Parkview Community Hospital Medical Center

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 44871 Based on interview and record review the facility failed to ensure the Important Message from Medicare (IMM, a required notice informing Medicare beneficiaries of their discharge appeal rights) was provided to patient’s representative when the patient was unable to acknowledge receipt due to medical diagnosis, for two of 15 sampled patients (Patient’s 4 and 6). This failure may have resulted in the patients’ representatives not being informed of the patients’ Medicare discharge appeal rights. Findings: 1. On June 22, 2026, at 12:58 p.m., a review of Patient 4’s medical record was conducted with the Special Program Coordinator (SPC). A facility document titled, “History and Physical,” dated April 11, 2026, at 7:48 a.m., was reviewed. The document indicated Patient 4 was admitted to the facility on April 10, 2026, and presented to the emergency department (ED, a specialized hospital unit providing 24/7, immediate care for acute, life-threatening injuries and illnesses) with altered mental status (a change in a person’s normal level of awareness, thinking, behavior, or ability to understand and respond appropriately to their surroundings), and agitation. A facility document titled, “...[Name of the Facility]...” dated April 10, 2026, at 7:42 p.m., was reviewed. The document indicated, “...EMER [Emergency] CONTACT [Name of emergency contact]...RELATIONSHIP...OTHPART...HOME PH [Phone] [representative’s home phone]...CELL PH [representative’s cell phone]...PRIMARY INSURANCE....MEDICARE [federally funded health program]...” A facility document titled, “Important Message from Medicare,” was reviewed. The document was undated and untimed. The documented indicated, “...Signature of patient or representative...pt unable to sign...” There was no documented evidence the Patient Access Representative (PAR) contacted Patient 4’s representative identified on the face sheet regarding the IMM when the patient was unable to sign due to altered mental status. 2. On June 22, 2026, at 1:15 p.m., a review of Patient 6’s medical record was conducted with the SPC. A facility document titled, “History and Physical,” dated March 25, 2026, at 10:19 a.m., was reviewed. The documented indicated Patient 6 was admitted to the facility March 23, 2026, and presents to the ED with gross mental status changes, hypoxia (low levels of oxygen in the body’s tissue). A facility document titled, “...[Name of the Facility]...” dated March 24, 2026, at 7:57 p.m., was reviewed. The document indicated, “...EMER [Emergency] CONTACT [Name of emergency contact]...RELATIONSHIP...DAU [Daughter]...HOME PH [Phone] [daughter’s home phone]...CELL PH [daughter’s cell phone]...PRIMARY INSURANCE....MEDICARE...” A facility document titled, “Important Message from Medicare,” dated March 24, 2026, was reviewed. The document indicated, “...Signature of patient or representative...pt unable to sign...” There was no documented evidence the Patient Access Representative (PAR) contacted Patient 6’s representative identified on the face sheet regarding the IMM when the patient was unable to sign due to altered mental status. On June 22, 2026, at 2:30 p.m., an interview and record review was conducted with the PAR. The PAR stated if the patient is confused or unable to sign due to medical reasons, she will call the nurse to sign the document. The PAR stated, “Reaching out to the patient’s representative is the last resort, the nurse and a representative will sign the document.” On June 22, 2026, at 3:10 p.m., an interview was conducted with the SPC. The SPC stated there was no documented evidence the PAR attempted to contact Patient’s 4 or 6’s representatives for the IMM. The SPC stated the policy was not followed, the expectation would be for the PAR to reach out to the patient’s representative and document. A facility document titled, “DISCHARGE PROCESS FOR MEDICARE PATIENTS,” dated March 16, 2025, was reviewed. The document indicated, “...Hospital must deliver this form within two calendar days of admission (by the admitting department), obtain a signature, and provide a copy, ensuring the patient understands their right to appeal...A signed copy of the form must be provided to the beneficiary and the patient’s chart...When patients are not in the capacity to sign, the IMM and the Patient Choice Form information should be provided to the responsible party upon admission...in person or if unavailable over the phone and documented in the chart to show compliance...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 44871 Based on interview and record review the facility failed to ensure patients’ rights were provided when the Consent of Admission (COA, an agreement between the patient and the hospital) was not properly completed for two of 15 sampled patients (Patients 4 and 6). This failure resulted in Patients 4 and 6 not having a legally authorized representative involved in the consent process when they were unable to provide consent themselves. Findings: 1. On June 22, 2026, at 12:58 p.m., a review of Patient 4’s medical record was conducted with the Special Program Coordinator (SPC). A facility document titled, “History and Physical,” dated April 11, 2026, at 7:48 a.m., was reviewed. The document indicated Patient 4 was admitted to the facility on April 10, 2026, and presented to the emergency department (ED, a specialized hospital unit providing 24/7, immediate care for acute, life-threatening injuries and illnesses) with altered mental status (a change in a person’s normal level of awareness, thinking, behavior, or ability to understand and respond appropriately to their surroundings), agitation. A facility untitled document dated April 10, 2026, at 7:42 p.m., was reviewed. The document indicated, “...EMER [Emergency] CONTACT [Name of emergency contact]...RELATIONSHIP...OTHPART...HOME PH [Phone] [representative’s home phone]...CELL PH [representative’s cell phone]...” A facility document titled, “CONDITION OF ADMISSION,” dated April 10, 2026, 12:32 p.m., was reviewed. The document indicated, “...LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN...UATS [unable to sign]...PERSONAL VALUABLES...UATS...NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL PRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR A COURT TRAIL, SEE ARTICLE 1 OF THIS CONTRACT...April 10, 2026...12:32 p.m...Patient Unable to Sign...[Signature of the RN] [Signature of PAR]...Pt [patient] UATS...” There was no documented evidence the PAR contacted Patient 4’s representative identified on the face sheet regarding the COA when the patient was unable to sign due to altered mental status. 2. On June 22, 2026, at 1:15 p.m., a review of Patient 6’s medical record was conducted with the SPC. A facility document titled, “History and Physical,” dated March 25, 2026, at 10:19 a.m., was reviewed. The document indicated Patient 6 was admitted to the facility March 23, 2026, and presents to the ED with gross mental status changes, hypoxia (low levels of oxygen in the body’s tissue. A facility document titled, “...[Name of the Facility]...” dated March 24, 2026, at 7:57 p.m., was reviewed. The document indicated, “...EMER [Emergency] CONTACT [Name of emergency contact]...RELATIONSHIP...DAU [Daughter]...HOME PH [Phone] [daughter’s home phone]...CELL PH [daughter’s cell phone]...” A facility document titled, “CONDITION OF ADMISSION,” dated March 24, 2026, 2:26 p.m., was reviewed. The document indicated, “...LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN...PT [patient] UTS [unable to sign]...PERSONAL VALUABLES...PT...UTS...NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL PRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR A COURT TRAIL, SEE ARTICLE 1 OF THIS CONTRACT...March 24, 2026...2:26 p.m...Patient Unable to Sign...[Signature of the RN] [Signature of PAR]...No Family Present...” There was no documented evidence the PAR contacted Patient 6’s representative identified on the face sheet regarding the COA when the patient was unable to sign due to altered mental status. On June 22, 2026, at 2:30 p.m., an interview was conducted with the PAR. The PAR stated if the patient is confused or unable to sign due to medical reasons, I will call the nurse to sign the document. The PAR stated, “Reaching out to the patient’s representative is the last resort, the nurse and a representative will sign the document.” On June 22, 2026, at 3:10 p.m., an interview was conducted with the SPC. The SPC stated there was no documented evidence the PAR attempted to contact Patients 4 and 6 representatives for the COA. The SPC stated the policy was not followed, the expectation would be for the PAR to reach out to the patient’s representative and document. A review of the facility Policy & Procedure titled, “ CONDITIONS OF ADMISSION (COA),” dated July 2024, was reviewed. The policy indicated, “...Upon admission/registration, the COA must be explained to the patient and their signature obtained. Signatures in the COA forms are required prior to services being rendered. Upon signing the COA form, the patient has given his/her approval for receiving treatment and ensured the facility financial responsibility...In the event the patient due to their medical condition, it is acceptable for their spouse, adult child or responsible party to sign...Two (2) additional attempts will be made to obtain patient signature...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48326 Based on interview and record review, the facility failed to ensure Medicare (a federal health insurance program in the United States primarily for people aged 65 or older, as well as younger individuals with specific disabilities or permanent kidney failure) patients or their representatives were informed in advance of their rights to appeal discharge when: 1. For Patients 3, 7, 8, 9, 10, 11, 17, and 18 the form “An Important Message from Medicare About Your Rights [IMM, a document indicating the patient’s right to appeal their discharge],” were not provided 48 hours prior to discharge; and 2. For Patients 10, 11, 17, and 18 the form “An Important Message from Medicare About Your Rights” were not given within two calendar days of admission. These failures had the potential for patients and/or their representatives to not be informed of their rights to appeal discharge decisions. Findings: 1a. On March 16, 2026, at 3:04 p.m., a review of Patient 3’s medical record was conducted with the Director of Quality (DQ). A facility document titled, “History and Physical [H&P],” dated March 14, 2026, at 12:44 p.m., indicated Patient 3 was admitted to the facility for altered mental status (not acting or thinking like their usual self). A facility document titled, “Important Message from Medicare About Your Rights,” dated March 15, 2026, was reviewed. The document indicated, Patient 3’s representative signed the document. A facility document titled, “Final Discharge Disposition,” dated March 16, 2026, at 2:23 p.m., was reviewed. The document indicated Patient 3 was discharged to an outside facility. During the review of Patient 3’s medical record there was no documented evidence the IMM dated March 15, 2026, was presented to the patient or patient representative prior to discharge. 1b. On March 17, 2026, at 9:58 a.m., a review of Patient 7’s medical record was conducted with the DQ. A facility document titled “History and Physical,” dated March 1, 2026, at 11:31 p.m., indicated Patient 7 was admitted to the facility for septic shock (a life-threatening infection that causes dangerously low blood pressure and organ problems.) A facility document titled “Important Message for Medicare,” dated March 1, 2026, was reviewed. The document indicated Patient 7 or their representative was unable to sign. A facility document titled “Final Discharge Disposition,” dated March 5, 2026, at 5:14 p.m., was reviewed. The document indicated Patient 7 was discharged to an outside facility. There is no documented evidence that the IMM dated March 1, 2026, was presented to Patient 7 or their representative prior to discharge. 1c. On March 17, 2026, at 10:41 a.m., a review of Patient 8’s medical record was conducted with the DQ. A facility document titled, “History and Physical,” dated February 15, 2026, at 12:42 a.m., indicated Patient 8 was admitted to the facility for failure of outpatient (a patient who received medical care without staying overnight in a hospital) antibiotic therapy (treatment with medicines that kill bacteria causing an infection). A facility document titled, “Important Message for Medicare About Your Rights,” dated February 13, 2026, was reviewed. The document indicated Patient 8 or their representative was unable to sign. A facility document titled, “Final Discharge Disposition,” dated February 16, 2026, at 5:56 p.m., was reviewed. The document indicated Patient 8 was discharged home. There is no documented evidence that the IMM dated February 13, 2026, was presented to the Patient 8 or their representative prior to discharge. 1d. On March 17, 2026, at 11:08 a.m., a review of Patient 9’s medical record was conducted with the DQ. A facility document titled, “History and Physical,” dated indicated Patient 9 was admitted to the facility for altered mental status. A facility document titled, “An Important Message from Medicare About Your Rights,” dated March 7, 2026, was reviewed. The document indicated Patient 9 or their representative was unable to sign. A facility document titled, “Final Discharge Disposition,” dated March 12, 2026, at 1:51 p.m., was reviewed. The document indicated Patient 9 was discharged to an outside facility. There is no documented evidence that the IMM dated March 7, 2026, was presented to the Patient 9 or their representative prior to discharge. 1e. On March 17, 2026, at 11:35 a.m., a review of Patient 10’s medical record was conducted with the DQ. A document titled, “History & Physical,” dated February 11, 2026, indicated Patient 10 was admitted to the facility for respiratory distress (trouble breathing). There was no documented evidence that the “Important Message from Medicare About Your Rights,” was given to the patient or their representative. A concurrent interview was conducted on March 17, 2026 at 11:40 a.m., with the DQ. The DQ stated there is no IMM in the patient’s chart and there should be one A facility document titled, “Final Discharge Disposition,” dated February 11, 2026, at 5:37 p.m., was reviewed. The document indicated Patient 10 was discharged to an outside facility. There was no documented evidence that the IMM was presented to the patient or the representative prior to discharge. 1f. A review of Patient 11’s medical record was conducted on March 16, 2026, at 1:04 p.m., with the Special Program Coordinator (SPC). An undated and untitled facility document was reviewed. The document indicated Patient 11 was admitted on March 11, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,” dated March 12, 2026, was reviewed. The document indicated,”...Chief Complaint: fall injured head...presents after being found on the ground with altered mental status...Patient admitted for acute metabolic [chemical changes in the body] vs.[versus] toxic encephalopathy [an acute change in how your brain works due to an underlying condition] due to cocaine [an addictive illegal drug] use vs. UTI [urinary tract infection- bacterial infection in the kidneys, bladder or ureters (tube where urine passes) or urethra(tube where urine passes), also rule out stroke (medical emergency that happens when something prevents your brain from getting enough blood flow).” A facility document titled, “Order Information,” dated March 11, 2026, at 9:22 p.m., was reviewed. The document indicated, “Admit as INP [Inpatient] to Tele [telemetry - electronic external heart monitor]...Diagnosis...Acute Encephalopathy...” A facility document titled, “Patient Progress Notes,” undated was reviewed. The document indicated,”...Discharge: 03/14/2026 [March 14, 2026]16:00[4 p.m.]...15:46[3:46 p.m.]...Assessment/Daily Note...Patient is okay with discharging to SNF[skilled nursing facility - an inpatient rehabilitation and medical treatment center providing short-term, high-level care]...Spoke with [Facility Staff] at [Name of Facility 1]...” An interview was conducted on March 17, 2026, at 8:41 a.m., with the SPC. The SPC stated there was no documented evidence that a signed IMM was provided to Patient 11 or Patient 11’s representative within 48 hours prior to discharge. 1g. A review of Patient 17’s medical record was conducted on March 16, 2026, at 3:54 p.m. with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 17 was admitted on February 15, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,”dated February 15, 2026, at 2:42 p.m. was reviewed. The document indicated,”...Date of Admit...02/15/2026 [February 15, 2026]...Chief Complaint...Altered...85-year-old...admitted with resp [respiratory -lungs] distress...lung congestion and altered ms [mental status]...” A facility document titled, “Order Information,” dated February 15, 2026, at 8:53 a.m., was reviewed. The document indicated, “Admit as INP [Inpatient] to Tele...Diagnosis...UTI[urinary tract infection [bladder infection]...” A facility document titled, “Final Discharge Disposition,”dated February 17, 2026, was reviewed. The document indicated,”...Condition on discharge...pt[patient]alert,confused...Discharge...Patient left the unit...1402 [2:02 p.m.]...” An interview was conducted on March 16, 2026, at 3:59 p.m., with the SPC. The SPC stated Patient 17 was admitted on February 15, 2026, there was no evidence that a signed IMM was provided to Patient 17 or Patient 17’s representative within 48 hours prior to discharge. 1h. A review of Patient 18’s medical record was conducted on March 16, 2026, at 3:49 p.m., with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 18 was admitted on February 5, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,” dated February 5, 2026, was reviewed. The document indicated,”...Date of Admit ...02/04/2026 [February 4, 2026]...Chief Complaint: Respiratory failure...presents to the ER [emergency room- hospital unit that provides treatment to persons requiring immediate medical care] with gross altered level of consciousness...noted to be in moderate to severe respiratory distress...intubated in the ER and admitted to the intensive care unit [a unit that provides care to severely sick patients]...” A facility document titled, “Order Information,” dated February 4, 2026, at 6:26 p.m., was reviewed. The document indicated, “Admit as Inpatient to ICU...Diagnosis...respiratory failure, pneumonia [infection of the lungs]...” A facility document titled, “An Important Message from Medicare About Your Rights,” dated February 4, 2026, was reviewed. The document indicated that patient was unable to sign the document. A facility document titled, “Discharge Summary,” dated February 13, 2026, at 10:23 a.m., was reviewed. The document indicated, “...Date of Discharge...02/08/2026 [February 8, 2026]...The patient was discharged back to [Name of Facility 2]...on 02/08/2026 [February 8, 2026] in stable condition...” An interview was conducted on March 17, 2026, at 9:14 a.m., with the SPC. The SPC stated Patient 18 was admitted on February 4, 2026, and there was no documented evidence that a signed IMM was provided to Patient 18 or Patient 18’s representative within 48 hours prior to discharge. 2 a. On March 17, 2026, at 11:35 a.m., a review of Patient 10’s medical record was conducted with the DQ. A document titled, “History & Physical,” dated February 11, 2026, indicated Patient 10 was admitted to the facility for respiratory distress. There was no documented evidence that the “Important Message from Medicare About Your Rights,” was given to the patient or their representative at admission. A concurrent interview conducted on March 17, 2026 at 11:40 a.m., with the DQ. The DQ stated there is no IMM in the patient’s chart and there should be one. On March 16, 2026, at 1:44 p.m., an interview was conducted with the CMM. The CMM stated that every patient has to have an IMM in their admission packet. 2b. A review of Patient 11’s medical record was conducted on March 16, 2026, at 1:04 p.m., with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 11 was admitted on March 11, 2026, and the primary insurance was Medicare. A facility document titled, “MD [medical doctor] History and Physical,” dated March 12, 2026, was reviewed. The document indicated,”...Chief Complaint: fall injured head...presents after being found on the ground with altered mental status...Patient admitted for acute metabolic vs. toxic encephalopathy due to cocaine use vs. UTI, also rule out stroke.” A facility document titled, “Order Information,” dated March 11, 2026, at 9:22 p.m., was reviewed. The document indicated, “Admit as INP to Tele...Diagnosis...Acute Encephalopathy...” An interview was conducted on March 16, 2026, at 1:10 p.m., with the SPC. The SPC stated Patient 11 was admitted on February 4, 2026, and there was no documented evidence that the IMM was provided within two (2) calendar days of admission. 2c. A review of Patient 15’s medical record was conducted on March 16, 2026, at 3:26 p.m. with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 15 was admitted on February 2, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,” dated February 2, 2026, at 10:59 p.m.. was reviewed. The document indicated, “...Chief Complaint: weakness...Poor historian only able to provide minimal information...CTAP [Computed Tomography Arterial Portography, a specialized imaging] showing R[right] emphysematous pyelonephritis [life threatening kidney infection]...will admit to tele for abx [antibiotic]. IVF [intravenous fluid]...” A facility document titled, “Order Information,” dated February 2, 2026, at 12:38 a.m., was reviewed. The document indicated, “Admit as INP to Tele Medical...Diagnosis...AKI [acute kidney injury - kidney damage]...” A facility document titled, “Mensaje Importante De Medicare Sobre Sus Derechos [An Important Message from Medicare About Your Rights],” dated February 3, 2026, at 12:38 a.m., was reviewed. The document indicated that patient was unable to sign the document. An interview was conducted on March 16, 2026, at 3:28 p.m., with the SPC. The SPC stated Patient 15 was admitted on February 2, 2026, and there was no documented evidence that a follow up on the IMM was provided within two (2) calendar days of admission. 2d. A review of Patient 17’s medical record was conducted on March 16, 2026, at 3:54 p.m., with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 15 was admitted on February 15, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,” dated February 15, 2026, at 2:42 p.m., was reviewed. The document indicated, “...Date of Admit...02/15/2026 [February 15, 2026]...Chief Complaint... Altered...85-year-old...admitted with resp distress...lung congestion and altered ms[mental status]...” A facility document titled, “Order Information,”dated February 15, 2026, at 8:53 a.m., was reviewed. The document indicated, “Admit as INP to Tele...Diagnosis...UTI...” An interview was conducted on March 16, 2026, at 3:58 p.m., with the SPC. The SPC stated Patient 17 was admitted on February 15, 2026, and there was no documented evidence that the IMM was provided within two (2) calendar days of admission. The Policy & Procedure (P&P) titled “ Important Message from Medicare,” dated February 2024, was reviewed. The policy indicated “ ...Upon admission or within two (2) days inpatient status as defined by CMS [Centers for Medicare & Medicaid Services] guidelines, the Patient Access staff will provide patients with Medicare Health Plan the IM notification ...” An interview was conducted on March 17, 2026, at 1:09 p.m., with the DQ. The DQ stated the policy does not include the process of providing the IMM before discharge. An interview was conducted on March 17, 2026, at 1:11 p.m., with the CMM. The CMM stated the policy was not followed. The CMM stated the only time they provide the IMM on discharge is when there is a dispute on the discharge plan. The CMM further stated she was not aware that providing the IMM before discharge is a regulatory requirement.”

“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: 48326 Based on interview and record review the facility failed to ensure the policies and procedures (P&P) were followed when: 1. For Patients 7, 9, 13, 16, and 17) the discharge instructions were not signed prior to discharge; and 2. For Patient 6, an abuse screening during the initial Emergency Department (ED) assessment was not done. These failure had the potential to place patients at risk for complications after discharge, higher occurrence for readmission, poor health outcomes, and risk for unrecognized abuse, neglect, or exploitation. Findings: 1a. On March 17, 2026, at 9:58 a.m., a review of Patient 7’s medical record was conducted with the Director of Quality (DQ). A facility document titled, “History and Physical,” dated March 1, 2026, at 11:31 p.m., indicated Patient 7 was admitted to the facility for acute encephalopathy [a sudden change in brain function] severe sepsis [a life-threatening infection that causes dangerously low blood pressure and organ problems]. A facility document titled, “Order Information,” dated March 5, 2026, was reviewed. The document indicated, “...D/C [Discharge] to SNF[Skilled Nursing Facility, a nursing home that provides medical care, therapy, and daily assistance]...f/u [followup] with hospice [care focused on comfort and quality of life for individuals with serious illness who are nearing the end of life]...scheduled date 3/5/2026 [March 5, 2026]...” A facility document titled, “Final Discharge Disposition,” dated March 5, 2026, at 5:14 p.m., was reviewed. The document indicated “...discharge disposition...skilled nursing facility...SNF with hospice...condition on discharge...alert, oriented x 4 [times four], arouses to voice/touch, follows commands, speech logical: exceptions to WNL [within normal limits]...patient left unit at 5:29 p.m...” There was no documented evidence of the patient signing the discharge instructions. A concurrent interview was conducted on March 17, 2026 at 10:00 a.m., with the DQ. The DQ stated the discharge instructions were not signed by the patient or the patient representative and should have been signed by the patient or patient’s representative. 1b. On March 17, 2026, at 11:08 a.m., a review of Patient 9’s medical record was conducted with the DQ. A facility document titled “History and Physical” dated March 7, 2026, at 11:17 a.m., indicated Patient 9 was admitted to the facility for altered mental status. A facility document titled, “Order Information,” dated March 10, 2026, was reviewed. The document indicated “...D/C to SNF...scheduled date 3/10/2026 [March 10, 2026] at 4:03 p.m...” A facility document titled, “Final Discharge Disposition,” dated March 12, 2026, at 1:51 p.m., was reviewed. The document indicated “...disposition...facility...skilled...PT [physical therapy, care that helps a person regain the ability to move and perform daily activities]...condition at discharge...alert, oriented x4, arouses to voice/touch, follows commands, speech logical...WNL...” There was no documented evidence of the patient signing the discharge instructions. A concurrent interview was conducted on March 17, 2026 at 11:12 a.m., with the DQ. The DQ stated the discharge instructions were not signed by the patient or the patient representative and should have been signed by the patient or patient’s representative. 1c. A review of Patient 13’s medical record was conducted on March 16, 2026, at 2:39 p.m.,with the Special Project Coordinator (SPC). A facility document titled, “MD [medical doctor] History and Physical,” dated March 12, 2026, at 11:54 p.m., was reviewed. The document indicated,”...Chief complaint: post seizure [a sudden, uncontrolled burst of abnormal electrical activity in the brain]...57 year old...Patient is poor historian of seizure event most obtained via report as caregiver not at bedside...Admit for observation with neuro [neurology - the branch of medicine focused on diagnosing and treating disorders the brain]...” A facility document titled, “Order Detail,” dated March 14, 2026, at 3:23 p.m., was reviewed. The document indicated,”...D/C [discharge] to Board and Care...” A facility document titled, “Final Discharge Disposition,” dated March 14, 2026, was reviewed. The document indicated,”...Condition on discharge...Alert, Oriented, x 4...Arouses to voice/touch, follows commands, speech logical...Discharge...Patient left the unit...1843 [6:43 p.m.]...” An interview was conducted on March 16, 2026, at 2:45 p.m., with the SPC. The SPC stated there was no documented evidence that the discharge instructions were signed by Patient 13 before being discharged. 1d. A review of Patient 16’s medical record was conducted on March 16, 2026, at 3:32 p.m., with the SPC. A facility document titled, “MD History and Physical,” dated February 23, 2026, at 11:49 a.m., was reviewed. The document indicated,”...Date of Admit...02/22/2026[February 22, 2026]...44-year-old...transferred from skilled nursing facility with draining stump wound from the right foot...Impression and Plan...Suspected osteomyelitis [bone infection and inflammation] of right foot...” A facility document titled,”Order Detail,” dated February 24, 2026, at 10:58 a.m., was reviewed. The document indicated, “...D/C [discharge] to SNF...” A facility document titled, “Final Discharge Disposition,” dated February 24, 2026, was reviewed. The document indicated, “...Discharge disposition...Skilled Nursing Facility...Condition on discharge...Alert, Oriented, x 4. Arouses to voice/touch, follows commands,speech logical...Discharge...Patient left the unit...1545 [3:45 p.m.]...” An interview was conducted on March 17, 2026, at 9:05 a.m., with the SPC. The SPC stated there was no documented evidence that the discharge instructions were signed by Patient 16 before being discharged. 1e. A review of Patient 17’s medical record was conducted on March 16, 2026, at 3:54 p.m., with the SPC. A facility document titled, “MD History and Physical,” dated February 15, 2026, at 2:42 p.m., was reviewed. The document indicated, “...Date of Admit...02/15/2026 [February 15, 2026]...Chief Complaint...Altered...85-year-old...admitted with resp [respiratory -lungs] distress...lung congestion and altered ms [mental status]...” A facility document titled, “Order Detail,” dated February 17, 2026, at 12:40 p.m., was reviewed. The document indicated, “...Discharge home with hospice care [a home providing care for the sick or terminally ill]...” A facility document titled, “Final Discharge Disposition,”dated February 17, 2026, was reviewed. The document indicated, “...Discharge disposition...Home...Condition on discharge...Exceptions to WNL[within normal limits] - see note...Note...pt [patient] alert,confused...Discharge...Patient left the unit...1420 [2:20 p.m.]...” An interview was conducted on March 17, 2026, at 9:10 a.m., with the SPC. The SPC stated there was no documented evidence that the discharge instructions were signed by Patient 17 before being discharged. A review of the facility’s policy and procedure (P&P) was conducted on March 17, 2026, at 8:35 a.m., with the Director of Quality (DQ). The P&P titled, “Discharge/Transfer of Patient,” revised May 2024, was reviewed and indicated, “...Discharge Instructions...The patient and/or family will sign the form indicating they have received and understood the instructions. The patient will receive a copy of the instructions...” A concurrent interview was conducted on March 17, 2026, at 8:36 a.m., with DQ. The DQ stated the policy was not followed. 2. On March 17, 2026, at 9:05 a.m., a review of Patient 6’s medical record was conducted with the DQ. The facility document titled, “Nursing Chart,” dated February 2, 2026, at 2:27 a.m., indicated “...chief complaint: chest pain (assault)...triage assessment...pt complaining right chest pain following an assault/pt was pushed, left knee pain, right elbow pain and chest pain...” A concurrent interview was conducted on March 17, 2026, at 9:41 a.m., with the DQ. The DQ stated there is no documented evidence that an abuse assessment was done. On March 17, 2026, at 9:48 a.m., an interview was conducted with the Emergency Department Director (EDD). The EDD stated the Registered Nurses (RN’s) in the Emergency Department (ED) are required to screen patients for abuse, including asking for safety at home or if they are afraid of anyone at home. The EDD further stated for Patient 6 an abuse assessment was not documented and should have been documented. On March 17, 2026, at 9:50 a.m., an interview was conducted with the DQ. The DQ stated there was no facility policy for abuse screening.”

“DISCHARGE PLANNING-D/C PLANNING LIST CFR(s): [The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.…. This Standard is not met as evidenced by: 48326 Based on interview and record review the facility failed to ensure a list of HHA’s (Home Health Agency, an organization that provides medical care and therapy services to patients at home), SNF’s (Skilled Nursing Facility, a facility providing 24 hr nursing care), IRF’s (Inpatient Rehabilitation Facility, a facility that provides intensive rehabilitation therapy for patients recovering from serious injury) or LTCH’s (Long Term Care Hospital, a facility providing extended medical care for complex conditions) that serves the geographic area in which the patient resides, were available for patient’s participating in the Medicare (a federal health insurance program) program, for six of 20 sampled patients, (Patients 7, 8, 9, 10, 11, and 18). This failure could limit the patient’s ability to make an informed choice about post-hospital care, and could delay or disrupt safe discharge planning. Findings: 1.On March 17, 2026, at 9:58 a.m., a review of Patient 7’s medical record was conducted with the DQ. A facility document titled, “History and Physical,” dated March 1, 2026, at 11:31 p.m., indicated Patient 7 was admitted to the facility for septic shock (a life-threatening infection that causes dangerously low blood pressure and organ problems). A facility document titled, “Order Information,” dated March 5, 2026, was reviewed. The document indicated “...D/C [Discharge] to SNF,...f/u [followup] with hospice [service for terminally ill patients]...scheduled date 3/5/2026 [March 5, 2026]...” During the review of Patient 7’s medical record there was no documented evidence that a list of hospice facilities was provided to the patient or patient representative. On March 17, 2026, at 1:11 p.m., an interview was conducted with the Case Management Manager (CMM). The CMM stated there is no list of facilities such as SNF, Hospice, HHA available to present to Medicare participating patients. 2.On March 17, 2026, at 10:41 a.m., a review of Patient 8’s medical record was conducted with the DQ. A facility document titled, “History and Physical,” dated February 15, 2026, at 12:42 a.m., indicated Patient 8 was admitted to the facility for failure of outpatient (a patient who received medical care without staying overnight in a hospital) antibiotic therapy (treatment with medicines that kill bacteria causing an infection). A facility document titled, “Order Information,” dated February 16, 2026, at 3:41p.m., was reviewed. The document indicated “...discharge home with hospice...” A facility document titled, “Patient Progress Notes,” dated February 15, 2026, and Febuary 16, 2026, was reviewed. There was no documented evidence that a list of hospice facilities was provided to the patient or their patient representative. On March 17, 2026, at 1:11 p.m., an interview was conducted with the CMM. The CMM stated there is no list of facilities such as SNF, Hospice, or HHA’s available to present to Medicare participating patients. 3. On March 17, 2026, at 11:08 a.m., a review of Patient 9’s medical record was conducted with the DQ. A facility document titled, “History and Physical,” dated March 7, 2026, at 11:17 a.m., indicated Patient 9 was admitted to the facility for altered mental status. A facility document titled, “Order Information,” dated March 10, 2026, was reviewed. The document indicated, “...D/C to SNF...scheduled date 3/10/2026 [March 10, 2026]...” A facility document titled, “Patient Progress Notes,” dated March 10, 2026, was reviewed. The document indicated, “...faxed SNF packet to [Name of Facility 3], [Name of Facility 4], [Name of Facility 5], [Name of Facility 6]. Pending review and acceptance...8:30 p.m...per [Facility 3 Staff] with [Name of Facility 3]. Pt [Patient] medically accepted but no bed till Friday...8:53 p.m...per [Facility 6 Staff]. Pt medically accepted to [Name of Facility 6]...3/11/26 [March 11, 2026]...10:47a.m...CM [Case Management] spoke to pt at bedside, pt a/o x 4 [alert and oriented times four] and informed him [Name of Facility 6] accepted pt. Pt agreeable to going to [Name of Facility 6]...” During the review of Patient 9’s medical record there was no documented evidence Patient 9 was provided a list of SNF’s, and given the option to choose. An interview was conducted on March 17, 2026, at 11:10 a.m., with the DQ. The DQ stated there was no documentation that a list of SNF’s was provided to Patient 9. On March 17, 2026, at 1:11 p.m., an interview was conducted with the CMM. The CMM stated there is no list of facilities such as SNF, Hospice, or HHA’s available to present to Medicare participating patients. 4. On March 17, 2026, at 11:35 a.m., a review of Patient 10’s medical record was conducted with the DQ. A document titled, “History & Physical,” dated February 11, 2026, indicated Patient 10 was admitted to the facility for respiratory distress (trouble breathing). A facility document titled, “Order Information,” dated February 11, 2026, at 11:07 a.m., was reviewed. The document indicated “...D/C to SNF...” A facility document titled, “Patient Progress Notes,” dated February 11, 2026, was reviewed. The document indicated “...4:46 p.m...[Facility Staff 2] also stated spouse wants more treatment and patient might go back to [Name of Facility 4] as custodial [non-medical care] and no longer be on hospice...CM made aware of DC order for SNF. Patient has been accepted at [Name of Facility 4]...” During the review of Patrient 10’s medical record there was no documented evidence, Patient 10 was provided a list of SNF’s, and given the option to choose. An interview was conducted on March 17, 2026, at 11:38 a.m., with the DQ. The DQ stated there is no documentation that a list of SNF’s was provided to Patient 10. On March 17, 2026, at 1:11 p.m., an interview was conducted with the CMM. The CMM stated there is no list of facilities such as SNF, Hospice, or HHA’s available to present to Medicare participating patients. 5. On March 16, 2026, at 1:04 p.m., a review of Patient 11’s medical record was conducted with the Special Program Coordinator (SPC). An undated and untitled document was reviewed. The document indicated Patient 11 was admitted March 11, 2026, and the primary insurance was Medicare. A facility document titled, “MD [medical doctor] History and Physical,” dated March 12, 2026, was reviewed. The document indicated, “...Chief Complaint: fall injured head...presents after being found on the ground with altered mental status...Patient admitted for acute metabolic [chemical changes in the body] vs.[versus] toxic encephalopathy [an acute change in how your brain works due to an underlying condition] due to cocaine [an illegal addictive drug] use vs. UTI [urinary tract infection- bacterial infection in the kidneys, bladder or ureters (tube where urine passes) or urethra(tube where urine passes), also rule out stroke (medical emergency that happens when something prevents your brain from getting enough blood flow).” An undated facility document titled, “Patient Progress Notes,” was reviewed. The document indicated, “...Discharge: 03/14/2026 [March 14, 2026] 16:00 [4 p.m.]...15:46 [3:46 p.m.]...Assessment/Daily Note...Patient is okay with discharging to SNF...Spoke with [Facility Staff] at [Name of Facility 1]...” An interview was conducted on March 17, 2026, at 1:17 p.m., with the CMM. The CMM stated there will be no documented evidence that a list of SNFs were provided to Patient 11 or Patient 11’s representatives during the discharge planning process because they only discuss the list but do not document it. 6. On March 16, 2026, at 3:49 p.m., a review of Patient 18’s medical record was conducted with the SPC. An undated and untitled facility document was reviewed. The document indicated Patient 18 was admitted on February 4, 2026, and the primary insurance was Medicare. A facility document titled, “MD History and Physical,” dated February 5, 2026, was reviewed. The document indicated, “...Date of Admit...02/04/2026 [February 4, 2026]...Chief Complaint: Respiratory failure...presents to the ER [emergency room- hospital unit that provides treatment to persons requiring immediate medical care] with gross altered level of consciousness...noted to be in moderate to severe respiratory distress...intubated [a breathing tube] in the ER and admitted to the intensive care unit [ a unit that provides care to severely sick patients]...” A facility document titled, “Order Information,”dated February 8, 2026, at 2:56 p.m., was reviewed. The document indicated, “...D/C [discharge] to SNF...” A facility document titled, “Discharge Summary,” dated February 13, 2026, at 10:23 a.m., was reviewed. The document indicated, “...Date of Discharge...02/08/2026 [February 8, 2026]...The patient was discharged back to [Name of Facility 2]...on 02/08/2026 [February 8, 2026] in stable condition...” An interview was conducted on March 17, 2026, at 1:18 p.m., with the CMM. The CMM stated there will be no documented evidence that a list of SNFs were provided to Patient 18 or Patient 18’s representatives during the discharge planning process because they only discuss the list but do not document it.”

“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: 48326 Based on interviews and record review the facility failed to ensure the policies and procedures (P&P) for pain management was followed for one of 25 patients (Patient 25) when the staff did not advocate for the patient’s breakthrough pain needs. These failures had the potential to result in unmanaged pain. Findings: A review of Patient 25’s medical record was conducted on September 9, 2025, at 2 p.m., with the Clinical Supervisor (CS). A facility document titled, “[Facility Name] PA [Physician Assistant]/NP [Nurse Practitioner] History and Physical,” dated June 28, 2025, at 10:15 a.m., was reviewed. The document indicated Patient 25 was admitted to the facility for worsening shortness of breath (SOB)...history...status post lung cancer a right upper lobe resection some years ago and is followed by oncologist [cancer doctor] [sic] and pulmonologist [lung doctor] but did not complete all of her treatment plan...pt [patient] was omitted [sic] to the hospital for shortness of breath, rule out recurrent neoplasm [tumor] vs [versus] pneumonia [infection of the lungs]...” An untitled facility document dated June 30, 2025, was reviewed. The document indicated Patient 25’s pain assessments as followed: - June 30, 2025, at 8 a.m., pain scale 4 (moderate pain 4-6); - June 30, 2025, at 12 p.m. pain scale 5 (moderate pain 4-6); - June 30, 2025, at 2:30 p.m., pain scale 8 (severe pain 7-10); - June 30, 2025, at 3:30 p.m., pain scale 5 (moderate pain 4-6); and - June 30, 2025, at 4:30 p.m., pain scale 4 (moderate pain 4-6). An interview was conducted on September 10, 2025, at 11:48 a.m.,with the DQ (Director of Quality). The DQ stated Patient 25, was still experiencing pain despite pain medication administration and the “...nurse should have called the provider...” to notify him the patient was still in pain. The DQ further stated Patient 25’s pain was not managed appropriately. The facility’s policy and procedure (P&P) titled, “[Facility Name] Pain Assessment and Management,” dated February 2023, was reviewed. The policy indicated “...the patient experiencing pain will be appropriately assessed and interventions will be made in a timely manner to provide pain relief...pain will be assessed, reassessed, and documented at regular intervals after the following...with each new report of pain...””

“Standard-level Tag for Pharmaceutical Service CFR(s): 482.25 Standard-level Tag for §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients... This Standard is not met as evidenced by: 48326 Based on interviews and record review, the facility failed to ensure Patient 25’s ordered cardiac medication was available in the pharmacy for administration. This failure had the potential to result in worsening cardiac issues. Findings: A review of Patient 25’s medical record was conducted on September 9, 2025, at 2 p.m., with the Clinical Supervisor (CS). A facility document titled, “[Facility Name] PA [Physician Assistant]/NP [Nurse Practitioner] History and Physical,” dated June 28, 2025, at 10:15 a.m., was reviewed. The document indicated, “...was admitted to the facility for worsening shortness of breath (SOB)...history...status post lung cancer a right upper lobe resection some years ago and is followed by oncologist [cancer doctor] [sic] and pulmonologist [lung doctor] but did not complete all of her treatment plan...pt was omitted [sic] to the hospital for shortness of breath, rule out recurrent neoplasm [tumor] vs [versus] pneumonia [infection of the lungs]...” A facility document titled,”Order Detail” dated June 27, 2025, was reviewed. The document indicated, “...Verapamil HCL[hydrochloride] [heart medication] (CALAN) 180 mg [milligrams unit of measurement] SR [suspended release] Tab [tablet]...dose 180mg...administer amount 1 tablet, extended release...route: oral...frequency: daily...start date/time 06/27/2025 18:20 [June 27, 2025, at 6:20 p.m.]...ordered:06/27/2025 18:20...entered:06/27/2025 18:20...nursing verified 06/27/2025 19:42 [June 27, 2025, at 7:42 p.m.]...pharmacy verified 06/27/2025 18:42 [June 27, 2025, at 06:42 p.m.]...06/28/2025 [June 28, 2025,] 09:55...omitted: other 180 mg...06/29/2025 [June 29, 2025] 08:42...omitted: med not available...06/30/2025 [June 30, 2025,] 08:17...omitted: med not available...” An interview was conducted on September 9, 2025, at 9:42 a.m., with the Pharmacist (PharmD). The PharmD stated if a medication is not stocked, they find and recommend an alternative to the provider or try to borrow the medication from another pharmacy. An interview was conducted on September 9, 2025, at 9:49 a.m., with the DOP (Director of Pharmacy). The DOP stated, “an occurrence happened a few months ago where it was brought to our attention about a medication not being available.” The DOP further stated they did not realize they had an issue with their process. An interview was conducted on September 10, 2025, at 1:46 p.m., with the Quality Manager (QM). The QM stated the dosage of the missed medication was not stocked in the pharmacy. The QM further stated there is a non-formulary medication (medication not approved on hospital’s approved drug list) request form that should have been completed but it was not done. The QM stated there was a failure in communication. A review of the facility policy and procedure (P&P) titled “[Facility Name] Drug Formulary of Available Medication,” dated January 2025, was conducted with the DQ. The policy indicated “...the director of pharmaceutical services is responsible for maintaining the supply of those medications considered to be necessary for the diagnosis and treatment of the patients...Non-Formulary Medications...Should a physician prescribe a non-listed (“non-formulary”) medication, the pharmacist will contact the prescriber and attempt to obtain authorization to use a therapeutically equivalent formulary medication...the prescriber shall complete a request for use non formulary medication. The information shall be reviewed by the director, pharmaceutical services, or designee, for appropriateness...if the physician confirms that only the non-formulary drug can meet the patients’ needs and sufficient justification is provided, the pharmacists will obtain the non-formulary medication for the specific patients need, and preferably only in the quantity for the current course of therapy period all requests for non-listed medications are reviewed by the Director of Pharmaceutical Services...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48776 Based on interview, and record review, the facility failed to ensure the facility’s policy and procedure (P&P) for pain management was implemented, for one of 30 sample patients (Patient 19), when: For Patient 19, pain medication was not administered for one and a half hours when the pain score (numerical pain tool where mild pain is scored 1-3, moderate pain is scored 4-6, and severe pain is scored 7-10) was 8; and the pain score was not reassessed and documented following pain medication administration. This failure had the potential to impact the health and treatment of the patients, and cause delays in patient care. Findings: A review of Patient 19’s medical record was conducted on December 10, 2024, at 3:45 p.m., with the Infection Preventionist (IP). A facility document titled, “Triage,” dated October 17, 2023, indicated Patient 19 presented to the Emergency Department (ED) for evaluation of “Chief complaint: pelvic pain...Severity: The severity of the pain was 8 (0-10 scale). The patient’s goal for today is 2...Toradol [medication used to treat pain] - 30 mg [milligrams, unit of measure] IVP [Intravenous Push, medication to be administered in the vein] Placed at 10/17/2024 [October 17, 2024] 14:57 [2:57 p.m.], [Name of Provider]...Completed at 10/17/2024 [October 17, 2024] 16:07 [4:07 p.m.]...[Name of Registered Nurse]...” An interview was conducted with the Quality Director (QD) on December 10, 2024, at 4 p.m. The QD stated the patient should have received medication for pain management sooner than one and half hours. The QD stated there was a delay in the pain medication being administered and there was no pain reassessment following the Toradol administration and this should have been done. The QD stated the pain reassessment should be completed after 15-30 minutes after IVP administration. On December 11, 2024, at 9:10 a.m., a concurrent interview and record review of Patient 19’s record was conducted with the Emergency Department Director (ED). The ED stated pain medication should have been administered timely to Patient 19 and this was not done. The ED stated the reassessment of pain should have been completed following the pain medication administration and this was not done. A review of the facility P&P titled, “[Name of Facility] Pain Assessment and Management,” dated February 2023, indicated, “...The patient experiencing pain will be appropriately assessed and interventions will be made in a timely manner to provide pain relief...Pain will be assessed, reassessed, and documented at regular intervals after the following...15-30 minutes after parenteral (intravenous) drug therapy and 1 [one] hour after oral administration...” A review of the facility P&P titled, “[Name of Facility] Triage,” dated June 2024, indicated, “...Triage assessment: Perform focused assessment of chief complaint to include the collection of subjective and objective data... Subjective data which may include, but not limited to, onset and progression of symptoms, location and description of problem, mechanism of injury, treatment prior to arrival and response and pain assessment... Reassessment every two (2) to four (4) hours and as needed...””