets. The air gap for the ice machine on Unit 1 did not meet regulatory requirements. These failures created unsafe conditions for patients, visitors and staff with the potential to cause preventable illness or injury, increase risk of fire, decrease life expectancy of and ability to properly clean expensive equipment, encourage microbial growth, attract disease-carrying insects and rodents, and result in foodborne illness or death for patients, staff, and visitors consuming food from the hospital’s food services. (Cross Reference A-0750). Findings: Review of facility policy titled “Utilities Management Program,” dated 2/2023, indicated, “This program is consistent in keeping with the Oroville Hospital philosophy of providing the most comfortable/safest environment for patients, visitors and employees/staff and the best medical care possible.” The program described inclusion of management, preventive maintenance, repair, assessment/evaluation, replacement/installation and follow-up. “All equipment used in the care of patients, use by visitors, staff/employees must be evaluated...to insure that all equipment is safe for its intended use and is adequately maintained to keep it in proper operating condition.” 1. During an observational tour on 8/14/25 at 1 pm, observed the Level 1 bathroom (BR 1) nearest the entrance to Unit 1 which was available for use by patients, staff, and visitors. Observed a wall thermostat that was not covered, which exposed sharp metal inner components; cracked and dirty floor tiles; a rusty-appearing loose metal strip hanging from the bottom of the stall wall nearest the sinks; dirty grout along the bottoms of the wall between the sink and stall wall; chipped/scratched/worn-off paint at the stall door’s lock and top of the door, which exposed bare metal underneath; and dried brown water rings on white ceiling tiles. During a concurrent observation of BR 1 and interview with Director of Plant Operations (DPO) and Assistant DPO (ADPO) on 8/14/25 at 1:125 pm, DPO stated the thermostat was not plugged into anything electrical, but DPO and ADPO acknowledged the thermostat should have a cover. When asked about the stall structure, DPO stated, “Paint needs to happen.” DPO and ADPO acknowledged the large patches of missing paint on the stall doors should be fixed and that the loose rusty-appearing piece of metal at the bottom of the stall wall was a safety issue with the potential to cause harm to someone who was scratched by it. DPO stated the ceiling tile rings were not wet, but they “need to be painted.” 2. During an observation on 8/11/25 at 10:15 am, multiple doors to patient rooms on Unit 3 were seen to be chipped, gouged, and heavily damaged. During a concurrent observational tour of Unit 1 and interview with Director of Medical-Surgical Services (DMS) on 8/12/25 at 3:03 pm, observed Unit 1 hallways with multiple scratches in the paint on walls and doorframes, small holes in drywall outside of Room 125, dirty floors, a cracked wall plate outside Room 125, and “bubbled up” paint beneath hand sanitizer dispensers throughout the hallways of Unit 1. DMS stated maintenance intermittently came through and scraped the bubbled paint off the walls and repainted. Observed the patient pantry on Unit 1 with dirty floor around sink pedals and patient refrigerator. There was an approximately 1-inch tall x 12-inch long piece of pink Formica-type covering missing from the counter edge that exposed plywood (uncleanable) underneath. DMS acknowledged the floor in the patient pantry was not clean. DMS stated the floors were the responsibility of housekeeping staff to clean, but maintenance staff patched/puttied damaged floor tiles. DMS stated the counters are typically cleaned by housekeeping, but if a staff member spilled coffee grounds, for example, they would clean it. During an interview with Director of Infection Prevention (DIP) on 8/13/25 at 8:32 am, DIP acknowledged damaged paint and holes in walls were “a problem throughout the hospital.” DIP acknowledged the Environmental Services (EVS) Director was out on leave and stated she did not know who was responsible for Quality Assurance for EVS. DIP acknowledged dirty floors throughout the facility, stating, “It’s a big challenge.” DIP acknowledged chipped and bubbled paint, stating, “Bare sheetrock can’t be cleaned. We can apply cleaner, but it’s not 100% ensured clean.” DIP stated, “We’ve mitigated some of that with nonporous tape until it’s [bare sheetrock] removed.” During a concurrent observation and interview with Registered Nurse (RN) D on 8/14/25 at 8:30 am, the wooden door to patient room 312 was seen to be visibly chipped and damaged, with missing chunks of wood. RN D stated “Yes, that’s damaged.” 3. During an observational tour of the facility on 8/11/25 at 12 pm, observed an “Out of Order” sign posted on the door of SR 6 on the Same-Day Surgery Unit (“Unit 6”). Asked how long the shower had been out of order, Registered Nurse (RN) S stated they were unsure, but it had “been a while.” RN S stated maintenance would know. On observation inside SR 6, the shower head was “capped,” and the Chlor-Hex 2 shower soap was outdated (expired 5/2025). RN S stated patients “don’t usually shower” on Unit 6. When asked what staff would do if a patient requested a shower, RN S stated the patient would be taken to a shower room on Unit 3. During an interview with Director of Plant Operations (DPO), Environmental Services Supervisor (EVSS 1) and Environmental Services Superintendent (EVSS 2) on 8/11/24 at 4:24 pm, discussed SR 6 being “out of order.” DPO stated he believed the shower had been dripping and was capped. DPO could not state how long it had been out of order. When asked what nursing staff should do if a patient wanted to take a shower, DPO stated staff could take the patient to Unit 3. During concurrent interview with Chief Nursing Officer (CNO) on 8/13/25 at 4 pm and review of “Maintenance Work Request Log Sheets,” dated 5/2025, the logs indicated: A. 5/28/25 (77 days ago): Staff notified maintenance that the shower on Unit 6 (Department Code 7760) next to Room 603 was leaking, “take head apart, search for shut off in ceiling unable to locate [sic].” 1.5 hours. B. 5/28/25: ‘Shower leaking, take apart try to look for water shut unable to locate [sic].” 1.5 hours. When asked what nursing staff should do if a patient wanted to take a shower on Unit 6, the CNO stated staff would “have to offer a bed bath.” CNO stated the shower had now been “fixed,” however. CNO stated she didn’t have the August Maintenance Work Request Log Sheet yet because they hadn’t been created yet, so there was no documentation of the fix. During observation of SR 6 on 8/13/25 at 4:26 pm, observed the “Out of Order” sign had been removed, a new shower head had replaced the previous “cap,” and confirmed running water was available from the shower head. The expired Chlor-Hex 2 shower soap was still present in the shower. 42448 4. During the initial tour of the hospital kitchen on 8/11/25 beginning at 9:40 am, paint was worn, damaged and missing throughout all Nutrition Services areas. There was wall damage above the coffee machine; four out of four air vents were soiled and with chipped paint; and there were six holes in the wall in the salad production area. An electric box fan had dust and grime accumulated and was positioned on top of cabinets where it could blow over most of the food production area. There was wall damage near the reach-in refrigerators, and around the edges of the hood. The dry storage room had wall damage, holes, and rusted shelving. Electrical boxes and conduits near the ovens/hood, and meal cart storage area were thick with dust and grime. In further observation of the kitchen during the initial tour on 8/11/25 beginning at 9:40 am, two out of six handles on the cabinets above the salad prep area were damaged, the finish was chipped off, and they were uncleanable. Wood cabinets that stored catering equipment were damaged interior and exterior, the finish was worn off in many areas, and they were uncleanable. During an interview with the Director of Plant Operations (DPO) on 8/11/25 at 3:05 pm, he stated Plant Operations responsibilities in the kitchen included maintenance of wall paint, and repair of holes in walls, and maintenance of cabinets. During an interview with DPO on 8/13/25 at 9:00 am, he stated Plant Operations was staffed 24 hours per day, seven days per week. He stated the night shift went into the kitchen to do any repairs, and they had a work order to go through the kitchen monthly to check equipment. They had a list of equipment to check. 5. During an interview with the Director of Plant Operations (DPO) on 8/11/25 at 3:05 pm, he stated Plant Operations responsibilities in the kitchen included maintenance of equipment (or call a repairman). A. Hood During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am the hood was not clean. The hood showed a film of grease over all areas and had visible drips of grease along the hood lights, grease and dust on hood filters and fire sprinklers. During an interview with the DPO on 8/13/25 at 9:00 am, he stated he assumed EVS was cleaning the hoods, and the hood was not on the list for Plant Ops to check in Dietary. Review of the undated owner’s manual for the hood, titled “Hoodmart Commercial Kitchen Hoods Installation, Operation, and Maintenance Manual” showed “According to NFPA (National Fire Protection Association), dirty hoods are the major cause of fire in commercial kitchens.” The hood maintenance guidelines directed daily and weekly cleaning tasks (assigned to Environmental Services (EVS)). They recommended hospital kitchens to have a certified hood cleaning company inspect and professionally clean their hood system every 90 days (3 months). They specified monthly preventive maintenance should be done including checking and addressing the condition of drive belts for tension, fraying and wear, replace when necessary. Clean exhaust fan wheel inside of fan housing. Heavy grease build up could be a fire hazard and could also cause the exhaust wheel to become unbalanced, resulting in premature bearing wear. Review of a receipt titled Proclean Restaurant Hood Exhaust Cleaning showed the hospital’s hood was last professionally cleaned 3/24/25 (approximately five months ago). Review of a document provided by the Director of Plant Operations (DPO), titled “Dietary PMs” (Preventive Maintenance), dated completed 4/1/25, did not show any preventive maintenance tasks related to the hood. B. Refrigerators During an observation of the Hobart 2-door reach-in refrigerator on 8/11/25 at 10:25 am, the interior shelving and the condenser fan protective cover were rusted. The door frames and gaskets had an accumulation of condensation, soil and mold. Review of a document provided by the Director of Plant Operations (DPO), titled Dietary PMs, completed 4/1/25 showed the cook’s Hobart refrigerator was checked on 4/1/25 including “clean coils, check temp, check door gasket, check operation.” C. Walk-in Freezer During an observation of the inside of the walk-in freezer on 8/11/25 at 10:25 am, there was an accumulation of ice on the ceiling and condenser fan shield. Review of a document provided by the Director of Plant Operations (DPO), titled “Dietary PMs,” completed 4/1/25, showed the walk-in freezer was not included on the list as equipment to be monitored or serviced. 6. Review of a policy titled Infection Control Practices (Dietary Department), revised 4/25, showed: “The outside of ice machines (including delivery system) are to be cleaned and sanitized regularly.” “The ice machine will be cleaned by the Engineering Department per the Manufacturer’s instructions and per the preventative maintenance schedule. The Manufacturer’s instructions are maintained by the Engineering Department.” During an interview with the DNS on 8/11/25 at 10:20 am, she stated the Maintenance (Plant Operations) department was responsible for cleaning the ice machines. During an observation and concurrent interview with the Director of Plant Operations (DPO) and Assistant Director of Plant Operations (ADPO) on 8/11/25 at 2:40 pm, the DPO showed the Manitowoc ice machine located in the cafeteria. The DPO stated his ice machine guys were not at work that day due to one being on leave and the other is off because he worked the weekend. The DPO stated he and the ADPO knew nothing about cleaning the ice machines. The ADPO removed the cover from the ice machine. A white paper towel test showed black mold growth along the ledge inside the opening from where the cover came off from the cuber area. An observation of nursing unit ice machines, accompanied by the DPO, ADPO and FPM, on 8/11/25 beginning at 2:55 pm showed: Unit 3 - A white paper towel test showed the Follett ice machine had black growth along the back edge of the ice catcher area, under the dispenser chutes. ICU - A white paper towel test showed the Follett Symphony ice machine had a small amount of black growth inside the ice dispenser chute. Units 1, 2, OB, and Emergency Departments - A white paper towel test showed the Follet ice machines were clean. During an interview with DPO, ADPO and the Maintenance Engineer (ME) on 8/13/25 at 9:00 am, the DPO stated the ME was who cleaned the ice machines. The ME stated he had observed ice machine cleaning, but had only actually cleaned the ice machines a couple of times. The ME presented the chemicals he used for ice machine cleaning: NuCalgon Nickel-Safe Ice Machine Cleaner for the Manitowoc ice machine, and Safe Clean Plus Ice machine cleaner for the Follett ice machines. In food production equipment, an air gap serves a critical purpose preventing contamination of the potable (drinkable) water supply from non-potable sources like wastewater or cleaning solutions. This physical separation prevents backflow, which is the unwanted reversal of water flow in the plumbing system. The FDA Food Code (2022) specifies that the air gap between the water supply inlet and the flood level rim of a plumbing fixture or equipment must be at least twice the diameter of the water supply inlet and no less than 1 inch. In ice machines air gaps are crucial to prevent the contamination of ice from backflowing drain water In an observation and concurrent interview with ADPO and ME on 8/13/25 beginning at 9:10 a.m., in the nursing pantries of Unit 1 and Unit 2, the surveyor reviewed the preventive maintenance of the ice machines. ME described the process of cleaning and sanitizing the machine. He stated the machines were cleaned using the manufacturer’s guidance. During the observation it was also noted that the ice machines on Unit 1 and Unit 2 did not have an air gap. The condensation line from Unit 1’s ice machine was placed in a drain that resembled a kitchen sink strainer embedded in the countertop. The condensation line for Unit 2’s ice machine did drain into a floor sink, however there was metal cone shaped attachment placed on top of the drain and the condensation line was placed inside the cone, below the flood level rim of the cone. In a follow up observation on 8/13/25 at 10:15 a.m., ME provided the sanitizing solution for the Unit 2 ice machine. It was noted the manufacturers’ specifications were to use a 5.25% (percent-a way of expressing a number as a fraction of 100), however the facility was using a 6% solution. Improper concentration of bleach on metals may result in weakening of the surface, cause pitting erosion, and rusting over time. 7. Poor repair and maintenance compromises the functionality of the physical facilities. This requirement is intended to ensure that the physical facilities are properly maintained to serve their intended purpose. Requirements for flooring are intended to ensure that regular and effective cleaning is possible and that insect harborage is minimized (Food Code Annex, 20220. During general kitchen observation on 8/12/25 beginning at 9:30 a.m., in the presence of the Dietary Supervisor it was noted there were multiple areas in the ante room outside of the walk-in freezer as well as areas throughout the kitchen where the coving from the flooring was pulling away from the wall. The length of the coving compromise in the multiple areas ranged from approximately 6 inches to greater than 12 inches. During an interview with the DPO on 8/13/25 at 9:00 am, he was asked about the flooring and coving disrepair in the kitchen. The DPO stated it was everyone’s responsibility to notice and report concerns, and Plant Operations did not have a PM on flooring and coving. 8. During concurrent observation of six nursing unit food pantries and interviews with DPO and ADPO on 8/11/25 starting at 2:55 pm, the food pantries were not well maintained. In addition to the unsanitary ice machines and missing air gaps cited above, the Formica counter in Unit 1 was chipped and the edging was broken off. In a concurrent interview, DPO stated they had not received a work order for that. The patient food refrigerator in Unit 2 had a broken drawer. The gaskets were cracked in the patient food refrigerators on both the Obstetrics Unit and the Emergency Department Unit. While the Plant Operations Department had some semblance of a preventive maintenance program, their lists may not reflect the manufacturer’s guidance for preventive maintenance and steps/products to be used. For example, further review of the document titled Dietary PMs, completed 4/1/25, listed “Cooks refers (refrigerators) (Hobart/True) - Work performed: clean coils, check temp, check door gasket, check operation.” Review of a “True Reach-in Refrigerator Manual” regarding preventive maintenance showed these tasks: A. Monthly: Verify appliance maintains temperature; inspect power cord for damage; inspect the overall condition of the appliance and its components such as castors, doors, and hinges; inspect any lamp holder connections, LED modules and LED module connections; B. Quarterly: Also check the physical condition of all gaskets and verify gaskets seal correctly; check physical condition of all condenser coils and evaporator coils; straighten fins as needed; Check all condenser coils (fronts and backs) for dust and debris, clear the debris; Verify the drain line is clear of debris. C. Annually: Also verify the power cord is fully plugged into the wall receptacle; Verify operation of all moving parts (such as fans motors, doors and door cords. In addition, the Dietary PMs list, or any other apparent system, did not include other areas within the responsibility of Plant Operations. There were no prompts for Plant Operations staff to look for, ask about, write a work order, or address the condition of paint, holes in walls, rusted interiors of refrigerators, ice accumulation in the walk-in freezer or other damaged equipment such as cabinet handles in the Nutrition Services Department. 17065 In food production equipment, an air gap serves a critical purpose preventing contamination of the potable (drinkable) water supply from non-potable sources like wastewater or cleaning solutions. This physical separation prevents backflow, which is the unwanted reversal of water flow in the plumbing system. The FDA Food Code (2022) specifies that the air gap between the water supply inlet and the flood level rim of a plumbing fixture or equipment must be at least twice the diameter of the water supply inlet and no less than 1 inch. In ice machines air gaps are crucial to prevent the contamination of ice from backflowing drain water In an observation and concurrent interview with ADPO and ME on 8/13/25 beginning at 9:10 a.m., in the nursing pantries of Unit 1 and Unit 2, the surveyor reviewed the preventive maintenance of the ice machines. ME described the process of cleaning and sanitizing the machine. He stated the machines were cleaned using the manufacturer’s guidance. During the observation it was also noted that the ice machines on Unit 1 and Unit 2 did not have an air gap. The condensation line from Unit 1’s ice machine was placed in a drain that resembled a kitchen sink strainer embedded in the countertop. The condensation line for Unit 2’s ice machine did drain into a floor sink, however there was metal cone shaped attachment placed on top of the drain and the condensation line was placed inside the cone, below the flood level rim of the cone. Neither of the drains had the required separation between the water outlet and the rim of the drain. In a follow-up observation on 8/13/25 at 10:15 a.m., ME provided the sanitizing solution for the ice machine on Unit 2. It was noted the manufacturers’ specifications were to use a 5.25% (percent-a way of expressing a number as a fraction of 100), however the facility was using a 6% solution. Improper concentration of bleach on metals may result in weakening of the surface, cause pitting erosion, and rusting over time.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 49418 Based on interview and record review, the Governing Body (GB - Board of Directors/Trustees, responsible for the conduct of the hospital, including the quality of care provided to patients) appointed a Director of Infection Prevention (DIP) who lacked the required certifications specified for the role. This failure had the potential for an unqualified DIP to lead the hospital’s Infection Prevention and Control Program (IPCP - a system of policies, procedures, and practices designed to prevent/control the spread of infection), which jeopardized the safety and well-being of patients and staff. (Refer to A-0750). Findings: A review of DIP job description titled “Director Employee Health Services/Infection Control/Workers Compensation,” dated 7/2019 and signed by the DIP on 1/16/24, indicated: A. “Professional Certifications” were required in Occupational Health Nursing Specialist (OHNS) and Infection Control (a timeframe to achieve the certifications was not indicated), B. DIP reported to the Chief Operating Officer (COO), and C. Qualifications included “advanced training” in microbiology and infection control. DIP responsibilities included: D. “Supervising and implementing the multiple facets of the Infection Control and Employee Health Program,” E. Ongoing review and updates of the Infection Control Manual based on current state-of-the-art principles and practices. F. Developing and implementing Infection Control Policies and Procedures (P&Ps) in line with federal and state regulations/guidelines/mandates. G. Consulting with Nursing Services, Ancillary Services, and Administration regarding infection control and the purchase of sterilization, disinfection, and decontamination equipment and supplies. H. Providing staff and patient education. I. Management of the facility’s Occupational Safety and Health Administration (OSHA - federal agency that ensures safe and healthy working conditions) Bloodborne Pathogens Standard Compliance Program, Tuberculosis (TB - an infectious lung disease) Exposure Control Plan, Employee Health and Workers Compensation Program, and National Healthcare Safety Network reporting system. J. Conducting Environment of Care surveillance and reporting to Administration. K. Overseeing annual employee TB screenings, Purified Protein Derivative (PPD - a skin test to detect TB infection) testing, and annual flu vaccines. L. Notifying of all reportable diseases to the County Health Department and providing support for their staff with follow-up information collection as directed by Administration. A review of “Job Description for Chief Nursing Officer (CNO),” dated 11/2017, indicated the CNO: A. Provided nursing expertise into planning and decision-making processes within the hospital, B. Ensured safe nursing care to patients of all ages by selecting employees who meet all educational, training, licensure (as appropriate), and experience requirements, C. Provided training/continuing education as indicated to maintain employee competence, D. Maintained safe working conditions as listed in the OSHA requirements, and E. Acted as liaison if needed for staff and other department directors. During an interview with the DIP on 8/13/25 at 8:32 am, DIP stated she had a Registered Nurse (RN) license and was appointed to the DIP position in 1/2024 (20 months ago) after serving as the Interim DIP. DIP stated she was “working on” obtaining the certifications listed in her job description for Infection Control and OHNS. DIP stated she could complete the OHNS certification “by the end of the year.” DIP stated the nationally recognized certification titled Certified in Infection Control (CIC - obtained through the Certification Board of Infection Control and Epidemiology, Inc., or CBIC) was a difficult test but that she would “probably” pass the exam in “about six months.” A review of the CBIC’s “CIC Initial Exam Eligibility Requirements,” (undated; obtained online 8/26/25), indicated the following requirements must be met to be eligible for the exam: 1. Post-secondary education through university, college, or community college in a health-related field such as medicine, nursing, laboratory technology, public health, or biology. 2. Direct responsibility for IPCP in a healthcare setting, reflected in current job description. 3. At least one year of full-time employment OR two years of part-time employment OR 3,000 hours (approximately 18 months) of compensated infection prevention work experience within the last three years. 4. Required practice elements included: a. Identification of infectious disease processes, b. Surveillance and epidemiologic investigation, c. Preventing and controlling the transmission of infectious agents, d. Environment of care, e. Cleaning/sterilization/disinfection/asepsis, and f. At least two of the following three elements must also be accounted for: employee/occupational health, management and communication, and education and research. During a concurrent interview with the Chief Nursing Officer (CNO) and review of the DIP Job Description on 8/13/25 at 4 pm, CNO stated that if a new DIP was appointed without having previously completed the required certifications for Infection Control and OHNS, she would expect the DIP to obtain the certifications “within six months of being eligible to test.” However, CNO added, “It’s not my call. It’s [the Administrator/Chief Operating Officer’s (ADM)].” During an interview on 8/14/25 at 8:15 am with CNO, ADM, Medical Doctor (MD) A, and MD B regarding the Governing Body (GB) and DIP qualifications, the ADM stated the former IPCP Director took a leave of absence in 2023. ADM stated the current DIP served as interim IPCP Director during that period, and he (ADM) was responsible for appointing the current DIP to her position in 1/2024 when the former Director did not return. MD A indicated he was a Co-Chair of the Board and was head of the Infection Control Committee. MD A stated, “I totally agreed with the appointment of [DIP].” CNO stated DIP had “a lot” of nursing experience including as a program manager for a healthcare company that provided medical/mental health services for correctional facilities, sitting on the Workman’s Compensation Board, and working in the Emergency Department. When asked if DIP was actively pursuing certifications in Infection Control and OHNS, CNO stated she believed DIP had taken a Centers for Disease Control and Prevention (CDC - a national organization that protects the public’s health) training course. CNO added, “I know she’s going back to school for her Master’s.” ADM stated the anticipated timeframe for DIP to achieve both required certifications was “within two to three years of appointment.” ADM stated, “I would give a window to obtain them” and, “Over time, we would want her to do the national certification.” When asked how involved leadership was in the DIP’s education, ADM stated he had “no knowledge” specific to certifications the DIP was working on, “so probably not as close as we should be.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, the facility failed to maintain sufficient infection control processes and surveillance to ensure a clean and sanitary environment, prevent potential sources and transmission of infections, and reduce the risk of food- and waterborne illness when: 1. The facility did not follow their Water Management Plan (WMP) Policy and Procedure (P&P) to inhibit growth of Legionella (bacteria that causes severe pneumonia) and other waterborne pathogens (microorganisms in water that cause harmful effects) in the facility water system. 2. Seven of 10 employee files had missing or incomplete immunization documentation. 3. The facility’s nursing unit food pantries were not clean. 4. Elevator floors were not clean, and Bathroom (BR) 1 was in disrepair and was not clean. 5. Upper- and lower-level stairway doors (SD) had dark discoloration at hand and foot levels. 6. The stove hood was not clean and was dripping with grease, a sanitation issue and potential fire hazard. 7. The kitchen was not maintained by the Plant Operations Department in a manner that met professional standards of practice to ensure food safety and sanitation in a hospital kitchen. 8. Kitchen sanitation tasks assigned and budgeted to the Environmental Services Department were not regularly completed in a manner that met professional standards of practice to ensure food safety and sanitation in a hospital kitchen. 9. Kitchen work areas and food production equipment were not clean. 10. Food was not stored in a sanitary manner. 11. Nutrition Services staff did not follow professional standards of practice to minimize the risk of cross-contamination (unintentional transfer of microorganisms with harmful effect) in the kitchen. 12. Nutrition Services staff and Environmental Services staff did not follow manufacturers’ instructions for cleaning fixed equipment (equipment that cannot be put through a dishwasher or 3-compartment sink such as counters, cabinets, carts, small appliances.) 13. Nursing staff did not follow professional standards of practice for use of Personal Protective Equipment (PPE) when delivering meals to patients. 14. Nutrition Services staff did not follow professional standards of practice to monitor and document ambient food cooling. 15. The facility’s ice machines were not clean. 16. The cafeteria beverage dispensing machine tubing was not routinely flushed to prevent microbial growth. 17. The breast milk refrigerator in the Obstetrics Department was not certified by the National Sanitation Foundation (NSF), and staff did not use food-safe chemicals to clean bins that separated and stored patient’s breast milk. These failures: 1. Had the potential to allow Legionella bacteria and other harmful waterborne pathogens (WPs - microorganisms that contaminate water and can cause infection) to grow and cause preventable negative health outcomes, including death, in patients, visitors, and staff. 2. Had the potential to delay treatment of undetected disease/infection in employees and allow transmission to patients, visitors, and staff. 3. Had the potential to result in cross-contamination (unintentional transfer of harmful bacteria or disease-causing microorganisms), foodborne illness (illness caused by ingesting contaminated food), and/or death for patients, visitors, and staff who consumed food from the kitchen. 4. Had the potential to cause illness or injury to patients, visitors, and staff who used BR 1. 5. Had the potential to cause illness to patients, visitors, and staff who touched unclean stairway doors. 6. Created a kitchen fire hazard and the potential for cross-contamination and/or foodborne illness for patients, visitors, and staff who ate food prepared on or near the stove. 7. Had the potential to cause cross-contamination and/or foodborne illness for patients, visitors, and staff who worked in or ate food prepared in the kitchen. 8-12. Had the potential to cause cross-contamination and/or foodborne illness for patients, visitors, and staff who ate food prepared in the kitchen. 13. Had the potential to contaminate food delivered to patients with illness-causing microorganisms. 14-16. Had the potential to cause cross-contamination and/or foodborne illness for patients, visitors, and staff who ate food prepared in the kitchen. 17. Had the potential to cause foodborne illness from contaminated or spoiled breast milk fed to infants and children in the facility. Findings: 1. A review of Director of Infection Prevention (DIP) job description titled “Director Employee Health Services/Infection Control/Workers Compensation,” dated 7/2019 and signed by the DIP on 1/16/24, indicated DIP responsibilities included “supervising and implementing the multiple facets of the Infection Control and Employee Health Program.” DIP responsibilities included: A. Ongoing review and updates of the Infection Control Manual based on current state-of-the-art principles and practices. B. Developing and implementing Infection Control Policies and Procedures (P&Ps) in line with Federal and State regulations/guidelines/mandates. C. Consulting with Nursing Services, Ancillary Services, and Administration regarding infection control and the purchase of sterilization, disinfection, and decontamination equipment and supplies. D. Providing staff and patient education. E. Management of the facility’s Occupational Safety and Health Administration (OSHA - federal agency that ensures safe and healthy working conditions) Bloodborne Pathogens Standard Compliance Program, Tuberculosis (TB - an infectious lung disease) Exposure Control Plan, Employee Health and Workers Compensation Program, and National Healthcare Safety Network reporting system. F. Overseeing annual employee TB screenings, Purified Protein Derivative (PPD - a skin test to detect TB infection) testing, and annual flu vaccines. A review of “Job Description for Chief Nursing Officer (CNO),” dated 11/2017, indicated the CNO: A. Provided nursing expertise into planning and decision-making processes within the hospital, B. Ensured safe nursing care to patients of all ages by selecting employees who meet all educational, training, licensure (as appropriate), and experience requirements, C. Provided training/continuing education as indicated to maintain employee competence, D. Maintained safe working conditions as listed in the OSHA requirements, and E. Acted as liaison if needed for staff and other department directors. Review of document titled “All Facilities Letter (AFL - a letter from the California Department of Public Health to health care facilities) 18-39,” dated 9/17/18, indicated “Subject: Reducing Legionella Risks in Health Care Facility Water Systems.” The AFL served to notify of the requirement to reduce the risk of Legionella in facility water systems. The AFL indicated facilities “must develop and adhere to Policies and Procedures (P&Ps) that inhibit microbial (microorganisms, especially disease-causing bacteria) growth” and the spread of Legionella and other “opportunistic pathogens” (can cause infection when a person’s immune system is compromised) in building water systems, for example: A. “Pseudomonas (bacteria found in soil and water), B. Acinetobacter (a drug-resistant “superbug” found in soil and water, potentially fatal), C. Burkholderia (bacteria found in soil and water), D. Stenotrophomonas (multidrug-resistant bacteria found in water and hospital equipment like inhalers and ventilators), E. Nontuberculous mycobacteria (an atypical bacteria found in soil, water, and dust), and F. Fungi (organisms such as yeast and molds).” A review of the “American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE - an international society of professionals that provides technical recommendations and minimum requirements for safe building operations) Guideline 12-2023,” dated 2023, indicated: I. In Section 4, “Legionellosis and Legionella: 4.2.2 Legionella in Building Water Systems:” a. Legionella bacteria are present in most natural water sources, often in low/undetectable concentrations. b. Complete elimination of Legionella bacteria from building water systems is “difficult to achieve and typically not sustainable.” c. Water entering a building, even if treated, is subject to formation of biofilm (a community of bacteria, fungi, or other microorganisms that forms a slimy layer and attaches to surfaces like water pipes) and microbial colonization. II. In “Informative Appendix C: Testing for Legionella in Building Water Systems:” a. Testing water samples for Legionella may be appropriate to confirm that a water management program effectively controls hazardous conditions throughout the building water systems. b. Testing for Legionella may help evaluate potential growth and transmission sources. c. Facilities with higher risk of disease, including healthcare facilities that care for at-risk patients, may find information from Legionella testing useful. A review of the Centers for Disease Control and Prevention (CDC) website titled “Control Legionella: Routine Testing for Legionella,” dated 1/3/25, indicated Legionella testing may be useful for: A. Routine Purposes: Establishing a baseline measurement of bacteria present, evaluating potential growth/transmission sources, and validating a water management plan (WMP). B. Non-routine Purposes: Confirming success or failure of remedial treatment (treating contaminated water of infectious agents), investigating potential sources of environmental exposure for people with disease. ASHRAE and the CDC recommended storing hot water above 140 degrees Fahrenheit (F - a unit of measure) and maintaining the water in circulation above 120 degrees F. Review of California State Water Resources Control Board “Legionella Assessment and Management Program System (LAMPS - a cloud-based application used by professionals to create/execute WMPs that control waterborne pathogens) WMP Checklist,” retrieved from the Internet 8/28/25, indicated WMPs “must be properly tested at key locations” for Legionella and other pathogens “from time to time” to determine whether control is adequate with the existing water quality conditions and control measures. During review of facility P&P titled “Guideline for Water System Purification of Legionnaires’ Disease,” dated 4/2022, the P&P indicated (1) an investigation would begin “upon identification of Legionnaires’ disease” in the facility and (2) which water treatment protocols to use “should a Legionnaires’ outbreak occur.” The P&P recommended that water heaters in domestic water systems (delivers water for hygiene, cooking, patient care, environmental cleaning, and equipment) be kept at a minimum of 140 degrees F and that all water be delivered at each outlet at a minimum of 122 degrees F. The P&P indicated rubber and plastic gaskets in the plumbing system may serve as a Legionella growth medium (a place that supports growth), identifying and removing stagnate water zones was “essential,” and staff should identify and test the integrity of backflow preventers (keep contaminated water from flowing into clean drinking water lines) to assure protection from cross-contamination. During review of facility P&P titled “Water Management for Legionnaires’ Disease Prevention,” dated 4/2022, the P&P indicated: A. The likelihood of contracting Legionnaires’ disease depended on the level of contamination in the water source, the susceptibility of the person exposed, and the intensity of exposure to the contaminated water; therefore, control and prevention measures were “imperative.” B. Water conditions that tended to promote Legionella growth included cooling towers, water heaters that operated below 140 degrees F and delivered water to taps below 122 degrees F, stagnant water in fire sprinkler systems, warm water for eye washes, showers, and water stored below 68 degrees F. C. Water sampling guidelines instructed staff to (i) trace the route of service from the point of entry of the water supply, (ii) take water samples from incoming water supply, each storage tank and water heater, a representative number of faucets from each of the hot and cold water systems, cooling towers, evaporative condensers, showers, and water entering/leaving any other type of fitting or piece of equipment under suspicion. D. Water sample culturing for the presence of Legionella would be performed by a CDC certified laboratory, with guidelines for interpreting culture outcomes provided. A review of 24 facility documents from 2025 titled “South Equipment Daily Check,” dated January 1, 18, 27; February 7, 15, 16; March 1, 13, 26; April 13, 29, 30; May 23, 26, 31; June 10, 19, 29; July 18, 22, 27; and August 10, 11, 12, indicated one temperature reading for each day as follows: A1. Domestic Hot Water Heater 1 Setpoint (thermostat setting) was 120 degrees F on the 24 recorded days. A2. Domestic Hot Water Heater 1 (actual) Tank Temperature was measured between 112-120 degrees F on 24 of 24 days. B1. Domestic Hot Water Heater 2 Setpoint was 118 degrees F on the 24 recorded days. B2. Domestic Hot Water Heater 2 Tank Temperature was measured between 111-123 degrees F on 24 of 24 days. During an interview with Director of Infection Control/Employee Health Services/Workers Compensation (DIP) on 8/13/25 at 8:32 am, DIP stated Facilities staff provide oversight for the WMP. DIP stated, “We do test for bacteria, but maybe not Legionella,” adding, “I think 2020 was the last time it was checked.” DIP stated water temperatures were tested “regularly.” During concurrent interview with the Assistant Director of Plant Operations (ADPO) and review of “South Equipment Daily Check” documentation (dates listed above) on 8/18/25 at 2:10 pm, ADPO stated water temperatures were checked three times a day at Domestic Hot Water Heaters in three areas of the facility: North, South, and (unnamed area). ADPO stated the South water heaters covered the Intensive Care Unit and Units 1 and 2, and the North area covered the Emergency Department, Same-Day Surgery (Unit 6), X-ray, and Units 3 and 4. (Note: Documentation of temperature checks in the North and unnamed areas was not provided when “temperature logs” were requested prior to this interview.) ADPO stated water in the South area “mixes at the tanks,” and the temperature gauge shows the mixed water temperatures. ADPO stated the “highest setpoint should be 122 degrees or less, or it will cause burns.” ADPO stated water temperatures are tested where the water mixes at the tanks but is not tested in any rooms or elsewhere. ADPO stated, “We aren’t testing for Legionella.” Asked how the facility would know if Legionella or other pathogens were in the water without testing, ADPO stated, “I don’t know if it’s there or not” and that the former Infection Preventionist had been “steering that train.” During an interview with Chief Nursing Officer (CNO) on 8/18/25 at 2:20 pm, informed CNO the ADPO stated they were testing water temperatures at the tanks but not at water faucets per their policy. CNO acknowledged they should be following their policy. State Agency requested proof of water culture results at any point in the last two years. CNO stated she knew Dialysis staff cultured the water from dialysis machines (act as an artificial kidney filtering waste products and excess fluid from the blood, returning “cleaned” blood to the body), but she “wasn’t sure” about water cultures in the rest of the hospital. CNO stated she would look for culture results. During an interview with CNO on 8/18/25 at 2:50 pm, CNO provided proof of dialysis water cultures from dialysis machines and a P&P issued by Dialysis Services titled “Water Culture Procedure,” dated 6/2025. CNO stated she could not locate specific water culture results for other areas in the hospital. Asked how the hospital might know if there was Legionella or other WPs present in the water system, CNO stated, “As a nurse, I’d look under a microscope” to confirm presence or absence of WPs. SA asked if they used ASHRAE as a resource for their WMP, noting their WMP P&P listed CDC but not ASHRAE as a nationally recognized source for their policy. CNO stated the policy was last revised in 2018, and she did not have access to this policy prior to 2017. CNO stated, “I feel we need to send this to Infection Prevention for revision.” 2. Review of facility P&P titled “Immunization of Health Care Worker,” dated 2/2025, indicated its purpose was to comply with Federal and State requirements to ensure the health and safety of employees, patients, families, and workers from potentially harmful, infectious exposures or outbreaks. The P&P indicated a health screening/review was to be conducted prior to employees beginning their assignment. This included: A. Completion of a health questionnaire and subsequent physical exam, recording any condition predisposing the employee to infections. B. Documentation of past diseases, vaccination history, and/or immunity for measles, mumps, rubella (German measles), varicella (chickenpox), Hepatitis B (viral infection that causes liver inflammation), tetanus, meningococcal disease (causes inflammation of brain and spinal cord), seasonal influenza (flu), and seasonal Covid-19. Seasonal vaccines such as flu and Covid were to be offered to employees; those wishing to decline “must do so in writing.” C. Screening for tuberculosis (TB - infectious bacterial lung disease) infection or disease. D. Procedure: Without prior disease or vaccination documentation, an antibody titer (blood test that measures immune response to a virus, bacterium, or vaccine) was needed. Employees with negative titers (not immune) “must be vaccinated or decline the vaccine in writing.” A review of the CDC website titled “Baseline TB Screening and Testing for Health Care Personnel” dated 12/19/23, a TB test helps determine if someone is infected with Mycobacterium tuberculosis (Mt), the bacteria that causes TB. There are two ways to test for TB: A. A Mantoux TB skin test: A small amount of tuberculin (a substance derived from Mt) is injected into the skin, and the results are visually read (looking for a skin reaction) by a medical professional within 48 to 72 hours. If the test is not read within 72 hours, the result is invalid, and a retest must be performed. B. Interferon-gamma release assay (IGRA): A simple blood test processed in a lab with a definite positive or negative TB result. The two blood tests available are QuantiFERON-TB Gold Plus and T-Spot. During an interview with the Director of Infection Prevention (DIP) on 8/13/25 at 8:32 am, DIP stated an initial check of immunization records and antibody titers for baseline immunities was performed at the time of each new hire. DIP stated free flu shots were offered annually to all employees and that staff must receive a vaccine or sign a declination annually. DIP stated employees were asked TB screening questions annually, noting that every four years they must also have a TB test (skin or blood test) or a chest x-ray to confirm the absence of TB infection. DIP stated that Covid vaccines were no longer required; they used to offer them alongside flu vaccines but have stopped doing so. During two interviews with DIP on 8/14/25 at 11:15 am and 2:55 pm and concurrent review of 10 employee health files: A. DIP acknowledged Patient Care Technician (PCT) A’s “Tuberculosis (TB) Screening Questionnaire” was not dated, and two screening questions were not answered by PCT A. DIP stated she was unable to determine PCT A’s TB status from the form due to incomplete documentation. B. DIP acknowledged Registered Nurse (RN) E was missing documentation of flu vaccination/declination for the 2020-2021 season. C. DIP acknowledged the Director of Medical-Surgical Services (DMS) had an incomplete and undated “TB Screening Questionnaire” and lacked documentation of flu vaccination/declination forms from 2020 and 2021. D. DIP acknowledged the Director of Interventional Services (DIS - minimally invasive medical procedures guided by imaging) was missing documentation of a 2023-2024 flu vaccination/declination form. E. DIP acknowledged Medical Doctor (MD) D was missing documentation of a “TB Screening Questionnaire” for 2020, 2021, and 2022 and flu vaccination/declination forms for 2020, 2021, 2022, and 2023. F. DIP acknowledged RN C was missing documentation of a flu vaccination or declination form for 2022. G. Review of RN N’s 2022 TB skin test documentation from an annual physical exam at an outside facility, dated 9/9/22, indicated a TB test had been given on 7/21/22 at 12:30 pm, but the result was not documented until 7/26/22, indicating it was read at 1 pm (greater than 72 hours). DIP acknowledged dates on the form showed “inconsistencies” and that it was possible the test was not read within the appropriate timeframe. DIP stated she was “unsure” but that the other facility deemed it a “complete” test, so they did, too. 3. Review of P&P titled” Infection Control Practices (Dietary Department),” revised 4/2025, indicated: “1. Food for patients is stored in refrigerators or other locations designated and labeled for patient food only ...b) 1) The Nutrition Services staff will assist monitoring pantries, discarding or removing items that have expired.” Review of P&P titled “Stocking Nourishment Centers,” reviewed 3/2025, showed a Nutrition Services staff member made rounds of the nursing unit pantries daily, checked on supplies, discarded out-of-date items and restocked them, logged refrigerator temperatures, and notified the Maintenance Department if they were out of range. The P&P indicated, “Routine or as needed cleaning of the refrigerators is via Nursing to Environmental Services.” A concurrent observation of nursing unit food pantries and interviews with the DPO, ADPO and FPM on 8/11/25 beginning at 2:55 pm indicated: A. Unit 2 - The patient food refrigerator was in poor condition and had a broken drawer. The interior of the microwave oven was soiled with food debris. B. Unit 1 - The edging on the Formica countertop was broken, exposing plywood (a porous, uncleanable surface). The DPO stated there was no work order for it. The refrigerator was soiled. The floor was not clean, especially in front of the refrigerator door, with evidence of brown dirt-like particles and a dried brown spilled substance along floor edges, sides of refrigerator, and walls. C. OB Unit - The refrigerator gaskets were cracked. The condiment bins in drawers were not clean. D. Emergency Department - The exterior of the refrigerator was soiled and had tape residue. The interior of the refrigerator was soiled, and its gaskets were cracked. The microwave oven had extensive food debris and splatter inside. Food storage and equipment drawers had built up grime and food debris inside. During an interview with Environmental Services Supervisor (EVSS) 1, EVSS 2, and Director of Plant Operations (DPO) on 8/11/25 at 4 pm, they were asked how nursing pantries were cleaned. EVSS1 stated EVS cleaned them. They took out the trash, cleaned the trash cans if they needed it, did floor care, cleaned the sinks, and wiped down the counters with Quaternary (Quat - a cleaning chemical that kills germs, bacteria, and viruses) sanitizer. He stated Dietary should clean the microwave oven if it was used for patients, or nursing should clean it if it was used for staff. During a concurrent observation and interview with Director of Medical-Surgical Services (DMS) on 8/12/25 at 3:03 pm, observed the Unit 1 patient pantry with evidence of cracked/broken floor tiles, brown dirt-like particles and dried spills around hot/cold sink foot pedals, under and around the refrigerator, on the wall next to the refrigerator, and along baseboards. Observed a thick layer of dust on top of the refrigerator and thick, cream/rust-colored, dried water deposits around the lid of the patient coffee pot. DMS acknowledged the refrigerator, wall, coffee pot, and floors were not clean. DMS stated floors were the responsibility of Housekeeping to clean but that Maintenance staff would patch or putty holes in floors. During an interview with Director of Infection Prevention (DIP) on 8/13/25 at 8:32 am, DIP was informed the State Agency team observed the facility’s floors were dirty throughout. DIP noted the floors were old and stated, “It’s a big challenge, but EVS over the past year has done a lot.” DIP stated they were “taking steps to fix it.” DIP acknowledged dirty floors can “harbor bacteria and body fluids.” DIP stated she did “infection surveillance” following the National Healthcare Safety Network (NHSN - Centers for Disease Control and Prevention healthcare-associated infection tracking system) plan. When shown pictures of Unit 1 patient pantry floors, DIP acknowledged they were not clean. During an interview with Chief Nursing Officer (CNO) on 8/14/25 at 10 am, CNO was shown photos of unclean Unit 1 patient pantry floors, coffee pot, top of refrigerator, and exposed plywood on the countertop. CNO acknowledged these areas were not clean and were an infection control risk. 4. During an observation on 8/11/25, 8/13/25, and 8/14/25, the public elevators located near the main lobby and Elevators 1 and 2 near Unit 1 were observed to have buildup of grey and black dusty debris in each corner of the elevator floor. This debris remained for the duration of the survey. When wiped with a white paper towel, the towel showed brown/black grime and dirt. During an interview with DIP on 8/13/25 at 8:32 am, DIP acknowledged dirty floors can “harbor bacteria and body fluids.” During an observational tour on 8/14/25 at 1 pm, observed the Level 1 bathroom (BR 1) nearest the entrance to Unit 1. Observed a wall thermostat that was not covered, which exposed its sharp metal “innards;” floor tiles with dark dirt-like smudges; white dried drip marks on the outer stall wall; a rusty-appearing loose metal strip hanging from the bottom of the stall wall nearest the sinks; dirty grout along the bottoms of the wall between the sink and stall wall; chipped/scratched/worn-off paint at the stall door’s lock and at the top of the door exposing bare metal underneath; black kick marks on the wall next to the toilet; and dried brown water rings on white ceiling tiles. During a concurrent observation of BR 1 and interview with Director of Plant Operations (DPO) and Assistant DPO (ADPO) on 8/14/25 at 1:125 pm, DPO stated the thermometer was not plugged into any electrical, but DPO and ADPO acknowledged the thermostat should have a cover. When asked about the stall structure, DPO stated, “Paint needs to happen.” Both acknowledged the large patches of missing paint on the stall doors should be fixed, and the loose rusty-appearing piece of metal at the bottom of the stall wall was a safety issue with the potential to cause harm to someone who was scratched by it. DPO stated the ceiling tile rings were not wet, but they “need to be painted.” DPO and ADPO acknowledged BR 1 did not appear clean. 5. During observational tours of the facility on 8/13/25 at 11:15 am and 8/14/25 at 9:15 am, observed upper-level stairway doors (SD) 1 near the lobby and lower-level SD 2 with dark discoloration at arm level (appeared to be multiple smudged handprints) and at the bottom (where shoes might touch). During an interview with Chief Nursing Officer (CNO) on 8/14/25 at 10 am, CNO was shown photos of SD 1 and SD2. CNO acknowledged the doors were not clean and were an infection control risk. 42448 6. Review of the 2022 FDA Food Code showed: 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. 4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. Review of the 2022 Food and Drug Administration (FDA) Food Code Preface showed “Foodborne illness in the United States is a major cause of personal distress, personal illness and death, and avoidable economic burden.” For persons who are “older adults in healthcare facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening.” Review of a policy titled “Infection Control Procedures; Dietary Service Section,” reviewed 11/21, showed “Procedures in the Dietary Department are established to eliminate the possibility of contamination and cross-infection for the safety of all patients and personnel ...Food Service is an important factor within the hospital, contributing to patient and employee morale, as well as to health maintenance. Unsanitary food service can play a significant role in disease transmission. Maintenance of sanitation standards is of paramount importance in medical-care facilities.” During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am the hood was not clean. The hood showed a film of grease over all areas and had visible drips of grease along the hood lights, grease and dust on hood filters and fire sprinklers, drips of grease from cooking utensils hung near the hood. Walls and equipment near the hood had a film of grease with dust stuck to it. During an interview with the Director of Nutrition Services (DNS) on 8/11/25 at 10:20 am, she was asked about the sanitation and maintenance of hood. She stated they had the hood professionally cleaned every six months, and the Environmental Services (EVS) staff came was responsible for cleaning the hood filters in between the professional cleanings. Review of a receipt titled Proclean Restaurant Hood Exhaust Cleaning showed the hospital’s hood was last professionally cleaned 3/24/25. During an interview and concurrent document review with Environmental Services Supervisors 1 (EVSS1) and 2 (EVSS2), and with the Director of Plant Operations (DPO) on 8/11/25 at 4:00 pm, EVSS1 an undated document titled “NOC Dietary Work Order” showed the responsibilities completed by EVS staff in the kitchen each night and included “Weekly: scrub stove hoods.” During an interview with EVSS1 and Environmental Services Lead (EVSL) on 8/14/25 at 3:25 pm, EVSL stated when EVS staff cleaned the hood filters, they used a ladder, took the filters to the “corral” outside, and sprayed them with water and degreaser until clean. He stated the hood filters should be cleaned by EVS staff twice a week. Review of the undated owner’s manual for the hood, titled “Hoodmart Commercial Kitchen Hoods Installation, Operation, and Maintenance Manual” showed “According to NFPA (National Fire Protection Association), dirty hoods are the major cause of fire in commercial kitchens.” The hood maintenance guidelines directed: Daily: “Inspect grease filters checking for accumulated grease, clean if necessary; Remove grease cup ...clean using mild detergent or degreaser if necessary; Wipe interior of hood to remove accumulated grease and debris using mild detergent if necessary. Do not use abrasive cleaners such as powdered cleaners, or abrasive cleaning cloths; Wipe globes on lights.” Weekly: “Remove baffle grease filters and wash in dishwasher or sink with mild detergent. If application is in a heavy grease-producing environment, more frequent cleaning may be required; Clean entire interior of the hood prior to replacing the baffle filters. Use mild detergent if necessary; do not use abrasive cleaners or cloths. There were additional guidelines for professional hood cleaning every 90 days (3 months), and monthly preventive maintenance of internal drive belts and wheels inside the hood mechanics by Plant Operations. Review of a document provided by the Director of Plant Operations (DPO), titled “Dietary PMs” (Preventive Maintenance), dated completed 4/1/25, did not show any preventive maintenance tasks related to the hood. 7. The kitchen was not maintained by the Plant Operations department in a manner to meet professional standards of practice to ensure food safety and sanitation in a hospital kitchen. During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am, the paint on walls, doors and trim was worn and chipped throughout the food services areas, rendering it uncleanable. There were holes and other damage to the kitchen walls near the hood, coffee maker, in the salad prep area, in the back entry area near the freezer, and in the dry storage room, providing potential harborage for insects and microbial growth. Four out of four air vents had missing paint and were crusted with grime. The exterior and interior finishes of multiple wood cabinets were worn and uncleanable. Two out of six cabinet handles above the salad prep counter had damaged handles with the finish chipped off and were uncleanable. The walk-in freezer ceiling and condenser fan had an accumulation of ice. An observation of the interior of the Hobart 2-door reach-in refrigerator on 8/11/25 at 10:25 am showed the shelves and bottom of the refrigerator were not clean, and the refrigerator shelves and the metal cover for the condenser fan were rusted. The refrigerator door frames and gaskets were soiled, with a large amount of condensation and what appeared to be mold growth, indicating a likely problem with the gaskets. On the exterior of the refrigerator the door handles had a buildup of black grime, and the doors had tape and tape residue, a potential source of cross-contamination. Review of a policy titled Utilities Management Program, reviewed 2/2023, showed “All equipment used in the care of patients, use by visitors, staff/employees must be evaluated ...to insure that all equipment is safe for its intended use and is adequately maintained to keep it in proper operating condition. Review of a document provided by the Director of Plant Operations (DPO), titled Dietary PMs (Preventive Maintenance), dated April 2025 (the most recent) showed the cook’s Hobart refrigerator was checked on 4/1/25 including “clean coils, check temp, check door gasket, check operation.” It included box fans x4 “check operation, clean surfaces, check electrical connections.” There were no prompts to look at, ask about, or address the condition of paint, holes in walls, rust or damaged equipment such as cabinet handles in the department. Poor repair and maintenance compromise the functionality of the physical facilities. This requirement is intended to ensure that the physical facilities are properly maintained to serve their intended purpose. Requirements for flooring are intended to ensure that regular and effective cleaning is possible and that insect harborage is minimized (Food Code Annex, 20220. During general kitchen observation on 8/12/25 beginning at 9:30 a.m., in the presence of the Dietary Supervisor it was noted there were multiple areas in the ante room outside of the walk-in freezer as well as areas throughout the kitchen where the coving from the flooring was pulling away from the wall. The length of the coving compromise in the multiple areas ranged from approximately 6 inches to greater than 12 inches. In a concurrent interview the DS stated she was unsure if the hospital conducted any environmental rounds in the kitchen. She stated to her knowledge the only environmental services staff that routinely entered the kitchen were those staff assigned to empty the trash cans, however she was unsure of the schedule. In an interview on 8/13/25 beginning at 8:30 a.m., the IPRN stated “I do walk-throughs, but I don’t document it in any way.” She also indicated that if issues were identified she would speak to the DFNS. Review of the 2022 FDA Food Code showed: §4-202.16 Nonfood-Contact Surfaces: “Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.” §6-201.11 Floors, Walls and Ceilings, “floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they smooth and easily cleanable.” §4-501.11 “(A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer’s specifications.” 8. No evidence was provided to show kitchen sanitation tasks assigned and budgeted to the Environmental Services department were completed regularly and in a manner that met professional standards of practice to ensure food safety and sanitation in a hospital kitchen. During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am the kitchen was not sanitary. The walls and ceiling were soiled throughout the food services area. Doors and doorknobs had grime. The plastic covering on the meat slicer was sticky with grease. The area behind the ovens and the electrical box near the hood had thick dust and grime. Trash cans were full and had thick buildup of black grime and food debris on all areas of the lid and handles. A box fan, positioned on top of cabinets so it could blow over most of the food production area, had a buildup of black grime and dust, creating the potential for cross-contamination of food. The floor and metal coving edge in front of the cafeteria refrigerator and freezer (both front and back door sides of it) had a buildup of soil and grime. During further observations of the kitchen on 8/12/25 at 9:45 am, and 8/13/24 at 10:00 am, the trash cans continued to exhibit built up grime on the lids and handles. During an interview with the Director of Nutrition Services (DNS) on 8/11/25 at 10:20 am, she was asked about the sanitation and maintenance of her department. She stated Environmental Services (EVS) received budgeted hours to come into the department every night and was responsible for the removal of trash, and the sanitation of trash cans, walls, ceilings, vents, floors, floor drains, hood filters, and loading dock. During an interview and concurrent document review with Environmental Services Supervisors 1 (EVSS1), 2 (EVSS2), and with the Director of Plant Operations (DPO) on 8/11/25 at 4:00 pm, EVSS1 provided an undated document titled “NOC Dietary Work Order” and stated it reflected the responsibilities completed by EVS staff in the kitchen each night. The form showed EVS staff were responsible to: Daily: pull all trash/chairs up; clean coffee van thoroughly and hose (floor) mats; dust mop whole floor/under vending machines; wipe tables/chairs/drinking fountain; clean windows inside and out; sweep/mop; take all mats and trashcans outside/ move food carts into hall; empty all trashes then spray all mats; sweep and mop kitchen; clean and stock bathroom; stock all paper products in kitchen; clean all stainless steel with correct cleaner. Weekly: wipe down vents; use flat mop on walls and ceilings; wipe down pot and pan rack; wipe down salad bar; dust bread rack; scrub floors; scrub stove hoods. Monthly: Lights/food carts. Further review of the “NOC Dietary Work Order” form showed the EVS staff was to work in Dietary from 10:00 pm to 2:00 am (four hours) daily, and in other areas of the hospital from 2:00 am to 6:30 am (4 ½ hours). Review of an EVS policy titled “Dietary Work Schedule “D”,” reviewed 10/23, showed EVS staff were to work an eight-hour shift in Dietary, with twelve areas of responsibility in the department, and 27 tasks that required completion daily including cleaning the floors, the hoods, walls, vents, multiple pieces of food production equipment, and trash can lids. When asked if EVS leadership ever followed up to ensure EVS staff completed their work in Dietary properly and timely, EVSS1 responded supervisors did “weekly check-ins with EVS staff.” The EVSS1 and EVSS2 supervisors were asked to provide documentation of staff completion of the daily NOC Dietary Work Orders for the past 2 weeks, and to provide any documentation of EVS management oversight/check-ins regarding their staff’s work. No documentation was provided by end of survey. During an interview with the Food Production Manager (FPM) on 8/12/25 at 9:50 am, she stated she did not think EVS cleaned the walls, not even occasionally. She stated EVS emptied the trash every night, but it did not appear they washed the trash cans. She stated they did a good job cleaning the floors and floor mats. During an interview with EVSS1 and Environmental Services Lead (EVSL) on 8/14/25 at 3:25 pm, EVSL stated he had worked the EVS night shift (NOC) in the Dietary department. He stated EVS staff worked there from 10:00 pm until about 1:00 am (3 hours), and then they had to start taking calls for service. He stated the EVS staff did Dietary first, for about 2 ½ hours, before other areas started calling, but if they didn’t get called, they could work in Dietary longer. When the surveyor stated it appeared tasks assigned to EVS in the kitchen weren’t being done, or were not done correctly, EVSS 1 and EVSL replied “There is so much to do, and then staff start getting calls” that pull them off to other areas. When asked how long it would take to do the assigned work in dietary correctly and completely, they replied it would probably take five to six hours daily. 9. During the initial tour of the hospital kitchen on 8/11/25 from 9:40 am to 11:15 am the kitchen was not sanitary. In addition to the concerns cited above, utility carts (black carts, meat slicer cart, mixer cart, etc.) had grease, food debris and grime, and the wheels of all carts in food services were thick with grime. Two out of two blender bases and lids were not clean. A wall-mounted wood holder for plastic wrap, the knife sharpener, and the yellow oven timer were black with grime. A thermometer on the wall near the reach-in refrigerators was caked with dust. Two out of two hanging racks near the grill, and 23 out of 23 large metal cooking utensils hung on those racks were covered with grease, including grease drips formed on one ladle. The large mixer had multiple areas with grime and stuck on food debris. The handles, door, hinges, window, and floor of the walk-in freezer were soiled. Muffin tins and at least six out of nine bake pans had burned on food debris. Two out of two rubber spatulas in the cook’s area had chunks of rubber missing from the edges, a potential food contaminant. The finish on six out of six wood handled pancake turners was worn and uncleanable. The grip handle on one dough cutter was broken in half and uncleanable. The ovens interior, exterior and knobs had built up grime. The can opener mount had thick black grime around the edges and down the sides of where the shank inserted into the mount. The Blue Safe Ice Tote on top of the ice machine in the cafeteria was not clean and was not included on a cleaning checklist. An additional area of concern observed during the initial tour included tape and tape residue on refrigerators, cabinets, doors, walls, and other equipment throughout the kitchen, a potential for cross contamination. During an observation of the 3-compartment sink area and concurrent interview with the FPM on 8/11/25 at 10:10 am, the side of a refrigerator abutting the dirty side of the 3-compartment sink held soiled laminated signs and tape residue. A soiled paper towel was left on the counter. The FPM stated the paper towel was soiled, and she could understand how the tape and tape residue was a problem. Review of the 2022 FDA Food Code §4-601.11 showed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 10. Review of the 2022 FDA Food Code 3-305.11 Food Storage showed (A) “Food shall be protected from contamination by storing food the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust or other contamination.” During an observation of the dry storage room on 8/11/25 at 10:40 am, shelving was rusted, a black plastic cart and two out of two round white food storage bins labeled powdered sugar and brown sugar were soiled with food debris and grime, and stored small equipment was dusty. In a concurrent interview with the Dietary Supervisor (DS) and DNS, the DS stated the cart was not clean. She agreed the round white bins and four out of four white rectangular food bins, and plastic disposable lids placed under bin feet were soiled. Small plastic signs mounted on shelves to direct food storage locations had grime build up. When asked if the signs ever got cleaned, the DNS replied “Probably not. It doesn’t look like it.” 11. Oxford Languages Dictionary defines cross contamination as the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect. Review of a policy titled “Infection Control Procedures; Dietary Service Section,” reviewed 11/21, showed “Unsanitary food service can play a significant role in disease transmission. Maintenance of sanitation standards is of paramount importance in medical-care facilities. Prevention of infection in a food service department requires healthy personnel, properly maintained equipment, uncontaminated supplies and an on-going awareness of proper sanitation and hygiene.” 11A. Staff facial hair was not consistently covered. Review of a policy titled Infection Control Practices (Dietary Department), revised 4/25, showed “Personal Hygiene: 1. Proper attire for food handlers must include proper hair covering ...2. Beards, moustaches, facial hair must be covered.” During observation of the dishwashing process on 8/12/25 beginning at 11:30 a.m., it was noted Food Service Worker (FSW) 6 had facial hair, without the benefit of a beard restraint. In a follow-up observation on 8/12/25 beginning at 12:15 p.m., it was noted FSW 6 was working on the tray line (the process of plating patient meal trays) without the benefit of a facial covering. In an interview on 8/15/25 beginning at 12:30 p.m., with the DNS and FPM they acknowledged they had noticed the lack of facial covering, that the hospital had facial covering available, and it was the expectation that staff with facial hair would utilize them. 11B. Unattended cleaning cloths and use/storage of other linens 11B.1. Cleaning rags and other linens that are not directly in use in a staff hand, or are not in a sanitizer bucket can be a source of cross contamination in the kitchen. Review of the 2022 FDA Food Code §3-304.14 showed: “(A) Cloths in-use for wiping food spills from tableware ...that occur as food is being served shall be maintained dry and used for no other purpose. (B) Cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution.” During an interview with the FPM on 8/12/25 at 9:25 am, she stated staff used spray bottles of Quaternary Ammonia (Quat) solutions to clean counters and in food production areas (no sanitizer buckets). Sanitizer buckets were only used in the dish room and were used for cleaning patient meal carts. During multiple observations throughout the survey cleaning rags (Chiks) were left unattended on food preparation surfaces. 8/11/25 at 10:40 am, one on cook’s prep counter 8/11/25 at 10:54 am, one on cook’s prep counter 8/11/25 at 10:54 am, one on Salad prep counter, 8/12/25 at 9:25 am, two on cooks prep counter, two on salad prep counter, one in coffee area. Review of a policy titled “Cleaning Cloths and Hot Pads,” reviewed 3/25, showed the purpose was to prevent cross contamination from improperly cleaned or soiled cleaning cloths or hot pads. It directed staff to use Chix Cloths (one-time use only cloths), and to place them in a bin for soiled cloths after use, but it did not direct staff to store cleaning cloths in sanitizer solution while they were still using them. The policy showed used, washed Chix Cloths could be re-used for deep cleaning but not for sanitizing food contact surfaces. 11B.2. Towels were not stored or used in a sanitary manner, creating potential for cross contamination. During an observation in the kitchen on 8/12/25 at 11:55 am, a stack of white towels had been placed on a shelf above the salad prep area. They were not covered or stored to maintain their sanitation. During an interview with Food Service Worker 1 (FSW1) and FSW2 on 8/13/25 at 10:10 am, they stated they used the stack of towels to clean up spills. During an observation near the 3-compartment sink on 8/13/25 at 9:56 am a large white towel positioned under racks of drying clean equipment and was a potential source of cross contamination. In a concurrent interview, DNS stated the towel shouldn’t be there. Review of the 2022 FDA Food Code §4-801.11 Clean LINENS shall be free from FOOD residues and other soiling matter. 11B.3. Aprons were not stored in a sanitary manner, creating potential for cross contamination. During an observation near the 3-compartment sink area on 8/11/25 at 10:10 am, a paper towel was on the counter. In a concurrent interview, FPM stated the paper towel was soiled, shouldn’t be there, and put it in the trash. In a concurrent observation, a black apron was wadded up and left on top of wall-mounted boxes of gloves above the dirty side of the sinks, and its ties dangled down close to soiled equipment stacked on the dirty side counter. In a concurrent interview with FPM, she stated “I would assume it (the apron) is clean because if it was dirty it would be over there (pointed across the kitchen). The apron remained in that location through 8/12/25 and 8/13/25. Review of the 2022 FDA Food Code Annex 4, Page 30 Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors showed F. In order to have active managerial control over personal hygiene and cross contamination, certain control measures must be implemented in all phases of the operation ...the following control measures should be implemented ...Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc., or raw animal foods. 12. Review of a policy titled “Procedures for Cleaning & Sanitizing Equipment in Dietary,” revised 3/25, showed: How to Clean a Bench Can Opener: Daily remove shank, scrub ...run through dish machine, rinse, air dry on clean surface, inspect blade and replace when notched, scrub base plate attached to table with hospital approved detergent, rinse base plate, remove base plate from table, scrape free of all food particles, scrub area, rinse, (no sanitizing process mentioned), replace base plate. How to Clean Tables, Drawers & Shelves: Remove any loose food particles. Wipe with hospital approved detergent. Rinse. Sanitize with Sanitizer at concentration of 200-400 ppm (parts per million). Air dry. Review of the manufacturer’s instructions for Quat Sanitizer II showed it was recommended for use in food service areas. Food Contact Surface Sanitization Directions showed “Wash equipment with a compatible detergent and rinse with potable water prior to sanitizing ...allow use-solution to remain in equipment for at least 60 seconds ...Drain thoroughly and allow to air dry before reuse. Do not rinse with potable water.” Review of the manufacturer’s instructions for Betco Citrus Chisel Cleaner/Degreaser showed Directions for Use: “For use on most surfaces where grease, oil and animal fats are a problem.” “For Food Plant and Other Industrial Use Only. Food contact surfaces are to be rinsed with potable water following treatment with this product. Avoid contamination of food in the application and storage of this product.” 12A. Nutrition Services and Chemical Use During an interview with the FPM on 8/12/25 at 9:25 am she stated kitchen staff used spray Quat bottles on counters and in food production areas (no sanitizer buckets). Quat sanitizer buckets were only used in the dish room and were used for cleaning patient meal carts. During review of the dishwashing process on 8/12/25 beginning at 9:50 a.m., FSW 7 was observed breaking down patient meal trays. FSW 7 indicated she removed leftover food and disposable items from the tray, gave the soiled items to the dishwasher, after which she would clean the patient meal carts. FSW 7 described the process as cleaning the outside and inside with a sanitizer that was dispensed from a pump station in the kitchen. FSW 7 stated this process was completed at the end of each meal. During an interview with FSW 5 on 8/12/25 at 4:20 pm, he stated at the end of his day, he cleaned up his mess. “I wipe everything down.” He stated he cleaned the steamer, the hot box, and went through the refrigerator to check for and discard expired food. FSW 5 stated to clean counters, he sprayed quat sanitizer and wiped it with a disposable cloth. When all food production was finished for the day, he cleaned the stove. He explained that if it was greasy he used degreaser. The Dietary Supervisor (DS) coached him to also say “and soap” as he was describing the process. FSW5 stated he sprayed the degreaser on, let it sit a couple of minutes, then wiped it down with a cloth. When asked if he rinsed it or did anything else, FSW5 stated there was no rinsing, and he just used a towel. When asked further about his use of soap/detergent in cleaning he replied it depended on how dirty something was whether he used any soap of degreaser. He stated he didn’t use soapy water regularly to clean his work area. FSW 5 stated he cleaned the can opener by spraying it with quat and wiping it with a cloth. He stated he never removed the can opener mount to clean it, and did not do any sort of deep cleaning process for the mount. 12B. Environmental Services and Chemical Use During an interview with EVSS1, EVSS2 and DPO on 8/11/25 at 4:00 pm, EVSS1 stated EVS staff used Quat sanitizer for daily cleaning of cafeteria tables and chairs and for wiping down counters in the nursing pantries. He stated EVS staff used degreaser to clean the kitchen hood and filters. During an interview with the DNS on 8/13/25 at 9:40 am, she was asked how staff should be cleaning fixed equipment. She stated staff should be using quat sanitizer in between tasks. If they made a mess they should use soap, rinse with water, then use sanitizer. At the end of shift, they should always use soap, rinse with water, then use sanitizer. She further explained staff should use quat sanitizer when moving from task to task. If they were working with raw chicken, they should wash, rinse and sanitize the area or equipment before moving to the next task. If they were only cutting produce on a cutting board, they could just wipe with sanitizer before cutting more produce. During an interview with EVS1 and EVSL on 8/14/25 at 3:25 pm, he stated EVS staff didn’t really clean food contact surfaces. He stated they mostly cleaned the floors, the sides of equipment, hoods, trash, trash cans, anything except food contact surfaces. EVS did the sides and handles of equipment, typically not carts. They cleaned the tables and chairs in the cafeteria. He stated they used automatically dispensed Citrus Chisel Degreaser and it wipe with yellow rags to clean the tables and chairs in the cafeteria. He stated there were no additional steps, there was no rinsing. EVSL stated they also used degrease to clean the trash cans and hood filters. When asked how they would define terms listed on their document “NOC-Dietary Work Order” cleaning duties for EVS staff, EVS11 stated: “Wipe down” meant use a cloth to wipe with a chemical appropriate for the job “Dust” meant use a cloth to remove dust “Scrub” meant clean using some sort of abrasion, a scrub brush or abrasion pads “Clean” meant use a yellow rag, appropriate chemical. Some chemicals need to be wiped off, wiped down with clean water cloth. EVSS1 stated he didn’t know which chemicals needed to be rinsed. He didn’t think of cafeteria tables as food contact surfaces. EVSS1 and EVSL did not include the steps of washing with detergent, rinsing with potable water, sanitizing, and air drying in their cleaning processes. 13. A patient meal delivery observation was conducted on 8/12/25 beginning at 12:35 p.m., on Unit 2. A meal delivery cart was transported to the unit after which nursing staff were notified of its presence. It was also noted one of the rooms was designated as having “contact precautions” (precautions used in healthcare setting to prevent the spread of germs by direct contact). The observation of the area also noted EVS 1 was preparing to clean the “contact precautions” room. EVS 1 proceeded to put on gloves and a yellow isolation gown. She then proceeded to enter the isolation room and close the door behind her. There was no observation of hand hygiene prior to entering the room. EVS 1 emerged from the room at 12:45 p.m., with filled trash bags, placing them in the hallway. She removed her gown but kept on the disposable gloves. A continuing observation on 8/12/25 at 12:50 p.m., noted certified nursing staff requested assistance with a patient care activity at which point EVS 1 put on a disposable gown and placed a second set of gloves over her existing soiled gloves. The standard of practice for placing and removing personal protective equipment (PPE) includes hand hygiene prior to placing gloves as well as removing gloves and gown, immediately followed by hand hygiene (Centers for Disease Control, 2025). In an interview on 8/13/25 at 9:30 a.m., EVSS 1 and 2 stated hand hygiene should occur prior to donning and all PPE should be removed prior to leaving the room followed by hand hygiene. They also stated the hospital did not support the action of double gloving. The surveyor also asked how staff competency was determined. They stated each staff member would complete mandatory training provided through a standardized educational portal. They also stated competency would be determined by asking questions or there may also be an observation of performed duties. The surveyor asked if in general competency was determined by observation of an employee completing assigned duties. They stated it was “unlikely.” Review of hospital document titled “Student and Group Transcript Report” generated on 8/13/25 revealed EVS 1 completed a training titled “Bloodborne Pathogens and Standard Precautions (non-clinical) on 5/22/25. It was also noted that the most recent documentation of competency was dated 5/19/2016 which spoke about the importance of hand hygiene. Hospital policy titled “Isolation Guidelines” reviewed 8/25 noted the hospital’s approach to infection control included “ ...1. Strict adherence to hand hygiene, either with soap and water, or the alcohol gel ...” 14. Review of the 2022 Food and Drug Administration (FDA) Food Code §3-501.14 regarding food cooling showed “Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.” Review of Annex, §3-501.16 showed “Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature “Danger Zone” of 41 degrees F to 135 degrees F for too long.” During an observation of the True 2-door reach in refrigerator on 8/11/25 10:20 am, it held a pan labeled Chicken Salad, dated 8/11/25, and a pan of crumbled hard-boiled eggs, dated “8/11 for 8/12.” In a concurrent interview, the FPM stated they purchased eggs already hard boiled for patients, but they cooked their own hard-boiled shell eggs for the cafeteria. She stated the bowl of hard boiled shell eggs was for the cafeteria. On 8/12/25 at 9:45 am, a posted document titled Cool Down Log with dates 8/2 through 8/12 was reviewed. It was largely illegible, with many items unclear about what the food was. In included one entry for egg salad dated 8/12. There were no entries for tuna salad or chicken salad on the cooling log. During an observation on 8/12/25 at 10:00 am, a pan of tuna salad in the reach-in refrigerator was nested in an ice bath, and was labeled Tuna Salad, 9:20 41 degrees. The surveyor measured it as 37 degrees F at 10:04 am. In a concurrent record review, Tuna Salad was not documented on the posted Cool Down Log. In a concurrent interview, the FPM stated there was another place to look and showed their posted document titled “Quality Assurance HACCP Report - Patient” where tuna salad on 8/12 was documented 36 degrees F. The FMB stated she thought that was “weird.” During an interview with FSW 4 regarding tuna salad on 8/12/25 at ~10:15 am, she stated she had made the tuna salad that morning, and the labeled 41 degrees F at 9:30 am was the start temperature for the Tuna Salad. She stated she normally wrote it on the cooling log when it was all done. She stated the ingredients were all stored in the produce refrigerator and showed where they were stored. During an interview with FSW4 regarding Egg Salad on 8/12/25 at 10:35 am, she stated she used a food processor to make it. She stated she used the purchased hard-boiled eggs, temped it as soon as she is finished, then temped it again every hour until it reached temperature less than 41 degrees F. During a record review on 8/12/25 at 11:43 am, the tuna salad had been added to the Cool Down Log. In a concurrent interview, the FPM agreed the tuna salad entry wasn’t there when we looked at the log that morning. Further review of documents titled Cool Down Log, dated 6/14/25 to 8/12/25 showed zero entries for egg salad, tuna salad or chicken salad until the 8/12/25 date of survey. It showed no entries for hard-boiled eggs. Further review of documents titled “Quality Assurance HACCP Report - Patient,” dated 7/1/25 through 8/11/25 showed Cold Salads (egg, tuna, turkey, chicken) was prepared and served for patients 40 times. During an interview with the FNS on 8/14/25 at 1:20 pm, she was asked about ambient food cooling. She stated she never thought of doing ambient cooling logs for tuna salad, egg salad, or chicken salad because the ingredients were all refrigerated. She never thought to do a cooling log when they hard boiled eggs for the cafeteria. She was asked if it was possible for staff to get pulled away in the middle of preparing products such as egg salad, tuna salad and chicken salad, resulting in increased temperatures and she replied yes. 15. Review of a policy titled Infection Control Practices (Dietary Department), revised 4/25, showed: “The outside of ice machines (including delivery system) are to be cleaned and sanitized regularly.” “The ice machine will be cleaned by the Engineering Department per the Manufacturer’s instructions and per the preventative maintenance schedule. The Manufacturer’s instructions are maintained by the Engineering Department.” During an interview with the DNS on 8/11/25 at 10:20 am, she stated the Maintenance (Plant Operations) department was responsible for cleaning the ice machines. During an observation and concurrent interview with the Director of Plant Operations (DPO) and Assistant Director of Plant Operations (ADPO) on 8/11/25 at 2:40 pm, the DPO showed the Manitowoc ice machine located in the cafeteria. The DPO stated his ice machine guys were not at work that day due to one being on leave and the other is off because he worked the weekend. The DPO stated he and the ADPO knew nothing about cleaning the ice machines. The ADPO removed the cover from the ice machine. A white paper towel test showed black mold growth along the ledge inside the opening from where the cover came off from the cuber area. An observation of nursing unit ice machines, accompanied by the DPO, ADPO and FPM, on 8/11/25 beginning at 2:55 pm showed: Unit 3 - A white paper towel test showed the Follet ice machine had black growth along the back edge of the ice catcher area, under the dispenser chutes. ICU - A white paper towel test showed the Follett Symphony ice machine had a small amount of black growth inside the ice dispenser chute. Units 1, 2, Obstetrics, and Emergency Departments - A white paper towel test showed the Follet ice machines were clean. During an interview with DPO, ADPO and the Maintenance Engineer (ME) on 8/13/25 at 9:00 am, the DPO stated the ME was who cleaned the ice machines. The ME stated he had observed ice machine cleaning, but had only actually cleaned the ice machines a couple of times. The ME presented the chemicals he used for ice machine cleaning: NuCalgon Nickel-Safe Ice Machine Cleaner for the Manitowoc ice machine, and Safe Clean Plus Ice machine cleaner for the Follett ice machines. In an observation and concurrent interview with ADPO and ME on 8/13/25 beginning at 9:10 a.m., in the nursing pantries of Unit 1 and Unit 2, the surveyor reviewed the preventive maintenance of the ice machines. ME described the process of cleaning and sanitizing the machine. He stated the machines were cleaned using the manufacturer’s guidance. During the observation it was also noted that the ice machines on Unit 1 and Unit 2 did not have an air gap. The condensation line from Unit 1’s ice machine was placed in a drain that resembled a kitchen sink strainer embedded in the countertop. The condensation line for Unit 2’s ice machine did drain into a floor sink, however there was metal cone shaped attachment placed on top of the drain and the condensation line was placed inside the cone, below the flood level rim of the cone. In a follow-up observation on 8/13/25 at 10:15 a.m., ME provided the sanitizing solution for the ice machine on Unit 2. It was noted the manufacturers’ specifications were to use a 5.25 percent (% - a way of expressing a number as a fraction of 100), however the facility was using a 6% solution. Improper concentration of bleach on metals may result in weakening of the surface, cause pitting erosion, and rusting over time. 16. During general observation of the hospital cafeteria on 8/12/25 beginning at 10:05 a.m., it was noted there was a beverage (soda) dispensing system. The beverage system consisted of a food grade plastic bag containing the beverage with a spout, surrounded by a cardboard box. The beverage syrup inside the bag is connected to a commercial dispensing pump, via a connector on the spout and through tubing into the dispensing machine. The syrup is then mixed with carbonated water prior to serving. It was noted there were six different beverage syrup boxes. It was also noted there was a build-up of a grey fuzzy material, resembling dust, on the tubing of the bottom box. In a concurrent interview the Dietary Supervisor described the cleaning of the connector spout. DS indicated the function was completed by a variety of staff members including, on occasion, herself. DS stated once a box was empty the hose would be disconnected from the bag and wiped with a sanitizing cloth prior to reconnection of a new bag. The surveyor inquired whether the lines were flushed. D indicated staff did not flush the lines as that was the responsibility of the beverage vendor. In an interview on 8/14/25 beginning at 1 p.m., Vendor 1 stated routine preventive maintenance of the dispensing machine is scheduled for every 6 months. He also stated he flushes the lines if there is a syrup bag that needs to be replaced at the time of his visit, however not all of the lines would be flushed. Vendor 1 indicated he did not have access to manufacturer’s recommendations for the maintenance of the beverage tubing. Vendor 1 advised the surveyor to call the central distribution location. Vendor 1 also stated he was unable to access any maintenance records for the hospital that were older than 90 days, however he has been placing stickers on the machine to indicate when the machine was serviced. A photo provided by the hospital of a sticker affixed to the machine indicated it was serviced on 3/12/25. On 8/14/25 at 3:04 p.m., the surveyor placed a call to the beverage distribution center. As of 8/18/25 at 1 p.m., the call was not returned. Review of the manufacturer’s instructions (www.pepsiequipmentservice.com) guided staff to complete multiple steps in sanitizing the connector and lines that included submerging the connector in a sanitizing solution and running the solution through the lines as well as a testing step to ensure the sanitizing solution was cleared from the dispensing lines. 17. National Sanitation Foundation (NSF) certification in food production equipment is primarily used to ensure food safety and sanitation. It signifies that the equipment has been rigorously tested and meets stringent standards for materials, design, and construction, minimizing the risk of contamination and promoting hygiene in food preparation and storage. This certification helps build trust with consumers, ensures compliance with regulations, and ultimately protects public health (NSF.org). A food contact surface is any surface, tool or piece of equipment that comes into contact with food, either directly or indirectly. In food production many focus on keeping the kitchen area clean to prevent germ spread. However, germs and bacteria can be found everywhere including items used to store food. Germs found on these surfaces can easily be transferred by hand-to-hand contact or hand-to-food contact when it is then ingested, potentially leading to illness or foodborne sickness. Food-grade, sometimes referred to as food-safe, sanitizers have been tested and certified safe for food contact. This means that even if the sanitizer comes into contact with food, it will not be harmful when ingested. Sanitizers that have not been approved for food contact should not be used in food prep or food contact areas (Imperial Dade). An observation of breastmilk storage was conducted in the well baby nursery on 8/13/25 beginning at 10:55 a.m. It was noted the hospital was utilizing a small undercounter type refrigerator and freezer for storage. The manufacturers’ label affixed to the rear of the machine indicated this unit was intended for “at home” use. In a concurrent interview Registered Nurse (RN) M was asked to describe the sanitation process related to clear plastic storage bins located in the refrigerator. RN M stated the bins were used to store any excess breast milk. RN M also stated these bins would be cleaned using the “purple top” sanitizing wipes. Review of the manufacturer’s use guidance indicated the product may be used on hard nonporous surfaces of patient equipment such as bed railings, blood glucose meters carts, chairs, counters, instruments trays and exam tables. The product did not specify use on food contact equipment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49418 Based on observation, interview and record review, the facility failed to meet the Conditions of Participation for Patient Rights when: 1. Following a suicide attempt at home, Patient 1 was brought to the facility’s Emergency Room by law enforcement officers for a 5150 hold (a 72-hour protective hold for evaluation and treatment of people in danger of harming themselves or others). Patient 1’s 5150 status was not communicated to all members of the care team. (Refer to A-0144.) 2. In accordance with national standards, the facility did not use a validated or evidence-based suicide risk assessment tool to detect the severity of Patient 1’s risk for suicide. (Refer to A-0144.) 3. Nursing staff did not implement suicide-risk safety interventions per facility Policies and Procedures (P&Ps): a. Patient 1’s belongings were not searched for contraband or items that could cause harm, and Patient 1 used a belt in his possession as a ligature (an item to tie or bind tightly) to attempt suicide by hanging. b. Patient 1 was allowed to wear his jeans (a potential hiding place) under his gown. c. House Supervisor (HS) A initially assigned Patient 1 to a room on the second floor (a jumping hazard) away from the nurses’ station (limiting monitoring and supervision capabilities of the nursing staff). d. A patient sitter was not requested for direct observation of Patient 1, which had the potential to reduce Patient 1’s risk of self-harm. (Refer to A-0144.) 4. Patient 1 was able to lock the door to his bathroom, where he attempted suicide. A master key was not readily available for the bathroom door, which delayed the entry of nursing staff and delayed resuscitative efforts and thereby transferred to the Intensive Care Unit for evaluation and monitoring. (Refer to A-0144.) The cumulative effect of these systemic problems had the potential to cause serious injury or death to Patient 1 and had the potential to compromise the safety, quality of care, and lives of all patients at risk for suicide.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49418 Based on observation, interview and record review, the licensed nursing staff failed to implement suicide-risk safety interventions per facility Policies and Procedures (P&Ps): a high-risk-suicide patient (Patient 1). These deficient practices resulted in Patient 1 to be found with bluish-purple skin, bulging eyes, not responding to questions, hanging from a weightbearing shower fixture. Licensed nursing staff called a Code 99 (a medical emergency code). Patient 1 “woke up,” was able to walk, and was transferred to a high-visibility bed in the Intensive Care Unit (ICU) with a one-to-one sitter in “guarded” condition (serious with an uncertain outcome). Findings: A review of P&P titled, “Suicide Precautions” by Nursing Services, dated 8/2023, indicated its purpose was to outline procedures to put in place when a patient’s suicide precaution assessment determines further interventions are necessary. The P&P indicated, “Suicide risk increases in patients who have made prior attempts.” Common modes of suicide include hanging, overdose, and jumping. The P&P indicated patients are assessed on admission for suicide risk, with suicide precautions to include: A. A room near the nurses’ station, preferably on the First Floor. B. The door and curtain of the room open. C. Complete hourly rounding or more often as needed. D. Belongings (including clothing and property) will be carefully inspected for contraband and/or denied articles that could potentially be used to harm. Removed items will be placed in a secured area. E. A patient sitter may be implemented with approval from the Nurse Manager and/or physician’s order. A review of facility Policy and Procedure (P&P) titled, “Psychiatric Patient Care” by Emergency Services, dated 7/2024, indicated its purpose was to establish a standard of care for psychiatric and behavioral health patients. Procedure: A. Patients presenting with psychiatric complaints will be interviewed by the Registered Nurse (RN) to determine patient’s need for safety. B. Patient will be asked to undress and placed into a gown. Belongings will be searched and kept outside the room at the discretion of the primary nurse. C. A Social Services consult will be placed, or Mobile Crisis staff (outside emergency mental health services) notified of patients needing a mental health evaluation. D. The Emergency Services Department physician will evaluate patient and determine if crisis intervention is needed. If the patient is found to be a danger to self or others, law enforcement and/or Social Services will be contacted to evaluate the patient for a 72-hour hold (5150). A review of record titled, “Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” (5150), dated 8/6/24, indicated Patient 1 was taken into custody by law enforcement officers on 8/6/24 at 9:34 am, at his home. Patient 1 admitted to officers he consumed a poisonous substance “because he wanted to die.” Patient 1 was a “danger to self” because of a mental health disorder. Patient 1 was transported to the facility by ambulance for a 5150 hold. A review of record titled, “Emergency Room (ER) Nurse Note” by Registered Nurse (RN) A dated 8/6/24 at 10:29 am, indicated Patient 1 arrived by ambulance as a Triage Level 2 (emergency, potentially life-threatening) with a chief complaint of ingestion of oleander and sulfur (poisonous life threatening) substances. The record indicated Patient 1 was considered a 5150. A review of record titled, “Emergency Room (ER) Nurse Note” by RN A, dated 8/6/24 at 10:29 am, indicated Patient 1 answered “NO” to Suicide Risk Assessment questions: (1) “Having suicidal thoughts” and (2) “Any items or objects that could be used to harm yourself or others.” There was no validated or evidence-based suicide risk assessment tools available for staff to use for Patient 1. During a concurrent interview and record review on 8/8/24 at 11:40 am, with Chief Nursing Officer (CNO), stated the internal document indicated Patient 1 was being admitted for “MHE/OD” - a mental health evaluation for overdose. CNO stated there was a “misstep” in communication as the intake form did not indicate Patient 1’s 5150 hold. CNO stated she was in the process of amending the facility’s form, noting, “Suicidal ideation needs to be added.” CNO stated the facility does not have a suicide risk checklist, but that they have identified an “appropriate” one for nursing staff. CNO stated it will be implemented after being approved in committee. During an interview with RN J on 8/8/24 at 12:32 pm, RN J stated he had seen patients in conjunction with the facility psychiatrist, Doctor (DOC) A. RN J stated it was his opinion that Patient 1 was not being honest when he stated he was not suicidal in the ER, and he would like to see the facility implement a suicide risk checklist. During an interview with Director of Medical-Surgical Department (RN F) on 8/8/24 at 4:15 pm, RN F stated the facility should implement a safety checklist. A review of All Facilities Letter “AFL 23-2,” a letter from California Department of Public Health dated 1/18/23, indicated the letter served to notify all general acute care hospitals about California Assembly Bill (AB) 1394 (Chapter 101, Statutes of 2022). AB 1394 will require hospitals to have written P&Ps by 1/1/25 that establish screening for risk of suicidal ideation and behavior in patients 12 and older. The letter indicated the intent of AB 1394 was to have hospitals adopt validated or evidence-based suicide risk assessment tools as recommended by the Joint Commission. A review of a Social Service Referral note dated 8/6/24 at 1:37 pm, indicated Patient 1 was a 5150 overdose. The note indicated Patient 1 intentionally ingested oleander and sulfur to end his life. Family member indicated Patient 1 had suffered from depression and suicidal ideation. The plan was to admit Patient 1 for further monitoring and medical intervention. Social Services will follow Patient 1 in conjunction with psychiatry to treat. During an interview with RN C on 8/8/24 at 2:20 pm, RN C stated RN A called to give her report on Patient 1. RN C stated she was not told that Patient 1 was 5150, only that he was wearing a telemetry monitor (a portable device that allows healthcare professionals to continuously monitor a patient’s heart activity) and had had [suicidal] “tendencies” before. RN C stated she did not learn of Patient 1’s 5150 status until he had arrived to the floor and reviewed his medical chart. A review of the facility’s nursing staff training module titled, “SafetyQ: Patient or Resident Safety Basics, Patient-Facing,” dated 2024, indicated checking risk of harm to themselves or others is important for suicidal patients. Look for items patients may use to cause harm. Protect people when they have thoughts of suicide. Notify others right away. One-to-one continuous monitoring may be needed. Facilities are to show how to check people at risk and how they are reducing those risks by using national standards. Hazards include ligatures (belts, shoelaces, oxygen tubing), poor staffing levels for direct observation of patients, sharp objects (glass, syringes, breakable windows), medicines and harmful substances (drugs, cleaning agents), and light fixtures (electrocution). Safety events that end in harm or the death of a person are called Sentinel, Adverse, or Serious Events. An Adverse Event is any safety event that reaches the person, an unsafe condition that increases the chance of a safety event, or a near miss that did not negatively affect the person. Serious Reportable Events (SREs), including suicide or attempted suicide, signal the need for immediate attention and response. A review of doctor’s orders dated 8/6/24 at 11:47 am, Patient 1 was admitted to inpatient Medical Surgical Floor (Unit 3-Second Floor) using adult standard admission orders. Condition was guarded (serious condition). A review of a RN Note dated 8/6/24 at 3:40 pm, Patient 1 arrived to Room 301B from the ER. At 3:45 pm, RN C documented that she spoke with Charge Nurse and “I voiced my urgent very strong concern over this patient coming to our floor.’’ RN C documented Patient 1 should not be so far away from the nurse’s station due to not being easily observed. Five minutes later, RN C contacted the House Supervisor (HS) related to finding in that Patient 1’s chart was a 5150 and had history of multiple suicidal tendencies. HS informed RN C that she would try to get Patient 1 a room on Floor 1. RN C documented this was a good idea and needs to have a sitter to observe Patient 1. At 4:15 pm, RN C was informed that Patient 1 could be transferred to Room 106, a private room near charge nurse. During an interview with RN C on 8/8/24 at 2:20 pm, RN C stated Patient 1 was transferred from the ER to Unit 3 on 8/6/24 at 3:40 pm, to Room 301B (not the preferred room for a suicidal ideation patient). RN C stated Patient 1 could have stayed in the ER until an appropriate room was available. RN C stated there was frequent patient “shuffling” between rooms, a “lot of chaos.” RN C stated, “This is not protecting patients. It’s not safe for nursing or patients. “RN C stated Patient 1 was wearing jeans, a gown, a telemetry monitor, and wool socks. RN C stated she did not search Patient 1’s belongings. RN C stated Patient 1 repeatedly tried to close the door to his room, but she informed him he needed to keep it open for his safety. RN C stated she noted as he was going back to his bed that his jeans kept falling off, and she did not believe he had a belt. During an interview with Director of the ER, (RN D), on 8/8/24 at 4:45 pm, RN D stated RN E was the acting charge nurse in the ER on 8/6/24 when Patient 1 arrived. RN D stated law enforcement officers brought in the substances Patient 1 ingested; RN E gathered Patient 1’s belongings and put them in a biohazard bag. RN D stated, “We don’t write down an inventory” when belongings are gathered. RN D stated the facility did not do strip searches and “We can’t go through their bags.” RN D stated suicidal patients’ belongings were typically bagged in the ER and taken to the radio room (charge nurse and physicians only have access) located behind the nurses’ station. RN D stated safety hazards like cords are removed, but it “depends on the severity of the patient.” During an interview with RN D on 8/8/24 at 4:45 pm, RN D stated Room 301B was “not appropriate” for Patient 1. RN D stated, “It’s safe in the ER.” RN D stated a patient’s risk for suicide should be determined so as to decide best placement. RN D stated, “I wish we had more resources.” During an interview with HS A on 8/9/24 at 7:37 am, HS A stated Patient 1’s intake form did not indicate a 5150 hold. HS A stated 8/6/24 started with a code (a patient requiring emergent life-saving measures), she was busy moving other patients, and she “didn’t have a chance” to go through Patient 1’s orders. HS A stated, “All 5150s need to go to Unit 1” but that she was unaware of his 5150 status. HS A stated she assigned Patient 1 to Room 301B (Unit 3) on the second floor at the end of a hallway out of line of sight from the nurses’ station. HS A stated she moved Patient 1 to Unit 1 as soon as possible after RN C called to request a safer room. During an interview with RN J on 8/8/24 at 12:32 pm, RN J stated staff did not know where Patient 1 got the belt he used as a ligature to attempt suicide. RN J stated Patient 1 had been in prison for nine years and “was probably good at hiding things.” During an interview with DOC A on 8/8/24 at 1:42 pm, DOC A stated she “wants to know where the belt came from” as the ER staff reported they “found nothing” when they collected Patient 1’s belongings. DOC A stated Patient 1 had been in prison and “knew how to hide things.” During an interview with RN A on 8/13/24 at 3:28 pm, RN A stated the suicide risk assessment she used for Patient 1 was the two questions in the computer template (a predesigned document) of the “ER Nurse Note.” RN A stated Patient 1 answered “no” to having suicidal thoughts and having any objects that could hurt himself or others. RN A stated nursing staff “legally” have to write down what patients say, even if they say no. RN A acknowledged concern for Patient 1 despite his “no” answers because he had a flat affect (lack of emotion), denied his suicide attempt, and he told her he only wanted to see what oleander tasted like. RN A stated she frequently checked Patient 1 because it was “the only way to keep him safe.” There was no validated or evidence-based suicide risk assessment tools available for staff to use for Patient 1. During an interview with CNO on 8/16/24 at 2:40 pm, CNO stated Patient 1 “was telling us what we wanted to hear” when he stated he was not suicidal. CNO stated the facility has a lot of new nurses who were timid to ask suicidal ideation questions, so they were “developing a script.” CNO stated they were also creating a “risk stratification tool” (identifies safety risks, predicts outcomes) because “we had to have one before 1/1/25” according to All Facilities Letter 23-2 (AFL 23-2). CNO acknowledged she was not aware Patient 1 was 5150. CNO stated her computer dashboard will give her an idea why each patient was here, but stated, “I don’t think I had looked when he came in that day.” A review of a Physician Critical Event (Code 99) note dated 8/6/24 4:51 pm, DOC A was notified that Patient 1 hung himself from shower with belt. Patient 1 was found on the ground outside the bathroom after nurses promptly took him down when he started breathing. Plan of care: Patient 1 transferred to Intensive Care Unit. A review of “Doctor’s Orders,” dated 8/6/24 at 7:06 pm, indicated “one to one sitter” ordered by DOC C, only after the suicide attempt in the patient’s room. There was no initial order for one to one sitter upon admission for Patient 1. A review of “Social Services Inpatient Follow-up,” dated 8/7/24 at 11:23 am, indicated Patient 1 was considered at “acute risk of suicide” due to planned suicide attempt prior to admission, additional suicide attempt in the hospital, extremely depressed presentation and continued statements of suicidal ideation. During an interview with CNO on 8/16/24 at 2:40 pm, stated “Suicide Precautions” orders may be in placed by the doctor or by Social Services in conjunction with the psychiatrist which included a one-to-one-sitter. DOC C’s admission order of 8/6/24 at 11:31 am showed a diagnosis of suicidal/self-harm ideation, oleander/sulfur ingestion. This order would indicate “Suicide Precautions should be in place.” CNO stated sitters were used if a patient was a “flight risk,” wander, suicide risk, traumatic brain injury and with cognitive impairments. CNO further stated she was unsure if DOC C felt a sitter was warranted for Patient 1. CNO stated staff who asked were never denied a one-to-one sitter. CNO stated, the nurse made the determination it was a safe environment for Patient 1 without a sitter.”