Valley Presbyterian Hospital

“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: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1. The facility failed to ensure for one of thirty sampled patients (Patient 2), appropriate nursing care was provided when Patient 2 was not given a patient-centered wound assessment during two Emergency Department (ED) visits. This failure had the potential to result in a delayed treatment and may have contributed to the deterioration of Patient 2 ’ s breast wound and potentially caused a decline of Patient 2 ’ s medical condition. (Refer to A-395). 2. The facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing glucose (a simple sugar that serves as the source of energy for the body) needs, bleeding (loss of blood), blood pressure (the pressure within the major arteries of the body), fluid/electrolyte imbalance (when the levels of fluid/minerals in the body are too high or too low), and pain for one of 30 sampled patients (Patient 8). This deficient practice had the potential to result in Patient 8 not receiving the right level of care and not meeting the needs for the identified patient concerns. (Refer to A-396). 3. Based on interview and record review, the facility failed to ensure two of 30 sampled patients (Patient 11 and Patient 13) was discharged from the facility free from pain. This deficient practice resulted in the following: Patient 11 left the facility in severe pain, without physician notification. Patient 13 left the facility in moderate pain, without physician notification. (Refer to A-398). 4. 1. Ensure one of 30 sampled patients (Patient 6) received the appropriate medication ordered during an emergent (something suddenly appear) situation. This deficient practice resulted in Patient 6 receiving the wrong medication, causing seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), that required intubation (a life-saving, medical procedure in which a healthcare provider inserts a tube through the mouth or nose, down the throat, and into the windpipe [trachea]) with mechanical ventilation (a life-support treatment using a machine [ventilator] to move oxygen-rich air in and out of the lungs when a person cannot breathe adequately on their own), and Patient 6 being transferred to the intensive care unit (ICU) for additional care. (Refer to A-405) 2.Ensure nurses document assessments of Richmond Agitation-Sedation Scale (RASS score, a validated, 10-point medical tool ranging from -5 to +4, used by healthcare professionals to quickly assess the level of agitation or sedation in critically ill or injured patients) for one of 30 sampled patients (Patient 14), as per order. This deficient practice has the potential to result in Patient 14 sedation level not being appropriately monitored. (Refer to A-405) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by: 1. the hospital failed to develop policies and procedures for the control and storage of medications, as evidenced by the hospital ’ s failure to develop the policy and procedures for a contracted vendor software, BlueSight ControlCheck (also known as BlueSight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion events to ensure accountability of medications) that has been in use since 2/28/2025. This failure had the potential for inadequate monitoring of medication errors, drug diversions (the illegal transfer of prescription drugs), and/or pilferage (stealing) that may affect patient safety. (Refer to A-491). 2. 1. Failed to ensure there were devices (tool) or a system to monitor the ambient (surroundings) temperature inside the medication rooms to ensure medications were stored within the temperature range as required by the labelling. 2.Failed to ensure the date of first medication due to expire was accurately documented on the pink Crash Cart Check Card for one of one malignant hyperthermia (MH, a rare, life-threatening hereditary disorder characterized by a severe hypermetabolic response to certain general anesthetics) cart (a specialized, readily available emergency cart, containing critical, time-sensitive, lifesaving supplies, primarily aimed at treating MH crises) located in the Labor & Delivery (LD) department. 3. Failed to ensure one of one AMI (acute myocardial infarction) kit (an emergency code kit designed for emergent heart attack situation) in the Emergency Department (ED) contained accurate lock numbers These deficient practices had the potential of having improperly stored and/or ineffective medications that may hinder treatment efficacy and/or affect patient outcomes during emergency. (Refer to A-500). 3. 1.Failure to ensure the anteroom (a room serves as a transition area that separates the dirty area from the clean area or room where IV(into the vein) medications are prepared) of the sterile compounding suite (IV room) was clean and free of residues(small amount of something left after the main part) and/or stains that could accumulate (collect)contaminants (spoils) and/or microorganisms (tiny living thing too small to be seen). 2.Failure to ensure Environmental Services (EVS) staff cleaned the back exterior (outside) of a CACI (Compounding Aseptic Containment Isolator, or glovebox) and the wall behind the CACI in one of two buffer rooms (specialized, controlled environment—typically ISO Class 7—designed to protect sterile compounding, pharmaceutical, or high-tech manufacturing areas from contamination), Chemotherapy (or hazardous drug [HD] room, the buffer room that is negative in air pressure for compounding chemotherapy and/or other hazardous drugs) room. 3.Failure to ensure the sterile compounding environment viable sampling plan (a map of sampling locations) used by the vendor that certified its IV room was included in the hospital ’ s procedure of environmental media testing (process of collecting and analyzing air, soil or water). These failures had the potential of exposing patients requiring IV (into the vein) medications to preventable contamination that may affect patients ’ health and safety. (Refer to A-501). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Surgical Services as evidenced by: 1.Ensure patient safety practices and care requirements unique to the operating room [OR, a facility within a hospital where surgical operations are carried out in an aseptic (free of germs) environment] were consistently followed for one of 30 sampled patients (Patient 1) when the OR staff did not follow the facility ’ s policy and procedure (P&P) for performing surgical counts (a critical and mandatory patient safety procedure in the operating room where the scrub technician and the circulating nurse count all instruments, sponges, and miscellaneous items before, during, and after a procedure to prevent retained surgical items) during Patient 1 ’ s surgery. The deficient practice resulted in Patient 1 undergoing a second surgical procedure to remove a retained surgical sponge (a highly absorbent pad made of cotton or synthetic material, used during a surgical procedure to control bleeding, absorb fluids, and maintain a clear, visible operating field), a prolonged recovery time, and negatively impacting Patient 1 ’ s overall well-being. (Refer to A-951). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 51860 Based on interview and record review, the facility failed to maintain documented audits listed in the Root Cause Analysis (RCA, a systematic process for uncovering and identifying underlying issues that, if resolved, can prevent the problem from recurring) Action Plan for a Retained Foreign Object (RFO, any item used during an operative procedure that is unintentionally left inside the patient) incident which occurred in October 2025. The deficient practice had the potential of not be able to analyze all data available to prevent another incident involving a Retained Foreign Object (RFO) during a surgical procedure. Findings; During a review of the facility ’ s QAPI RCA Action Plan, dated 11/18/2025, the RCA indicated a description of the events leading up to the RFO event. The RCA Action Plan indicated action plans for the facility staff, the surgery circulating Registered Nurses [a Registered Nurse who manages the non-sterile (does not have the complete elimination of organisms) logistics of an operating room and is responsible for patient safety] and the surgical scrub technicians [an operating room professional who prepares the sterile (an area or item free from microorganisms), instrument heavy environment and assists surgeons directly during a surgical procedure]. The RCA Action Plan indicated steps for re-education of Operating Room (OR) policies regarding sponge counts, changing the electronic medical record system for counting surgical items used during a surgery, re-education for mandatory use of sponge counters (an instrument used for placement of sponges, making surgical sponge counts easier to visualize), and surgical count observation audits/spot checks by OR manager and audits by QAPI department. The RCA Action Plan indicated audit follow-up to be 30 days from the approval date listed on the RCA form, date entered is 11/18/2025. During an interview on 2/03/2026 at 2:30 p.m. with OR Nurse Manager (NM) 2, NM 2 stated he performs surgical count spot audits on a daily basis. NM 2 stated the audits are done visually for an active OR case or electronically for completed cases. NM 2 stated the goal of the surgical count audits is to reach 10% of the surgery cases per week, which would equal approximately 15 audits per week. NM 2 stated he has not kept track of audits performed. NM 2 stated he does not have proof or logs to indicate he has completed surgical count audits. During an interview on 2/03/2026 at 2:30 p.m. with Interim Chief Nursing Operator (CNO), CNO stated the QAPI department would be the ones to obtain the percentage of surgical count audits. During an interview on 2/03/2026 at 3:00 p.m. with the Vice President of Quality (VP Quality), VP Quality stated the QAPI staff was to begin the surgical counts audits on 02/01/2026 but did not. During an interview on 2/03/2026 at 3:17 p.m. with Quality Coordinator (QCO), QCO stated, “We don ’ t have a number. We were supposed to start audits today, but we didn ’ t. [Performance Improvement Coordinator] PIC was tasked with performing the audits. The audits would be electronic medical record reviews to see if the policy is being followed. There was an expectation of monthly audits (to have begun 2/03/2026). If the plan (audits) had been initiated, the numbers would be presented to me to present at a QAPI meeting.” A review of the facility’s policy and procedure (P&P) titled “Quality Assurance and Performance Improvement (QAPI) Plan revise dated 8/30/2023 indicate, VII. Collecting Data on Performance: A. Scope of Data Collection, The organization collects data in the following areas but not limited to: 3. Operativeand invasive procedures. 15. Adverse events or near misses 16. Readmissions and unplanned returns to surgery”

“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: 38310 Based on interview and record review, the facility failed to ensure one of thirty sampled patients (Patient 10) had a pre-surgical assessment prior to surgical procedure. This deficient practice had the potential for adverse events (any unintended medical occurrence) with increased length of stay in the hospital if patient had a change on condition, since the last history and physical. Findings: A review of Patient 10 ’ s History and Physical (H&P – a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination), dated 11/12/2024, from transferring facility, indicated the following: Assessment – history of pulmonary embolism, (sudden life-threatening blockage of one of the arteries in the lungs) anxiety (feeling of worry) and high blood pressure. Plan to admit to telemetry unit (hospital unit for patients with heart problems are monitored) with medications for thinning blood. A review of Patient 10 ’ s face sheet (a concise document summarizing essential patient information, including demographics, insurance, emergency contacts and key medical details), dated 11/24/2024 to 12/12/2024, indicated patient diagnosis was acute embolism (a sudden life-threatening blockage of a lung artery, caused by a clot). A review of Patient 10 ’ s H&P, dated 11/26/2024, indicated the following plan and assessment: History of two heart attacks on 11/15/2024, Ventilator (breathing machine) dependent. History of anoxic brain injury (when the brain is completely deprived of oxygen, causing cell death). History of multiple pulmonary emboli (a sudden, life-threatening blockage in the pulmonary arteries, in the lungs). Dialysis treatment. A review of Patient 10 ’ s conditions of admissions, dated 11/25/2024, indicated that patient was unable to sign document due to medical condition. On 2/6/2026, at 1:13 AM, during concurrent interview with Registered Nurse (RN) 8 and record review of Patient 10 ’ s informed consent for tracheostomy (a surgical procedure creating an opening in the neck into the trachea to establish an airway, facilitate mechanical ventilation, or remove lung secretions), dated 12/10/2024, RN 8 stated Patient 10 ’ s family member signed the consent. Concurrently, during review of Patient 10 ’ s Informed Consent, dated 12/9/2024, indicated the physician, MD 2, indicated the following discussion with patient ’ s representative: The planned placement for tracheostomy procedure. The risks and benefits of the procedure. The adverse reactions for this procedure. The alternative treatments for this procedure. The potential problems during recuperation from this procedure. The potential need for blood transfusions and associated risks and benefits. Any research or economic interests, regarding this treatment. Concurrently, during review of Patient 10 ’ s Operative Report, dated 12/10/2024, indicated the following: Operation performed – tracheostomy Anesthesia type – general Estimated blood loss – minimal Patient condition post procedure – stable Surgeon – MD 3 Concurrently, RN 8 stated there was no pre-surgical assessment done by MD 3, who performed the surgery for tracheostomy placement. RN 8 stated Patient 10 should have had a pre-surgical assessment prior to the procedure to see if Patient 10 ’ s condition has changed since Patient 10 ’ s last H&P, dated 11/24/2024. A record review of facility ’ s Medical Staff Rules and Regulations, dated 2024, indicated the following: A medical history and physical (H&P) must be completed and documented for each patient 24 hours after admission or registration. When a medical H&P has been completed, an updated examination of the patient, including any changes in the patient ’ s condition, must be completed and documented prior to surgery or a procedure requiring anesthesia services.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure for one of thirty sampled patients (Patient 2), appropriate nursing care was provided when Patient 2 was not given a patient-centered wound assessment during two Emergency Department (ED) visits. This failure had the potential to result in a delayed treatment and may have contributed to the deterioration of Patient 2 ’ s breast wound and potentially caused a decline of Patient 2 ’ s medical condition. Findings: During a review of Patient 2 ’ s “Discharge Summary,” dated 9/22/2025, indicated, Patient 2 was admitted to the facility on 9/13/2025 with a worsening left breast pain and swelling and a failed outpatient treatment of antibiotics (medication that destroy or inhibit the growth of bacteria to treat and prevent infections). The Discharge Summary indicated after Patient 2 was admitted she underwent a breast Magnetic Resonance Imaging scan (MRI, a non-invasive medical imaging technique used to produce images of organs and soft tissue) which showed left breast mastitis (inflammation of the breast tissue) complicated by a 10 centimeter (cm, a metric unit of measurement for length) multiloculated (describes a structure that is divided into many small, separate chambers) abscess [a localized and painful pocket of pus (fluid which accumulates at an infection site)] for which clinical follow-up was recommended. The Discharge Summary indicated Patient 2 underwent a Computer Tomography-guided (CT, a noninvasive imaging procedure) aspiration (removal of fluid or tissue via suction) on the left breast on 9/19/2025. The Discharge Summary instructions were to follow-up with surgeon (MD) 5 for a repeat ultrasound (an imaging technique that uses sound waves to create images), antibiotics for 10 days, pain medication, and instructions, “If you notice significant t increase in drainage, increasing redness, pain, induration (hardness), develop fever or chills, please call MD 5 or return to the emergency room.” During a review of surgeon (MD) 6 consultation note, dated 9/13/2025, the consultation note indicated Patient 2 had “an area of cellulitis (a skin infection that causes swelling and redness) and erythema (abnormal redness of the skin) over the left breast starting in peri-nipple (the pigmented area around the nipple) area and extending to lower out quadrant of the breast ...” During a review of Patient 2 ’ s “ER (Emergency Room, Emergency Department) Discharge Summary dated 9/24/2025, Physician Assistant (PA) 1 indicated Patient 2 presented to the ED for concern of “yellow drainage coming from it (wound) and she wants to make sure that it is not worsening. Patient says it has been improving and swelling, pain and redness. Patient says it has been increasing in yellow discharge and that her left nipple is retracted (the nipple lies flat). Endorses being adherent (compliant) to oral antibiotics that were prescribed from her recent discharge.” Patient 2 ’ s ED Discharge Summary indicated, “Patient subjectively says that the breast mass (a lump or abnormal growth) has been improving in terms of pain, redness, swelling and general size however has been increasing and serosanguineous (a type of wound drainage that is thin, watery, and pale pink or light red in color) discharge.” The Discharge Instructions section of the Discharge Summary indicated, “ ...their symptoms worsen/become more concerning, they are to return to the ER for reassessment immediately.” During a review of Emergency Department (ED) Registered Nurse (RN) 10 ’ s “ED Intake/Sepsis Screening” form, dated 9/24/2025, indicated Patient 2 presented to the ED for a chief complaint of “left breast surgical incision check, increased pain and discharge,” and a “Pain Intensity score of 10 (pain scale 0-10, with 0 indicating absence of pain and 10 indicating severe level of pain).” During a review of ED Registered Nurse (RN) 11 ’ s “ED Skin Risk Assessment” form, dated 9/24/2025, the form indicated Patient 2 ’ s wound assessment as, “Left Breast ...Wound Type: Abscess, Dressing (a protective material applied directly to a wound) Status: Open to air.” During a review of RN 11 ’ s “Wound Assessment Short,” dated 9/24/2025, the form indicated, “Dressing Status: Open to air.” The form indicated no descriptions marked under “Wound Measurement,” “Drainage Description,” “Drainage Color,” and “Wound General Appearance” categories. During a review of RN 11 ’ s “ED Depart/Discharge Instructions,” dated 9/24/2025, the form indicated Patient 2 ’ s “Condition at Discharge: Improved, Pain Improved.” During a review of Patient 2 ’ s ED Discharge Instructions, dated 9/24/2025, the instructions indicated to “Call your healthcare provider if you see any of the following signs of a problem: ...Increased drainage ...Increased swelling or pain, or redness or swelling in the skin around the wound ... A change in the color of the wound ...An increase in the size of the wound.” During a review of ED Registered Nurse (RN) 12 ’ s “ED Intake/Sepsis (a body ’ s extreme response to an infection) Screening” form, dated 9/28/2025, the form indicated Patient 2 presented to the ED for a chief complaint “wound check left breast, states feels burning/discharge,” and “Pain Intensity 5 (0-10).” During a review of ED Registered Nurse (RN) 13 ’ s “ED2 Assessment,” dated 9/28/2025, the note indicated “Integumentary (related to the skin) Assessment Comment: L (left) lower breast wound redness/scaling (scaling: tending to crack).” During a review of RN 13 ’ s “Vital Signs (objective measurements of the body ’ s most basic functions)” note, dated 9/28/2025, the note indicated Patient 2 had a “Current complaint of pain,” and “Pain Intensity 2 (0-10).” During a review of Patient 2 ’ s “ER Discharge Summary,” dated 9/28/2025, the Discharge Summary indicated upon physical exam, “Left breast with cellulitic (a bacterial infection of the skin) skin changes to inferior-lateral (a position of the body that is below and away) breast without fluctuance (a fluid-filled sensation felt when pressing on a swollen area) ..., there is a (sic) area of superficial ulceration (an open sore or lesion of the skin).” During a review of Patient 2 ’ s History and Physical (H&P), dated 10/02/2025, the “H&P” indicated Patient 2 was transferred to facility General Acute Care Hospital (GACH 1) from GACH 2 ’ s ED after presenting to GACH 2 for “worsening pain and more drainage from the wound despite being on Zyvox (an antibiotic). Patient also notes a fever (an increase in body temperature) yesterday but no vomiting (an expulsion of stomach contents). She also states the pain is now radiating (traveling along a path) to her left flank (the side of the body between the ribs and the hip) area.” During a review of Patient 2 ’ s “Operative Report,” dated 10/02/2025, the Operative Report indicated Patient 2 ’ s Preoperative Diagnosis as necrotizing soft tissue infection (a rare, life-threatening “flesh-eating” bacterial infection that rapidly destroys skin, fat, and muscle tissue) left breast. The Operative Report indicated Patient 2 ’ s the Postoperative Diagnosis as (1) necrotizing soft tissue infection left breast and (2) left breast abscess. The Operative Report indicated Patient 2 ’ s Operation/Procedure Performed as (1) left breast excision (the removal of tissue) wound debridement [the removal of dead (necrotic), damaged, or infected tissue], (2) left breast abscess drainage, and (3) localized adjacent tissue transfer (a surgical procedure that removes healthy skin from an area immediately neighboring a wound to cover the wound area) 40 cm squared [an area of 6.2 inches (a unit of measure for length)]. During a concurrent interview and record review on 2/05/2026 at 10:53 a.m. with ED Educator (EDE), Patient 2 ’ s electronic medical records from 9/13/2025 to 10/08/2025 were reviewed. Patient 2 ’ s electronic medical records indicated one GACH 1 hospitalization, two GACH 1 ED visits, and a third ED visit to GACH 2 which resulted in a transfer and admission to GACH 1. EDE stated Patient 2 ’ s GACH 1 ’ s ED nursing assessments did not indicate measurements or descriptions of Patient 1 ’ s left breast open wound, redness, or color of discharge. EDE stated it was important to take measurements of a wound to monitor and determine changes over time. EDE stated that the ED does not have a policy or procedure to determine what should be included in an ED nursing assessment regarding wounds and drainage. During an interview on 2/06/2026 at 2:20 p.m. with ED Nurse Manager (NM) 3, NM 3 stated there are no standards of practice, policies, procedures or guidelines regarding wound assessments for ED nurses. NM 3 stated ED nursing assessments are “driven by chief complaints.” During an interview on 2/06/2026 at 2:25 p.m. with ED Registered Nurse (RN) 14, RN 14 stated an ED triage nurse would not be required to describe a wound or drainage other than to indicate if there is a dressing and if there is drainage. RN 14 stated an ED triage nurse would not take measurements of a wound. RN 14 stated a primary care ED nurse would take measurements of a wound but a primary care ED nurse is not required to do so. RN 14 stated, “I would quantify a size but I won ’ t take a measuring tape out. I would describe the wound as large, weeping, things like that,” and it is the expectations but not a requirement to take wound measurements. RN 14 stated there are no standards of practice, written guidelines, policies, or procedures on how to assess wounds.”

“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: 38310 Based on interview and record review, the facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing glucose (a simple sugar that serves as the source of energy for the body) needs, bleeding (loss of blood), blood pressure (the pressure within the major arteries of the body), fluid/electrolyte imbalance (when the levels of fluid/minerals in the body are too high or too low), and pain for one of 30 sampled patients (Patient 8). This deficient practice had the potential to result in Patient 8 not receiving the right level of care and not meeting the needs for the identified patient concerns. Findings: During a review of Patient 8 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/16/2025 at 11:22 am, indicated that Patient 8 had a past medical history of hypertension (HTN, high blood pressure), diabetes mellitus ((DM, a condition in which the body does not use insulin [a hormone that helps regulate blood sugar levels] effectively or does not produce enough insulin), renal transplant (a surgical procedure that places a healthy kidney from a donor into a person whose own kidney(s) have failed). Patient 8 presented to the hospital with reported diarrhea (passing loose, watery, or slimy stool three or more times in a single day), dizziness (sensations of feeling lightheaded, woozy, faint, or unsteady), and nausea (an unpleasant, queasy sensation in the stomach that creates an urge to vomit) for one month resulting in the findings of gastrointestinal bleeding (GIB, blood loss originating from any part of the digestive tract [any part of the body from the mouth to the anus that transports food through the body]), anemia (a common blood condition where the body lacks enough healthy red blood cells [RBC] or hemoglobin to carry sufficient oxygen to tissues), and hyponatremia (a common, serious condition where the sodium [salt] level in the blood is abnormally low). Patient 8 also had a history of the right renal transplant in 2012, and on medications to prevent organ rejection (the process where a transplant recipient ’ s immune system recognizes a new organ as foreign and attacks it, damaging or destroying the tissue). During a concurrent interview and record review on 2/5/2026 at 11:13 am, with the Performance Improvement Coordinator (PIC), PIC stated there was no care plans found addressing Patient 8 ’ s HTN, DM, risk for bleeding related to Patient 8 ’ s GIB and administration of Heparin (use to treat blood clots), and fluid/electrolyte imbalance (when essential minerals in the body become too high or too low, disrupting vital functions like heart rhythm, muscle contraction, and hydration) related to Patient 8 ’ s use of immunosuppression medications (drugs that intentionally weaken or “turn down” the body ’ s immune system), anemia , hyponatremia, and GIB. A review of Patient 8 ’ s care plans resulted in no care plan identifying Patient 8 ’ s previously mentioned needs. PIC stated that the care plans should have been initiated to ensure consistency of care and identify a plan of care to ensure Patient 8 ’ s safety by identifying and addressing all individual needs. During a review of Patient 8 ’ s “Medication Administration Record (MAR, a document that provides a list of all medications given to a patient by a healthcare professional)”,indicated that Patient 8 received morphine (a medication used to treat moderate to severe pain), prednisone (a medication used to treat inflammation, severe allergies, asthma, and autoimmune diseases by reducing swelling, redness, and itching), tacrolimus (a powerful medication that suppresses the immune system to prevent the body from rejecting transplanted organs), mycophenolate (an immunosuppressant medication used to prevent the body from rejecting transplanted organs), carvedilol (a medication used to treat high blood pressure and heart failure), dapagliflozin propanediol (a medication used to treat type tow diabetes, heart failure, and chronic kidney disease), heparin (an injectable anticoagulant medication [blood thinner] that prevents and treats harmful blood clots in veins, arteries, and the lungs), Norco (an opioid medication used to treat moderate to severe pain), and insulin aspart (a rapid-acting, human insulin used to treat diabetes). During a review of Patient 8 ’ s “Discharge Summary”, dated 1/26/26 at 3:10 pm, the discharge summary indicated that Patient 8 had a discharge diagnosis of end-stage renal disease (the final, permanent stage of kidney failure where kidneys function at less that 15% of normal capacity) status post donor transplant in 2012, hypokalemia (low potassium in the blood), hyponatremia (low sodium in the blood), anemia, hypomagnesemia (low magnesium in the blood), DM, and colorectal cancer (a disease where cells in the colon or rectum grow uncontrollably, often developing from precancerous polyps) with metastatic disease (cancer that has spread from the part of the body where it first started to other, distant parts of the body). Patient 8 refused intervention and treatment though Patient 8 was at risk for obstruction. Patient 8 ’ s hospital course was for 71 days with a plan to discharge Patient 8 to a skilled nursing facility to hospice (specialized compassionate care for people with terminal illnesses). During a review of the facility ’ s policy and procedures (P&P), titled “Assessment, Reassessment, and Interprofessional Plan of Care”, dated 2/27/2025, indicated: Plan of Care: The patient, family, and health care team members, in partnership, will formulate the patient ’ s plan of care. Interprofessional plans of care will reflect the patient ’ s needs and progress from admission to discharge. The key components of the plan of care may include, but are not limited to: Integrating assessment findings Identification of patient individualized goals Identification of patient needs/problems Coordination of referrals and interventions Identification of possible discharge planning needs Evaluation and documentation of progress toward individualized goals Review and educate the patient/family on the plan of care Integration and analysis of data for the plan of care will be based on: LP History and Physical Physical Examination Diagnosis/condition/co-morbidities Interprofessional assessments and interventions Patient/family interviews Interprofessional team member collaboration and recommendations The plan of care will be reviewed and updated, as appropriate, every shift with any changes in the patient ’ s condition. Reassessments will address possible barriers to the patient reaching his/her goals. Evaluation of patient ’ s goals, self-care, and/or continuing care will be completed by the nurse upon discharge or transfer to include: Communication of continuing needs and interventions Discharge instructions”

“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: 38310 Based on interview and record review, the facility failed to ensure two of 30 sampled patients (Patient 11 and Patient 13) was discharged from the facility free from pain. This deficient practice resulted in the following: Patient 11 left the facility in severe pain, without physician notification. Patient 13 left the facility in moderate pain, without physician notification. Findings: 1.A record review of facility ’ s operating room schedule, dated 7/16/2025, indicated Patient 11 was scheduled for surgery at 4:30 PM. A review of Patient 11 ’ s face sheet (a concise document summarizing essential patient information, including demographics, insurance, emergency contacts and key medical details), dated 7/16/2025, indicated that patient was admitted to same day surgery (SDS) with an admitting diagnosis of sterilization. A review of Patient 11 ’ s consent for surgery, dated 7/16/2025, indicated that patient consented for bilateral salpingectomy surgery (BTL – a surgical procedure to permanently remove both fallopian tubes for irreversible sterilization). A review of Patient 11 ’ s consent for anesthesia (medication to prevent pain), dated 7/16/2025, indicated that patient consented for general anesthesia (reversible state of unconsciousness and pain relief) and nerve blocks (injection in the nerve to temporary stop pain). On 2/5/2026, at 3:11 PM, during concurrent interview with same day surgery nurse (RN) 3 and nurse manager (NM) 1 and record review of Patient 11 ’ s records, dated 7/16/2025, RN 3 stated the following: On 7/16/2025, at 1:13 PM, patient was admitted to the hospital, at Same Day Surgery (SDS) unit, for BTL surgical procedure. At 3:31 PM to 4:05 PM, patient was transferred to the holding area for pre-operative care, where she met with the surgeon and anesthesia provider, was examined, and consented for surgery and anesthesia. From 4:06 PM to 4:57 PM, patient was transferred to the operating room (OR – a room in the hospital specially equipped for surgical operations and procedures) for the surgery. After surgery, patient was taken to the post anesthesia care unit (PACU – a specialized hospital area where patients are closely monitored immediately after surgery or procedures requiring anesthesia) from 4:58 PM to 6:13 PM. From 6:13 PM to 6:52 PM, patient was transferred to SDS and was assigned to the nursing care of registered nurse (RN) 1, until discharge home. Concurrently, during record review of Patient 11 ’ s orders for pain medications, RN 3 stated the anesthesia provider ordered pain medications, including fentanyl (managing severe pain) and Percocet (use to treat moderate to severe pain). Concurrently, during record review of Patient 11 ’ s medication administration record (MAR – a critical tool that provides a comprehensive, organized record of each medication administered to a patient), dated 7/16/2025, RN 3 stated the following: In PACU, patient had severe pain, with a pain score of 7 out of 10, at 5:09 PM, and received pain medication for severe pain, fentanyl 75 micrograms by intravenous (IV – into the vein). In PACU, patient ’ s pain improved and became moderate, with a pain score of 4 out of 10, at 5:45 PM. In SDS, patient was administered pain medication by RN 1, for moderate to severe pain, Percocet 5/325 milligrams with tablets by mouth, at 6:37 PM. Concurrently, during interview and record review of Patient 11 ’ s nursing flowsheet (a spreadsheet with rapid documentation of assessments, interventions, and other data by nurses), dated 7/16/2025, at 6:49 PM, RN 3 stated patient ’ s last vital signs, before being discharged home, included a pain score of 7 out of 10 (severe pain). RN 3 stated there was no documentation, by RN 1, that Patient 11 ’ s physician was notified of patient having severe pain, after pain medication was administered and prior to being discharged home. Concurrently, during record review of Patient 11 ’ s pain assessment, dated 7/16/2025, RN 3 stated the following: The patient had a pain score of 7 out of 10, which was severe pain. Patient ’ s goal level for pain relief was 2 out of 10. Patient ’ s physician/provider, who ordered Patient 11 ’ s pain medications, should have been notified of patient ’ s response to pain medication administered. RN 1 should not have discharged Patient 11 home, with severe pain. 2.A review of Patient 13 ’ s face sheet (a concise document summarizing essential patient information, including demographics, insurance, emergency contacts and key medical details), dated 2/3/2026, indicated admitting diagnosis of appendicitis (the inflammation of the appendix (small organ located in the lower right abdomen [body cavity]), causing sudden severe pain that starts near the belly button and moves to the lower right abdomen). On 2/6/2026, at 11:11 AM, during concurrent interview with Pediatric nurse manager (NM) 4 and record review of Patient 13 ’ s Consent for Surgery, dated 2/3/2026, NM 4 stated that patient ’ s mother consented for patient to have laparoscopic appendectomy (surgical removal of appendix). Concurrently, during review of Patient 13 ’ s Consent for Anesthesia, dated 2/3/2026, NM 4 stated that patient ’ s mother consented for patient to have general anesthesia. On 2/6/2026 at 11:15 AM, during concurrent interview and record review of Patient 13 ’ s history and physical (H&P – a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination), dated 2/3/2026, with NM 4, NM 4 stated the following: Patient was 10 years old without any prior medical problems, complained of abdominal pain for three days, at the right lower quadrant of the abdomen. An abdominal ultrasound (imaging test) of the abdomen indicated dilated appendix. Diagnosis – acute appendicitis. Plan for consultation with surgeon. Concurrently, during review of Patient 13 ’ s Interval H&P, dated 2/3/2026, NM 4 stated that patient ’ s H&P was reviewed, patient was examined and found without any changes, since H&P. Concurrently, during review of Patient 13 ’ s Intra-operative record, dated 2/3/2026, NM 4 stated that patient was in the operating room (OR– a room specially equipped for surgical operations) from 4:40 PM to 5:30 PM. Concurrently, during review of Patient 13 ’ s Pain assessment, dated 2/4/2026, NM 4 stated the following: On 2/4/2026, at 12:00 PM, patient complained of pain 8 out of 10 (severe pain). At 12:06 PM, patient was given pain medication, Toradol (management of moderated to severe pain)15 milligrams by vein. At 12:56 PM, patient complained of pain 7 out of 10 (severe pain) and the physician was not notified of the ineffectiveness of the pain treatment given. Concurrently, during review of Patient 13 ’ s nursing note, dated 2/4/2026, at 1:00 PM, nurse documented that patient was able to ambulate around the unit and tolerated activity well. Concurrently, during review of Patient 13 ’ s vitals signs, dated 2/4/2026, at 4:00 PM, NM 4 stated patient stated he had pain 5 out of 10 (moderate pain). Concurrently, NM 4 stated Patient 13 was discharged from the facility on 2/4/2026, at 5:10 PM, with his parents. A review of facility ’ s Pain Assessment, Reassessment and Management policy, dated 9/28/2022, indicated the following: Pain level will be assessed using the appropriate and approved pain scale. The patient ’ s stated level of pain is the most accurate indicator of the amount of pain that he/she is experiencing. Initial assessment for pain will be documented in the medical record. Reassessment will include a new pain rating, which will be recorded. Appropriate pain rating scales included FLACC for infants from 1 to 12 months, and numeric for adults. Pain assessments will be documented in the electronic medical records (EMR). If the pain goal is not met with interventions implemented, medications ordered as “PRN” (as needed) will be administered, and the provider will be notified. Reassessment following treatment of pain – if a treatment intervention for pain is provided, the response to that intervention will be assessed within 15 – 60 minutes following treatment. Pain reassessment will occur at the time of discharge.”

“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: 38310 Based on observation, interview, and record review, the facility failed to: Ensure one of 30 sampled patients (Patient 6) received the appropriate medication ordered during an emergent (something suddenly appear) situation. This deficient practice resulted in Patient 6 receiving the wrong medication, causing seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), that required intubation (a life-saving, medical procedure in which a healthcare provider inserts a tube through the mouth or nose, down the throat, and into the windpipe [trachea]) with mechanical ventilation (a life-support treatment using a machine [ventilator] to move oxygen-rich air in and out of the lungs when a person cannot breathe adequately on their own), and Patient 6 being transferred to the intensive care unit (ICU) for additional care. Ensure nurses document assessments of Richmond Agitation-Sedation Scale (RASS score, a validated, 10-point medical tool ranging from -5 to +4, used by healthcare professionals to quickly assess the level of agitation or sedation in critically ill or injured patients) for one of 30 sampled patients (Patient 14), as per order. This deficient practice has the potential to result in Patient 14 sedation level not being appropriately monitored. Findings: During a review of Patient 6 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem)”, dated 6/28/25 at 8:15 pm, the H&P indicated that Patient 6 was a gravida 1 (G1, the total number of times a woman has been pregnant, regardless of the outcome), para 0 (P0, the number of times a woman has given birth to a fetus that reached a viable gestational age) intrauterine pregnancy (a normal pregnancy where the fertilized egg implants and grows inside the uterus [womb]) at 38.3 weeks, who successfully delivered a baby. Patient 6 received Oxytocin (use to stimulate uterine contraction in childbirth) and an epidural injection (medication into the spine) with ropivacaine (a local anesthetic injected by professionals to cause temporary numbness or pain relief during surgery, labor, or for post-operative care) during the delivery. Patient 6 had seizures (uncontrolled sudden changes of electrical activities in the brain) after delivery of the baby, concerning for preeclampsia (a serious blood pressure disorder that develops after 20 weeks of pregnancy [or postpartum], characterized by high blood pressure and signs of damage to organ systems). Patient 6 also had postdelivery bleeding (bleeding after delivery of a fetus), status post tranexamic acid (TXA, a medication that helps stop or prevent excessive bleeding). Patient 6 received ropivacaine intravenously (IV, delivering medicine, fluids, or nutrients directly into a vein using a needle or tube) and developed sudden cardiac arrest (unexpected malfunction of the heart ’ s electrical system that causes it to stop beating, halting blood flow to the brain and body) that required advanced cardiac life support (ACLS, a set of medical interventions designed to treat life-threatening cardiovascular emergencies) with subsequent return of spontaneous circulation (ROSC, when a patient ’ s heart starts beating on its own again after cardiac arrest, restoring a pulse and blood pressure). Patient 6 ’ s cardiac arrest etiology (cause) was secondary to either preeclampsia or a reaction from ropivacaine. During a review of Patient 6 ’ s “Labor and Delivery Note”, dated 6/28/25 at 8:12 pm, the note indicated that a physician was called to the room for delivery/hemorrhage (severe or uncontrollable bleeding)/seizure. Patient 6 received fundal massage (a firm, sometimes uncomfortable, postpartum technique where a provider presses down on and rubs the top of the uterus [fundus] through the abdomen) after delivery of an intact placenta (temporary organ that develops in the uterus during pregnancy to support a growing fetus). The fundus was boggy (a soft, spongy, or “mushy” feeling instead of the normal firm feeling), with heavy bleeding noted. Cervical/uterine sweeps (a procedure where a healthcare provider inserts a hand into the uterus/cervix to remove retained placenta fragments, membranes, or blood clots to prevent postpartum hemorrhage and infection) were performed, with clots expressed. Bimanual massage (an emergency, two-handed technique used to treat severe postpartum hemorrhage caused by a boggy uterus) was provided until medications were given and Jada system (a medical device designed to rapidly treat abnormal postpartum uterine bleeding or hemorrhage by using low-level vacuum to induce uterine contraction) was opened onto the table. The Jada was placed with 120 milliliters (mL) in the bladder and placed to suction on the wall. Physician orders were placed for Hemabate (a medication used to treat severe, life-threatening bleeding from the uterus [postpartum hemorrhage, PPH] after childbirth), Misoprostol (a medication used to induce labor, manage miscarriages, or safely terminate pregnancies by causing uterine contractions), TXA, and vital signs (measurable indicators of the body ’ s most basic functions, used to evaluate physical health, detect illnesses, and monitor recovery) every five minutes. Prior to performing laceration (a torn, ragged, or cut wound in the skin and underlying soft tissues caused by trauma) repair, Patient 6 reported feeling faint. During the repair, Patient 6 began not responding when spoken to. A sternal rub (a medical, pain-based technique used to check if an unconscious person is responsive) was performed with no response. The registered nurse (RN) called out for help and Patient 6 began to seize. A code blue (a hospital-wide alert indicating a patient is experiencing a critical, life-threatening emergency) was initially called at 6:45 pm with the code blue team arriving at 6:48 pm. There was a total of 10 seizures ranging from 10 seconds to approximately 60 seconds observed. Patient 6 ’ s estimated blood loss was 1,461 milliliters (mL). During a review of Patient 6 ’ s “Quick Note”, dated 6/28/25 at 9:32 pm, the quick note indicated that Patient 6 was brought in for induction (artificial initiation of uterine contractions before they start spontaneously, using medication or mechanical methods to deliver the baby) due to gestational hypertension (high blood pressure that develops for the first time after 20 weeks of pregnancy in women with previously normal blood pressure) and did develop preeclampsia with severe features. The physicians were informed by the bedside nurse that ropivacaine was given (hung) in lieu (instead) of TXA. During a review of Patient 6 ’ s “Quick Note”, dated 6/28/25 at 23:25, the quick note indicated that Patient 6 had an extensive delivery with a large amount of blood volume loss (when a person loses a significant amount of blood or body fluids). Patient 6 was given IV Ativan for seizures with no resolution. Patient 6 was intubated (tube place into the windpipe to help to breath) for respiratory protection for the active seizures. The provider was informed by another provider that Patient 6 was accidentally given ropivacaine instead of TXA, with likely around 200 milligrams (mg) of the dose given intravenously. About 30 seconds after intubation, Patient 6 lost pulses, pulseless electrical activity (PEA, a type of cardiac arrest where the heart monitor shows an organized, working rhythm, but the heart muscle is not pumping blood, resulting in no detectable pulse) on initial monitor. Lead toxicity (a serious, often irreversible health condition caused by the accumulation of lead in the body) could not be excluded given the accidental ropivacaine administration. Patient 6 became intermittently hypotensive (abnormally low blood pressure) and started on Levophed drip (a powerful medication used to rapidly raise dangerously low blood pressure). During a review of Patient 6 ’ s “Consultation” note, dated 6/28/25 at 10:21 pm, the consultation note indicated that in the ICU, Patient 6 had possible seizure activity. Patient 6 was given Ativan (a medication used to treat anxiety disorders, insomnia, seizures, and acute alcohol withdrawal by calming the central nervous system [CNS]) again, placed on a Versed drip (a medication used for procedural sedation, anxiety relief, and to induce amnesia during medical procedures or for sedating intubated patients in critical care), and started on Keppra (an anticonvulsant medication used to treat various types of seizures). Per chart, Patient 6 had no past medical problems other than gestational hypertension. Patient 6 had no prior history of seizures per the family at bedside. Per chart, there was concern for IV administration of ropivacaine and cardiac arrest related to this. Poison control was contacted with a recommendation to check for methemoglobinemia (a rare, potentially dangerous blood disorder where red blood cells cannot properly release oxygen to the body ’ s tissues). During a concurrent interview and record review on 2/4/26 at 4:39 pm, with the clinical supervisor of labor and delivery (CSLD), CSLD stated that the Omnicell (a computerized, automated dispensing cabinet [ADC] used in healthcare facilities to securely store, manage, and dispense medications and supplies) report indicated that TXA was removed at 4:30 pm by Patient 6 ’ s assigned nurse on 6/28/25. Per CSLD, the medication was removed prior to Patient 6 ’ s delivery as this is routinely done in anticipation that bleeding may occur. CSLD further stated that during an emergency the nurse may not have time to go grab medications needed, as the reason for the medication being removed prior to Patient 6 ’ s delivery/hemorrhage. During a concurrent interview and record review, on 2/4/26 at 3:25 pm, with the Labor & Delivery Nurse Educator (LDNE), the LDNE stated that Patient 6 ’ s assigned registered nurse (RN) documented Patient 6 ’ s Magnesium Sulfate (a compound used medically to treat magnesium deficiencies, eclampsia, severe constipation, and muscle aches) being administered at a rate of 1 gram (Gm)/hour (hr) at 11:27 on 6/28/25 per the “LD-Flowsheet Medications” documentation. LDNE stated that the documentation was “probably” an error as the entry before and after indicated a drip rate of 2 Gm/hr, as ordered. The physician ’ s order was for Magnesium Sulfate IV 2 Gm/hr. Per LDNE, Magnesium Sulfate was given to gestational hypertensive patients to prevent seizures. During a concurrent interview and record review, on 2/4/26 at 3:50 pm, with LDNE, LDNE stated that the “LD-Flowsheet” entry on 6/28/25 at 6:40 pm, by Patient 6 ’ s assigned RN, indicated that an order was received for TXA for continued bleeding. The RN administered 152 mg of Ropivacaine instead of Tranexamic Acid (TXA) in error. The flowsheet entry on 6/28/25 at 6:42 pm indicated that the RN realized that ropivacaine was administered instead of the ordered TXA. Patient 6 started to seize. The rapid response team (RRT, a specialized group of critical care professionals who are called to a patient ’ s bedside to treat early signs of clinical deterioration, preventing cardiac arrest or death) was called overhead. Per LDNE, the error was captured when another nurse came in to assist the assigned nurse and attempted to scan the medication being administered, for documentation purposes, and could not scan the medication due to it being the wrong medication. The assigned nurse realized the medication administered (hung) was ropivacaine versus the ordered TXA. During a concurrent observation and interview on 2/3/26 at 2:35 pm, with the Director of Pharmacy (DOP), the DOP provided a visual display of how to appropriately remove medications from the Omnicell (a computerized, automated dispensing cabinet [ADC] used in healthcare facilities to securely store, manage, and dispense medications and supplies). Per DOP, the Omnicell was designed with multiple security features to assist with the prevention of medication errors when used correctly. All medications stored in the Omnicell are in separate bins (containers used for storing, organizing, or disposing of items). The top and bottom compartments of the Omnicell contain larger medications like intravenous piggybacks (IVPB, a smaller IV bag that is “piggybacked” into the main, primary IV line) and are stored in individual bins without lids. The middle compartment of the Omnicell contained smaller medications that are stored in separate bins, with closed lids. All staff removing medications from the Omnicell must sign-in using their user code provided. The staff member must also use a fingerprint. This was designed to prevent user code sharing or using other staff members ’ user codes. The staff member must then select a patient and may remove medications that are ordered for the selected patient, one medication at a time. The Omnicell identifies which compartment and bin the selected medication(s) are stored. The bins without lids are illuminated by a green light for easy visualization of the location, and the bins with lids automatically pop open to identify the location. Once removed, the staff member must press the green light and scan the medication to ensure the correct medication was removed, allowing the Omnicell to subtract the removed item(s) from the remaining quantity. The staff members would not be allowed to proceed if the medication removed did not match the medication selected. During a concurrent observation and interview, on 2/3/26 at 2:39 pm, with the clinical supervisor of L&D (CSLD), CSLD provided a demonstration of how to appropriately remove medications from the Omnicell for a patient. Per CSLD, all permitted staff must sign in the Omnicell and provide a fingerprint for 2-step security measures. The staff member must then select a patient and/or type the patient ’ s name. A list of medications ordered for the selected patient were displayed. The staff members must select which medication to be removed. Once the medication was selected, the Omnicell compartment storing the medication would unlock and the drawer containing the medication would illuminate by a flashing green light. Each compartment contained drawers. The drawer was pulled open and the bin storing the medication would pop open (bins with lids) or an individual green light for the bin would illuminate (bins without lids), to identify the location of the medication. Once the medication was removed, the green light was pressed. The medication was then scanned, as a second form of security/safety to identify the correct medication selected matched the medication removed, and the drug was deducted from the remaining quantity. If the wrong medication was removed, the system would not allow the staff member to proceed without a manual override (a mechanism that allows a human to take direct control of a machine or system, bypassing its automatic settings). The medication would then be taken to the patient ’ s bedside and reviewed using the 5 medication administration rights (a safety framework, ensuring the right patient receives the right drug, in the right dose, by the right route, at the right time) before being scanned again and administered. Per CSLD, if the process was correctly followed the chance of making a mistake would not occur. CSLD reported being present during the medication error incident with Patient 6. CSLD believed the assigned nurse did not appropriately follow the Omnicell protocol due to urgency of the situation resulting in the wrong medication being removed. During an interview, on 2/5/26 at 2:04 pm, with the Chair of Obstetrics and Gynecology (COG), COG stated that there was a way to calculate the estimated blood loss during a delivery via quantitative blood loss (QBL, the precise measurement of blood lost during childbirth or surgery, used to identify postpartum hemorrhage early). COG stated the provider should be actively looking for QBL during the delivery and after. More than 1,000 mL blood loss would be considered hemorrhage. Patient 6 ’ s estimated blood loss was determined to be 1,461 mL total. COG stated a blood loss of 1,400 mL would be concerning for other interventions based on the patient ’ s status, like vital signs; however, a blood loss of 1,400 mL leading to seizures and a code would be very uncommon. COG believed Patient 6 ’ s situation was related to receiving the wrong medication and unrelated to the blood loss. During a review of Patient 6 ’ s “Discharge Summary”, dated 7/2/25 at 10:35 am, the discharge summary indicated that Patient 6 was G1 now P1, status post normal spontaneous vaginal delivery (NSVD, a childbirth process where a pregnant person goes into labor on their own and delivers the baby through the birth canal without the use of surgical intervention or tools) after induction at 38.5 weeks for preeclampsia with severe features. Patient 6 ’ s immediate postpartum (the period immediately following childbirth) course was complicated by seizures and the need for ACLS, etiology (cause) eclampsia (a serious, life-threatening complication of pregnancy characterized by the sudden onset of seizures or coma in a woman who has already developed preeclampsia) versus ropivacaine effect. Patient 6 also had postpartum hemorrhage (PPH, excessive bleeding after childbirth, generally defined as losing more than 1,000 mL of blood or showing signs of low blood volume within 24 hours of delivery) of about 1,400 mL due to uterine atony (a serious pregnancy complication where the uterus fails to contract [tighten] properly after childbirth) and underwent massive transfusion protocol (an emergency plan designed to rapidly replace massive blood loss) during the ACLS. Neurology (the branch of medicine focused on diagnosing and treating disorders of the nervous system, which includes the brain, spinal cord, and peripheral nerves) recommended Keppra and an electroencephalogram (EEG, a test that records the electrical activity of a person ’ s brain using small, metal discs [electrodes] attached to the scalp). Patient 6 was started on Procardia XL (an extended-release medication used to treat high blood pressure) on 7/1/25. Patient 6 ’ s hemoglobin (Hgb, an iron-rich protein inside red blood cells that transport oxygen from the lungs to the rest of the body ’ s tissues) was 8.5 grams (G)/dL, which decreased from 10.5 g/dL on admission. During a review of the facility ’ s policy and procedure (P&P) titled, “Medication Administration and Safety”, dated 2/2/2024 indicated under Procedure: Before administering a medication, the licensed nurse must: Verify that the medication selected is the correct one based on the medication order and product label Verify that the medication is stable based on visual exam for particulates or discoloration and that the medication has not expired Verify that there is no contraindication Verify that the medication is being given at the proper time, in the prescribed dose and by the correct route Verify the correct patient using two identifiers. The facility has chosen the patient ’ s name and the patient’s date of birth. Verify the correct patient by scanning the patient’s armband barcode. Documentation of medication administration on the electronic medication administration record (e-MAR) is required for medications given. Documentation includes: Scanning of the correct patient’s armband barcode Scanning of the correct medication barcode Verifying the correct dose given as ordered by the physician Edits/Undo documentation made in error During an emergency situation when verbal orders are given, the nurse is required to follow this procedure when administering medications: The prescriber gives a verbal order for the medication with the route and dose to the nurse. The nurse reads back the verbal order to the prescriber for verification. The nurse draws up the medication ordered and administers the medication. If the nurse that has drawn up the medication will not be administering the medication then the medication vial and the syringe containing the medication shall be handed to the person administering the medication. The nurse that has drawn up the medication then performs a read back with the person administering the medication and the medication is administered. During a review of Patient 14 ’ s fentanyl (a potent opioid used to treat pain or used in sedation) drip (continuous infusion) medication order (dated 1/21/2026 at 4 AM), and a concurrent interview, on 2/9/2026 at 2:20 PM, the nurse manager (NM 5) stated the medication order indicated to start [Patient 14] on 1000 micrograms (mcg, an unit to measure mass) per (/) 100 milliliter (ml, an unit to measure volume) at a infusion rate of 25 mcg/hour (hr), may titrate by 25 mcg/hr every 1 hour to a sedation goal of RASS score (a validated, 10-point medical tool ranging from -5 to +4, used by healthcare professionals to quickly assess the level of agitation or sedation in critically ill or injured patients) between “-2 to -3”. NM 5 stated the order indicated nurses to assess RASS score every 1 hour. During an interview on 2/9/2026 at 2:44 PM and a concurrent review of Patient 14 ’ s electronic medical record, NM 5 stated she could not find nursing documentation of Patient 14’s RASS score between 1/21/2026 from 10:01 PM through 6:24 AM on 1/22/2026. NM 5 stated there was no notes or documented reasons that might prevent the nurse from assessing the patient for a RASS score. During a review of the hospital ’ s policy and procedures, “Medication Administration and Safety” (dated 2/2/2024), the policy indicated “ ...The RN will administer medications using the nursing process ... Documenting any required [assessments] specific to that medication ...””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 38310 Based on interview and record review, the hospital failed to develop policies and procedures for the control and storage of medications, as evidenced by the hospital ’ s failure to develop the policy and procedures for a contracted vendor software, BlueSight ControlCheck (also known as BlueSight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion events to ensure accountability of medications) that has been in use since 2/28/2025. This failure had the potential for inadequate monitoring of medication errors, drug diversions (the illegal transfer of prescription drugs), and/or pilferage (stealing) that may affect patient safety. Findings: During an interview on 2/6/2026 at 1:10 PM, the director of pharmacy (DOP) stated the hospital “used BlueSight (a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion events to ensure accountability of medications) to monitor narcotic usage”. During an interview on 2/6/2026 at 1:13 PM, DOP stated the hospital started using BlueSight for about a year. During an interview on 2/6/2026 at 4:15 PM, the interim Chief Nursing Officer (CNO) stated that BlueSight went live on 2/28/2025. During an interview on 2/6/2026 at 4:18 PM, the Emergency Department Nurse Manager (NM 3) stated he was one of the super users for BlueSight. NM 3 stated there had been ongoing data integration (combining) issues between Omnicell (the automated dispensing cabinet system that included a secure computerized cabinet that stores and dispenses medication and integrate with the hospital ’ s electronic medical record system), Meditech (the hospital ’ s electronic medical record system), and BlueSight. NM 3 stated nurse leaders were responsible for reviewing their units’ data in BlueSight. NM 3 stated the hospital did not develop or provided staff with a policy or Standard Operating Procedure (SOP, a set of step-by-step instructions compiled by an organization to help workers carry out routine operations safely, consistently, and efficiently). During a review of the hospital ’ s contract with the vendor of BlueSight, the contract was signed on 12/14/2023. During a review of the hospital ’ s policy and procedures, “Controlled Substance Storage, Dispensing, Reporting, and Monitoring” (dated 9/24/2025), the policy referred to a program called “Pandora Analytic” (provides analysis and reporting in regard to medication management and supply inventory) and did not mention BlueSight or ControlCheck. During an interview on 2/9/2026 at 11:20 AM, Director of Pharmacy (DOP) stated Bluesight replaced Pandora Analytic as the diversion surveillance tool. DOP stated Pandora Analytics was decommissioned (removed) on 8/5/2025.”

“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: 38310 Based on observations, interviews, and record review, the hospital: Failed to ensure there were devices (tool) or a system to monitor the ambient (surroundings) temperature inside the medication rooms to ensure medications were stored within the temperature range as required by the labelling. Failed to ensure the date of first medication due to expire was accurately documented on the pink Crash Cart Check Card for one of one malignant hyperthermia (MH, a rare, life-threatening hereditary disorder characterized by a severe hypermetabolic response to certain general anesthetics) cart (a specialized, readily available emergency cart, containing critical, time-sensitive, lifesaving supplies, primarily aimed at treating MH crises) located in the Labor & Delivery (LD) department. Failed to ensure one of one AMI (acute myocardial infarction) kit (an emergency code kit designed for emergent heart attack situation) in the Emergency Department (ED) contained accurate lock numbers These deficient practices had the potential of having improperly stored and/or ineffective medications that may hinder treatment efficacy and/or affect patient outcomes during emergency. Findings: 1. During an observation in the medication room in Labor & Delivery (L&D) department on 2/3/2026 at 2:04 PM, there was no thermometer. During a concurrent interview, the director of pharmacy (DOP) stated the medication room ambient (surroundings) temperature should be monitored. During an interview on 2/3/2026 at 2:22 PM, the facility stationary engineer (FE) stated there was “no temperature monitoring inside the medication rooms, all medication rooms at nursing units”. FE stated the hospital monitored the ambient temperature of each unit as a whole and the thermometer/thermostat was located outside of the medication room. 2. During an observation of the MH (a rare, life-threatening hereditary disorder characterized by a severe hypermetabolic response to certain general anesthetics) cart in the Labor and Deliver (L&D) on 2/3/2026 at 1:28 PM, the MH cart had a pink crash cart check slip that indicated the first drug expires on 7/30/2026. During a concurrent interview, Director of Pharmacy (DOP) confirmed there was one count of sodium bicarbonate injection (a prescription medication administered into the vein to treat serious medical conditions) expiring on 6/26 in the medication tray. During a review of the hospital ’ s policy and procedures, Code Cart Care and Maintenance (dated 6/3/2025), the policy indicated “ ... Pharmacy will ensure a pink Crash cart check card ... with the name and expiration date of the first medication due to expire ...” 3. During an interview in the Emergency Department(ED) medication room (ED main) on 2/4/2026 at 10:40 AM, Director of Pharmacy (DOP) stated the rapid response kits were stored in Omnicell (the automated dispensing cabinet system that included a secure computerized cabinet that stores and dispenses medication and integrates with the hospital ’ s electronic medical record system). During a concurrent observation, there was an AMI (acute myocardial Infarction) kit in the Omnicell on the bottom right cabinet. The pharmacy operations manager (POM) retrieved the AMI kit from Omnicell, and the AMI kit had 2 red locks. The locks were numbered 9518062 and 9518061. However, during a review of the pharmacy sticker on the lid of the kit, DOP confirmed the stickers had 2 numbers that were different than those on the red locks securing the kit. During an interview on 2/4/2026 at 10:55AM with Director of Pharmacy (DOP), DOP stated the lock numbers should match and it may be an old sticker that should have been updated and replaced. During a review of the hospital ’ s policy and procedures, Code Cart Care and Maintenance (dated 6/3/2025), the policy indicated “ ...Code Carts must be kept locked to ensure integrity of the medications ... Each Code cart has [two] locks ... Medications will be secured by a red exterior lock. Pharmacy will ensure a pink Crash cart check card ... lock numbers will be documented on the Code Cart Check Sheet ...””

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the hospital failed to ensure its sterile (germ-free) compounding process (a process of making sterile intravenous, IV, medications) was performed in a safe and consistent manner, as evidenced by: Failure to ensure the anteroom (a room serves as a transition area that separates the dirty area from the clean area or room where IV(into the vein) medications are prepared) of the sterile compounding suite (IV room) was clean and free of residues(small amount of something left after the main part) and/or stains that could accumulate (collect)contaminants (spoils) and/or microorganisms (tiny living thing too small to be seen). Failure to ensure Environmental Services (EVS) staff cleaned the back exterior (outside) of a CACI (Compounding Aseptic Containment Isolator, or glovebox) and the wall behind the CACI in one of two buffer rooms (specialized, controlled environment—typically ISO Class 7—designed to protect sterile compounding, pharmaceutical, or high-tech manufacturing areas from contamination), Chemotherapy (or hazardous drug [HD] room, the buffer room that is negative in air pressure for compounding chemotherapy and/or other hazardous drugs) room. Failure to ensure the sterile compounding environment viable sampling plan (a map of sampling locations) used by the vendor that certified its IV room was included in the hospital ’ s procedure of environmental media testing (process of collecting and analyzing air, soil or water). These failures had the potential of exposing patients requiring IV (into the vein) medications to preventable contamination that may affect patients ’ health and safety. Findings: During an observation on 2/5/2026 at 10:38 AM with the Director of Pharmacy (DOP) and the Pharmacy Operations Manager (POM) in the ante room of the pharmacy IV room (a room serves as a transition area that separates the dirty area from the clean area or room where IV(into the vein) medications are prepared), various areas of the floors and underneath the bench brown stains and debris. The trash bin was placed directly in front of the air return vent potentially blocking the airflow. The red demarcation line (a designated line separating the dirty and clean areas of the room) was peeling off and exposing the adhesive underside seen with dark residues (small amount of something left after the main part). Lastly, there were uneven surfaces on the walls. During an observation on 2/5/2026 at 11 AM with DOP and POM at the entrance to the Chemotherapy buffer room (specialized, highly controlled and sterile pharmacy area), the red demarcation line had corners peeling and exposing dark brown, grey residues. The chemotherapy buffer room had a CACI (Compounding Aseptic Containment Isolator, or glovebox-used for specialized or hazardous drug preparation) and the room seemed crowded with a large steel table placed to the right of the CACI. During an interview on 2/5/2026 at 3:13 PM, the Environmental Services (EVS) staff (EVS 1) stated he did not clean the wall behind the CACI and the back exterior (outside) of the CACI. During an interview on 2/5/2026 at 3:15 PM, with the EVS Director (EVSD), EVSD stated they were told not to clean the back wall behind the CACI in the chemotherapy buffer room. During concurrent interview and record review of EVS staff competency records with Pharmacy Operations Manager (POM) on 2/6/2026 at 4:05 PM, POM stated the EVS staff competency form did not include evaluating staff in cleaning the walls and ceilings of the IV room. During an interview on 2/6/2026 at 4:08 PM, and a concurrent review of compounding records, POM stated the chemotherapy room was rarely used and there was no current patient on any chemotherapy or hazardous drugs. During a review of the hospital policy and procedures, “Pharmacy Compounding – Sterile Compounding Process & Requirements” (dated 11/4/2025), the policy referred to the US Pharmacopeia (USP) chapter 797 (USP 797 is a chapter of the United States Pharmacopeia that provides guidelines and standards for compounding sterile preparations (CSPs) in healthcare settings, ensuring patient safety by preventing harm from microbial contamination, endotoxins, and other errors. It covers various aspects of sterile compounding, including personnel training, facility requirements, and quality control procedures). The policy also indicated “ ... Sterile preparation areas, including anterooms, buffer rooms, ... will be cleaned and disinfected ... EVS is responsible for daily cleaning of floors ... Terminal cleaning of floor, wall, and ceiling is done by EVS ...” During an interview on 2/5/2026 at 11:40 AM, and a concurrent review of the hospital ’ s policy and procedures, “Pharmacy Compounding: Environmental Monitoring & Quality Assurance” (dated 11/19/2025), the policy also referred to the USP (Set of enforceable standards to prevent patient harm and ensuring safety compounds sterile preparations). POM stated the aforementioned policy did not include a sampling diagram or map. During a review of the current edition of USP 797 (Set of enforceable standards to prevent patient harm and ensuring safety compounds sterile preparations) current edition, the chapter indicated “ ... The surfaces of ceilings, walls, floors, doors, door frames, fixtures, shelving, work surfaces, counters, and cabinets in the classified area must be smooth, impervious, free from cracks and crevices, and nonshedding, so they can be cleaned and disinfected and to minimize spaces in which microorganisms and other contaminants can accumulate ... The microbiological air and surface monitoring program must be clearly described in the facility ’ s SOPs, which must include a diagram of the sampling locations ...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to: 1.Ensure patient safety practices and care requirements unique to the operating room [OR, a facility within a hospital where surgical operations are carried out in an aseptic (free of germs) environment] were consistently followed for one of 30 sampled patients (Patient 1) when the OR staff did not follow the facility ’ s policy and procedure (P&P) for performing surgical counts (a critical and mandatory patient safety procedure in the operating room where the scrub technician and the circulating nurse count all instruments, sponges, and miscellaneous items before, during, and after a procedure to prevent retained surgical items) during Patient 1 ’ s surgery. The deficient practice resulted in Patient 1 undergoing a second surgical procedure to remove a retained surgical sponge (a highly absorbent pad made of cotton or synthetic material, used during a surgical procedure to control bleeding, absorb fluids, and maintain a clear, visible operating field), a prolonged recovery time, and negatively impacting Patient 1 ’ s overall well-being. Findings: On 2/06/2026 at 10:08 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ’ s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Vice President of Human Resources (VPHR), Vice President and Chief Information Officer (VPCIO), Interim Chief Nursing Officer (CNO), Executive Vice President/Chief Operating Officer/Chief Financial Officer (EVP), Chief Executive Officer (CEO), Associate Administrator (AAdmin), and Vice President/General Counsel/Chief Compliance Officer/Chief Privacy Officer (VPGC). The facility failed to provide a safe practice during surgery for Patient 1 when two of the three surgical counts, the closing count and the final count, were not performed according to the facility ’ s P&P regarding surgical counts during a laparoscopic [a minimally invasive technique for viewing and operating on abdominal (the area of the human body below the ribs and above the pelvic region) organs using a slender camera and tiny tools inserted through small incisions] appendectomy [the surgical removal of the appendix (a small pouch attached to the large intestine)] on 10/16/2025. As a result, Raytec (a brand of surgical sponges containing a blue detectable string that allows for detection on imaging if left inside a patient) sponges were left in the abdominal cavity. This led to Patient 1 returning to the facility for fever (elevated body temperature) and abdominal pain eight days after the appendectomy. Imaging studies ordered indicated Patient 1 had two surgical Raytec sponges in the abdominal cavity, at the site of a laparoscopic appendectomy one week prior. Patient 1 underwent a second surgery on 10/25/2025 to remove the Retained Foreign Object (RFO, an object, usually a sponge, gauze, or surgical instrument, retained in a body of the cavity after skin closure has occurred following an invasive procedure) to retrieve the sponge, drain the intra-abdominal (within the abdominal cavity) abscess [an accumulation of fluid and pus (liquid produced in infected tissue) caused by an infection], and undergo an abdominal cavity washout (a procedure where a salt-water solution is introduced into the abdominal cavity to wash out contaminants such as pus). On 2/09/2026 at 6:00 p.m., the IJ was removed in the presence of the Vice President of Quality (VP Quality), VPGC, Nurse Manager/Administration (NM 4), VPF, CNO, Performance Improvement Coordinator (PIC), Quality program Coordinator (QPC), EVP, Director of ICU/Tele/Dialysis (DICU), CEO, Director of Pharmacy (DOP), Pharmacy Operations Manager (PM), Medical Director/Dialysis (MD 4), Director of Service and Support (DSS), and Emergency Department Nurse Manager (NM 3). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observations, interviews, and record review. The IJ Removal Plan indicated: On 10/09/2025, the facility purchased and implemented dedicated sponge counters with attached poles in each OR. The sponge counter (a disposable and transparent holder of items used in surgery, with each of the 10 slots dedicated to one item for easy viewing and counting) holders were replaced with a sponge counter with a contrasting color as backing (previously clear) so that the sponges can be more visible to staff. On 10/28/2025, all perioperative (refers to the three phases of surgical care: preoperative, meaning before surgery; intraoperative, meaning during surgery; and postoperative, meaning after surgery) staff were assigned education modules related to performing a surgical count in HealthStream (online courses for health care providers). The completion date requirement was 12/13/2025. One hundred percent of staff completed the courses by 12/13/2025. From 10/30/2025 to 11/03/2025 perioperative leadership held meeting, called huddles, to communicate topics related to surgical counts, use of the sponge counter, two-person process for surgical counts, and system changes. On 10/31/2025, the perioperative educator presented the staff with the appropriate count expectations and reviewed the Policy and Procedure (P&P), titled, “Surgical Counts – Prevention of Retained Surgical Items,” last revised 4/03/2024. On 10/31/2025, three communication white boards were placed in the surgeon ’ s lounge, staff lounge, and the central nurses ’ station of the OR to communicate system and policy updates and other communications related to surgical count process. From 11/3/2025 to 11/06/2025, perioperative leadership communicated the anticipated change to the electronic medical record (EMR) and the roles and responsibilities for the required documentation. On 11/06/2025, revisions to Meditech, the facility ’ s EMR system, went live. The revisions align with current policy regarding surgical counts. The previous documentation of surgical counts in the EMR only allowed the circulating nurse to document ’ correct ’ and ’ incorrect ’ related to surgical counts. The revisions to Meditech now allow for surgical counts to be quantitative (provide an actual number). The updated Meditech system aligns with the facility ’ s Labor and Delivery Surgery Department ’ s Meditech EMR and the facility ’ s P&P regarding surgical counts. On 11/07/2025, perioperative leadership started performing daily audits of surgical counts for all first cases of the day. This practice began on 11/07/2025 and documenting evidence of these audits began on 2/03/2026. On 12/01/2025, a summary of the RFO findings, Root Cause Analysis (RCA), and actions were discussed at the Patient Safety Committee meeting. The Committee included the Risk Department and the Quality Improvement Department. On 1/07/2026, a summary of the RFO findings, Root Cause Analysis (RCA, a systematic process for uncovering and identifying underlying issues that, if resolved, can prevent the problem from recurring) and actions were discussed with the Quality Committee. The Committee includes Medical Staff and Quality Improvement Departments. Starting Quarter 1 2026, Quality Improvement (QI) will begin random audits to ensure the daily management count audits are completed and documented. QI will also randomly review perioperative documentation to ensure compliance with the new documentation process in Meditech. On 2/06/2026, an email memo was sent to facility surgeons updating them of the system and process changes related to surgical counts and their role in the process and its impact on patient safety. A review of Patient 1 ’ s “History and Physical (H&P- a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination),” dated 10/15/2025, the “H&P” indicated, Patient 1 was admitted to the facility for acute appendicitis (sudden inflammation of the appendix), hypertension (HTN – high blood pressure), and chronic alcohol abuse (a disease characterized by a persistent, compulsive pattern of drinking despite severe negative consequences on health, relationships, and responsibilities). A review of Patient 1 ’ s “Diagnostic Imaging (non-invasive medical technique used to create images of the body ’ s internal structures) Report,” dated 10/15/2025, the report indicated, Patient 1 ’ s CT (CT, Computed Tomography, a non-invasive scan used for imaging) of the Abdomen and Pelvis Impression identified, “Fluid-filled distended (swollen) appendix with adjacent (next to) inflammatory changes consistent with acute (sudden) appendicitis.” A review of Patient 1 ’ s “Operative Report,” dated 10/16/2025, the report indicated, Patient 1 ’ s Operation/Procedure performed: 1. Laparoscopic (small incision in the stomach using a camera to treat conditions in abdomen or pelvic) appendectomy (removal of the appendix)and 2. Wedge liver biopsy [removal of a larger piece of the liver (a major organ that performs essential functions) than can be obtained by a needle]. A review of Patient 1 ’ s “Surgical Case Record,” dated 10/16/2025, the Surgical Case Record indicated three surgical counts were signed off in the EMR by the circulating (a specialized Registered Nurse who manages the non-sterile logistics of the operating room) Registered Nurse (ORCN) 1 and surgical scrub (a person who prepares the operating room, sterilizes equipment, and assists surgeons by passing instruments and supplies before, during, and after surgery) technician (ORST) 1 during Patient 1 ’ s laparoscopic appendectomy surgery. The surgical counts are: first count is the initial count, performed prior to Patient 1 entering the operating room (OR); the second count is the closing count, performed when the surgeon was closing Patient 1 ’ s abdominal cavity; and the third count is the final count, performed when the surgeon begins to close Patient 1 ’ s skin. The Surgical Case Record indicated the items ’ Sharps ’ (medical items that can cut or puncture), ’ Sponges, ’ and ’ Misc ’ under count category. Patient 1 ’ s Surgical Case Record indicated, under the category of “Sponges,” the word “Correct” is entered for the three surgical counts (initial count, closing count, and final count). A review of Patient 1 ’ s “Discharge Summary,” dated 10/17/2025, the Discharge Summary indicated, Patient 1 was discharged home with instructions to follow up with primary care physician after discharge. A review of Patient 1 ’ s “ER (Emergency Room, also known as an ED, Emergency Department) Discharge Summary,” dated 10/25/2025, the ER Discharge Summary indicated, Patient 1 presented to the ED with complaints of “intermittent fevers (on and off elevated temperatures) and persistent right lower quadrant (lower part of the abdominal area) pain status post surgery. He endorses (confirms) intermittent nausea (an unpleasant queasiness in the stomach that creates an urge to vomit) with an episode of vomiting (involuntary expulsion of stomach contents) yesterday ...” The ER Discharge Summary further indicated, “CT imaging is read as showing 2 presumed surgical sponges in the intraperitoneal space (a space in the abdomen) of the right pelvis with a complex fluid collection (a non-simple collection of liquid in the body) concerning for abscess ...Patient started antibiotics (medication to treat an infection). Require admission for both surgical and IR (Interventional Radiology, a specialty using advanced imaging to guide minimally invasive, targeted treatments, reducing the need for open surgery) evaluation.” A review of Patient 1 ’ s “Diagnostic Imaging Report,” dated 10/25/2025, the Report indicated, Patient 1 ’ s CT of the Abdomen and Pelvis indicated, “There are 2 presumed surgical sponges in the intraperitoneal space (space within the abdomen [stomach]) of the right pelvis. There is a complex fluid collection around the sponges concerning for abscess (swollen area within the body tissue).” An addendum (additional)to Patient 1 ’ s “Diagnostic Imaging Report,” dated 10/25/2025, confirmed the findings. A review of Patient 1 ’ s “Diagnostic Imaging Report,” dated 10/25/2025, the Report indicated, Patient 1 ’ s X-ray (a non-invasive imaging tool) of the abdomen found: “There are 2 radiopaque (materials, such as bone or metal, that block images on an X-ray) foreign bodies (an external object that enters the body) in the right lower quadrant (section) of the abdomen, consistent with retained surgical sponges.” A review of Patient 1 ’ s History and Physical, dated 10/25/2025, the H&P indicated, Patient 1 was admitted to the hospital from the ED for abdominal pain, vomiting, fever, and “CTAP (CT Scan of the abdomen and pelvis) showed 2 presumed surgical sponges in the intraperitoneal space of the right pelvis, complex fluid collection around the sponges concerning for abscess ..., KUB (X-ray of the kidneys, ureters, and bladder) showed ...retained surgical sponges in the right lower quadrant of the abdomen.” A review of Patient 1 ’ s “Surgical Consultation,” dated 10/25/2025, the consultation note indicated, Patient 1 presented with intra-abdominal abscess and retained surgical sponge after laparoscopic appendectomy and wedge liver biopsy. The consultation note indicated, “KUB was performed that confirmed the presence of 2 retained surgical sponges in the right abdomen.” A review of Patient 1 ’ s “Operative Report,” dated 10/25/2025, the Report indicated, Patient 1 underwent: 1. Exploratory (to find the cause of unexplained symptoms) laparoscopy and removal of the retained foreign body, 2. Drainage (removal of fluid) of the intra-abdominal abscess, and 3. Abdominal cavity washout (a procedure where a salt-water solution is introduced into the abdominal cavity to wash out contaminants such as pus). Patient 1 ’ s Report also indicated, “The retained surgical Ray-Tec was clearly identified and easily removed.” A review of Patient 1 ’ s “Diagnostic Imaging Report,” dated 10/25/2025, the Report indicated, Patient 1 ’ s post-operative X-Ray of the abdomen found: “Retained foreign bodies in the right side of the abdomen have been removed.” A Review of Patient 1 ’ s “Tissue Examination Report, Anatomic (body structure) and Clinical Pathology (the cause and effects of disease) Consultation,” dated 10/25/2025, the Report indicated, Patient 1 ’ s “Gross Examination (visible to the naked eye): Received fresh from the surgical suite is a sponge with a blue stripe measuring 30 x 14.5 x 0.2 cm (centimeter, a metric unit of length) .” During an interview on 2/03/2025 at 2:19 p.m. with Operating Room Scrub Tech (ORST 1), ORST 1 stated that on 10/16/2025 she was the scrub tech for Patient 1 ’ s laparoscopic appendectomy surgery and the circulating nurse was (ORCN 1). ORST 1 stated for Patient 1 ’ s surgery, she (ORST 1) performed an initial count, a closing count, and a final count with ORCN 1. ORST 1 stated the process for surgical counts is to verify counts visually and verbally with ORCN 1. ORST 1 stated the counts are documented by both ORST 1 and ORCN 1 in the electronic medical record. In addition, ORST 1 stated the counts are written by ORCN 1 on a white board in the Operating Room (OR). ORST 1 stated an initial surgical count was performed before Patient 1 entered the OR. ORST 1 stated the closing surgical count was performed by ORST 1 and ORCN 1 when the surgeon (SG 1) was ready to close the abdominal cavity (not close the skin). ORST 1 stated during Patient 1 ’ s closing count she (ORST 1) visually observed the items counted and verbally confirmed the items counted, including sponges used in Patient 1 ’ s surgery. ORST 1 stated she placed the sponges into a bucket, from which ORCN 1 obtained the sponges to place in the sponge count receptacle. ORST 1 stated the next step was for ORCN 1 to retrieve the sponges from the bucket and place the sponges in a sponge count receptable (a disposable and transparent holder of items used in surgery, with each of the 10 slots dedicated to one item for easy viewing and counting). ORST 1 stated during Patient 1 ’ s laparoscopic surgery she did not observe ORCN 1 obtain the sponges from the bucket and place in the sponge count receptable. ORST 1 stated that when the other surgical items were completely counted, she (ORST 1) considered the count correct and continued to assist SG 1 with the surgery. ORST 1 stated at the time of Patient 1 ’ s closing count, she (ORST 1) and ORCN 1 performed a visual and auditory (hearing)count of items, including sponges, used in Patient 1 ’ s surgery. ORST 1 stated at the time of Patient 1 ’ s final count, she and ORCN 1 performed a visual and auditory count of items, including sponges, used in Patient 1 ’ s surgery. ORST 1 stated ORCN 1 ’ s had the responsibility to update the three surgical counts on the white board and in the electronic record after each count was completed. During an interview on 2/03/2026 at 2:30 p.m. with ORST 1, ORST 1 stated during Patient 1 ’ s laparoscopic appendectomy on 10/17/2025, she (ORST 1) believed the Raytec sponges may have not been counted properly and therefore one sponge was left in the abdominal cavity. ORST 1 stated she was holding the camera (part of the laparoscopy scope used during Patient 1 ’ s surgery) while performing the closing count. ORST 1 stated, “I don ’ t recall a discrepancy (difference) since I was holding the camera while doing the count.” During an interview on 2/04/2026 at 10:21 a.m. with Catheter Lab Nurse Manager (CLNM) 1, CLNM 1 stated a surgical scrub tech should not be participating in other tasks while performing any of the three surgical counts. During an interview on 2/04/2026 at 10:21 a.m. with Operating Room Nurse Manager (ORNM) 2, NM 2 stated when a scrub tech is tasked with performing another task while involved in a surgical count, there is an increased chance there can be a mistake and something like this [a retained foreign object (RFO)] can occur. During an interview on 2/04/2026 at 10:21 a.m. with OR Charge Nurse (ORCN) 2, ORCN 2 stated for the closing surgical count, it is the responsibility of the circulating nurse to obtain the sponges from the bucket and place in the sponge count receptable. During an interview on 2/04/2026 at 12:41 p.m. with SG 1, SG 1 stated he was not involved in Patient 1 ’ s initial surgical count, was present during Patient 1 ’ s closing count, and supervised and received report for Patient 1 ’ s final surgical count. During an interview on 2/04/2026 at 12:41 p.m. with SG 1, SG1 stated he was the surgeon at the time of Patient 1 ’ s laparoscopic surgeries on 10/16/2025 and 10/25/2025. SG 1 stated he was not involved in the Root Cause Analysis (RCA-process to identify the causes of problems) process regarding Patient 1 ’ s Retained Foreign Object (RFO). SG 1 stated he has not been informed by Medical Staff or Surgical Services of a change of process (regarding surgical counts). SG 1 stated he is not aware if Patient 1 ’ s RFO incident has been brought up in any Surgical Services meeting. SG 1 stated he is not aware of any change of process regarding surgical counts. A review of the facility ’ s P&P titled, “Surgical Counts – Prevention of Retained Surgical Items,” last revised 4/03/2024, indicated: “Counts will be performed ...Prior to the closure of a cavity within a cavity and before wound closure begins.” “Closing counts will be audible and visual.” “Counts will be audible and visualized by both the scrub person and the RN circulator.” “Counts will be noted on the count board.” “ ...raytec (sponges) are separated as they are counted. Sponges are to be placed into counter bags to facilitate counting and disposal at the end of the case ...Ten (10) raytecs will be placed in each counter bag.” “All counts (sponge, sharps, instruments, and accessory items) shall be documented with the name of the RN circulator and the name of the scrub person(s) included on the intraoperative record.””

“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: 50516 Based on interview and record review, the facility failed to ensure for two of 36 sampled patients (Patients 16 and 22), the following: 1. Patient 16 and/or the patient’s representative was provided a Conditions of Admission (CoA, contract between the hospital and patient explaining patient’s right and responsibilities) upon admission to the facility. 2. For Patient 22, the CoA provided was in Patient 22’s preferred language of Spanish. These deficient practices resulted in Patients 16 and 22, and/or the patients’ representatives, to not be informed of their rights as a patient, which may lead in Patients 16 and 22’s inability to effectively make decisions regarding their care and treatment. Findings: 1. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/28/2024, the H&P indicated Patient 16 was admitted to the facility on 10/28/2024 for cardiac arrest (heart stops beating, which leads to emergency life saving measures) and respiratory failure (lungs are poorly functioning). During a review of Patient 16’s “Facesheet (front page of the chart that contains a summary of basic information about the patient),” the record indicated Patient 16 had an emergency contact listed. During a concurrent interview and record review on 10/31/2024 at 1:47 p.m. with the Patient Access Manager (PAM), the PAM stated the purpose of the CoA was to discuss patient rights and admission. The PAM verified Patient 16 had a Conditions of Admission (CoA) dated 10/28/2024 (date of admission), indicating “Pt unable to sign due to medical condition” and was signed by two Patient Access Representatives (PAR). In the same interview and record review on 10/31/2024 at 1:47 p.m., the PAM verified Patient 16’s “Electronic Medical Record (EMR, digital version of the chart),” indicated that Patient 16 had an emergency contact listed. The PAM stated Patient 16’s record had a note written on 10/28/2024 by the PAR, who made one attempt to contact Patient 16’s emergency contact and was unavailable. The PAM verified there was no documentation a second attempt was made to contact Patient 16’s emergency contact to provide the patient’s CoA. The PAM further stated on 10/31/2024 at 1:47 p.m., that the facility’s process for providing CoA was to make two attempts in reaching out to the patient and/or the patient’s representative. The PAM stated there should have been a second attempt to reach out to the patient’s emergency contact to provide Patient 16’s CoA. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Conditions of Admission,” dated 2/28/2024, the P&P indicated, “The Patient and/or the patient’s legal representative ... must sign a Conditions of Admission form upon registering or being admitted as a patient ...In the event that the patient’s medical/mental condition does not allow the patient to sign, the patient’s legal representative may sign.” 2. During a concurrent observation and interview on 10/30/2024 at 10:18 a.m. with the Chief Nursing Officer (CNO), Patient 22 was observed in her room, sitting in a chair, watching the television in Spanish. Patient 22 stated she (Patient 22) only speaks Spanish, and the CNO translated Patient 22’s responses about her care. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/19/2024, the H&P indicated, Patient 22 was admitted on 10/19/2024 for left groin pain. During a review of Patient 22’s “Facesheet (front page of the chart that contains a summary of basic information about the patient),” the record indicated Patient 22’s preferred language was Spanish. During a concurrent interview and record review on 10/31/2024 at 1:40 p.m. with the Patient Access Manager (PAM), the PAM verified Patient 22’s “Electronic Medical Record (EMR),” indicated Patient 22’s preferred spoken and written language was Spanish. The PAM also verified Patient 22’s CoA, written in English, was signed by Patient 22 on 10/19/2024. The PAM stated there was no documentation a language interpreter (helps bridge the communication gap between patients who do not speak the same language as the healthcare providers) was used when the English version of the CoA was provided to the patient. In the same interview on 10/31/2024 at 1:40 p.m., the PAM stated Patient 22 should have been given a CoA in Spanish or a language interpreter should have been used and documented when the CoA was given in English. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Admission of a Patient,” dated 12/2/2023, the P&P indicated, “ Patient Access Representative is responsible for obtaining the appropriate demographic information and providing the standard admission packet...If the patient or patient representative’s preferred language is not English, interpreter service should be used.””

“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: 45774 Based on interview and record review, the facility failed to ensure registered nurses (RNs) were competent in the hemodialysis (HD - the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency), in the event a HD RN (a RN who was trained in HD) became incapacitated (a state of not having the necessary ability, qualification, r strength to perform a specified act or function) while providing HD to a patient in the facility. This deficient practice resulted in the RNs, who provides direct nursing care to HD patients, to not have the knowledge to safely shut off the HD machine in case of an emergency which may cause harm and/or death to the patients during HD. Findings: During a concurrent observation and interview on 10/29/24 at 2:42 p.m. with Registered Nurse 6 (RN 6), outside of room 403, RN 6 (a HD RN) was observed at the bedside providing HD to the patient. A written instruction titled, “emergency procedure if RN incapacitated” was hanged on the HD machine. RN 6 stated she (RN 6) was a contracted employee for HD. RN 6 stated she was not sure if the facility gave an in-service to the nurses regarding an emergency procedure if the HD RN became incapacitated. During an interview on 10/29/2024 at 2:50 p.m. with RN 7, RN7 stated she was the primary nurse assigned to the patient in room 403. RN 7 stated the patient was on HD and a nurse-to-nurse verbal handoff communication would be conducted before and after HD treatment. RN 7 stated they were not given an in-service regarding an emergency procedure if the HD RN became incapacitated while providing HD to the patient. During an interview on 10/29/2024 at 2:55 p.m., with the Director of Service and Support (DSS), the DSS stated the primary nurse and HD nurse would verbally communicate and there was instruction on the HD machine. DSS was questioned by surveyor how to verify or validate the nurses were competent on how to handle an emergency situation if the HD nurse was incapacitated, DSS stated should have a in-service for that. During an interview on 10/31/2024 at 12:07 p.m. with the Director of Quality (DQ), the DQ stated the facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff. The DQ verified there was no record of the RNs having a training or in-service for emergencies during HD including safely shutting shut off HD machine in case of an emergency. The DQ stated there should have a training for the RNs on proper handling of HD machine for the patient’s receiving HD treatment in an emergency situation case as needed.”

“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: 50516 Based on observation, interview, and record review, the facility failed to ensure for one of 36 sampled patients (Patient 24), safe care was provided when Patient 24 was not wearing an identification arm band (facility armband that contains information such as name, date of birth and medical record number) in accordance with the facility’s policy and procedure. This deficient practice resulted in Patient 24 to not to be accurately identified and had the potential for the patient’s safety to be compromised, while in the facility, such as with medication errors, etc. due to lack of proper identification. Findings: During a concurrent observation and interview, on 10/29/24 at 3:10 PM, with Charge Nurse 1 (CN 1), Patient 24 was observed lying in bed, awake, and oriented (a mental state marked by knowing time, place, or who one is). Patient 24 was not wearing an identification armband. CN 1 stated Patient 24 should wear an identification armband at all times. CN 1 stated the risk of Patient 24 not having an identification armband attached would be the possibility of falsely identifying a patient and causing medical errors. During a review of Patient 24’s “History and Physical (H&P),” dated 9/26/2024, the H&P indicated, Patient 24 was admitted to the facility for complaints of chest pressure, right sided facial paresthesia (the feeling of tingling, numbness or “pins and needles”), and right arm and leg weakness and bilateral (both side) hand paresthesia along with slurred speech. During a review of the facility’s policy and procedure (P&P) titled, “Patient Armband Replacement: Guidelines,” dated 11/3/2023, the P&P indicated, “Every patient will have an armband placed on their person upon entrance to the hospital. Said armband must remain on their person at all times while on the premises of the hospital.””

“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: 50632 Based on interview and record review, the facility failed to ensure for two of 36 sampled patients (Patients 22 and 28), the following: 1. Patient 22’s Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) was given as ordered by the physician. This deficient practice had the potential to worsen Patient 22’s condition due to uncontrolled Hypertension which can lead to complications such as stroke (clot in the brain), seizures (abnormal electrical activity in the brain that can cause abnormal behavior, movements, etc.) , prolonged hospitalization and/or death. 2. Patient 28’s cefepime (antibiotic, use for treatment of an infection) and azithromycin (antibiotic, use for treatment of an infection) were given in accordance with the physician’s order and the facility’s policy and procedure regarding medication administration. This deficient practice resulted in delay of treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 28’s infection. Findings: 1. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/19/2024, the H&P indicated Patient 22 was admitted for left groin pain. Patient 22 had a history of high blood pressure, kidney failure (when the kidneys can no longer function properly to remove waste and excess water from the blood) requiring hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/31/2024 at 11:20 a.m. with the Director of Service and Support (DSS), the DSS verified Patient 22’s “Medication Detail,” dated 10/22/2024, included a physician’s order for Patient 22 to be given Hydralazine 10 milligram (mg, unit of measure) intravenously (IV, through the vein), every four hours as needed (PRN) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure). In the same interview and record review, on 10/31/2024 at 11:20 a.m., the DSS verified Patient 22’s “Vital Signs Flowsheet,” dated 10/27/2024, Patient 22 had the following BP readings: -At 7:54 a.m., Patient 22’s BP was 166/82 mmHg; -At 11:42 a.m., Patient 22’s BP was 177/79 mmHg; -At 3:43 p.m., Patient 22’s BP was 172/68 mmHg; -At 9:07 p.m., Patient 22’s BP was 186/79 mmHg; -At 11:50 p.m., Patient 22’s BP was 185/78 mmHg. In addition, the “Vital Signs Flowsheet,” dated 10/28/2024 at 3:12 p.m., Patient 22’s BP was 173/77 mmHg. The DSS further stated on 10/31/2024 at 11:20 a.m., Patient 22’s “Medication Administration Record” had no documentation of Hydralazine given when Patient 22’s BP was greater than 160 mmHg on 10/27/2024 at 7:54 a.m.; at 11:42 a.m.; at 3:43 p.m.; at 9:07 p.m.; at 11:50 p.m., and on 10/28/2024 at 3:12 p.m. The DSS stated it was important to give Patient 22 Hydralazine to lower the patient’s BP. The DSS stated not giving Patient 22 Hydralazine as needed could put the patient at risk for stroke and other life-threatening complications. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Safety, “dated 2/2/2024, the P&P indicated, “The RN will administer medications using the nursing process assessment, planning, implementation, evaluation ...” 2. During a review of Patient 28’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/23/2024, the H&P indicated Patient 28 was admitted to the facility for failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and pneumonia (lung infection). 2.a. During a concurrent interview and record review, on 10/31/2024 at 10:30 a.m., with the Clinical Manager, the CM verified Patient 28’s “Medication Administration Record (MAR),” dated 10/23/2024, included a physician’s order for Patient 28 to be given cefepime (antibiotic, use for treatment of an infection) 1 gram intravenous (IV - within the veins), to be given every 12 hours, with a start date of 10/23/2024 at 9:00 PM. In the same interview and record review, on 10/31/2024 at 10:30 a.m., the CM stated Patient 28’s MAR indicated Patient 28 was given cefepime on 10/24/2024 at 8:36 a.m.. The next cefepime dose was given at 10:02 p.m. (13 hours and 27 minutes since the last dose was given). The CM stated Patient 28’s cefepime dose given on 10/24/2024 at 10:02 p.m. was 1 hour and 27 minutes late. The CM stated the antibiotic should have been given within one hour of scheduled dose. 2.b. During a concurrent interview and record review, on 10/31/2024 at 10:40 a.m., with the CM, the CM verified Patient 28’s “Medication Administration Record (MAR),” dated 10/23/2024, included a physician’s order for Patient 28 to receive azithromycin (antibiotic, use for treatment of an infection) 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) IV, to be given once a day, with a start date of 10/23/2024 at 9:00 a.m. In the same interview and record review, on 10/31/2024 at 10:40 a.m., the CM stated Patient 28’s MAR indicated Patient 28 was given azithromycin 500 mg IV on 10/23/2024 at 11:13 a.m. (2 hours and 13 minutes after the initial dose of antibiotic was ordered to be given). The CM stated the azithromycin should have been given to Patient 28 within an hour of scheduled dose. In a follow up interview on 10/31/2024 at 10:45 a.m., the CM stated antibiotic dose should be given within one hour of scheduled time to make sure a therapeutic level of antibiotics remains in the bloodstream to treat the infection. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Safety,” dated 2/2/2024, the P&P indicated the following: -“Before administering a medication the licensed nurse must...Verify that the medication is being given at the proper time, in the prescribed dose and by the correct route. -“Non-time-critical scheduled medications are to be administered within 60 minutes before or after the schedule dose time. Scheduled time will be indicated in the electronic-MAR (e-MAR)”.”

“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: 42937 Based on interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to evaluate and document psychosocial assessment (the evaluation screen on domestic violence, abuse history and suicidal tendency of a patient) on one (1) of thirty sampled patients (Patient 17). The deficient practice has the potential of failing in identifying Patient 17 and other patients, who are at risk of domestic violence, abuse, and/or suicide. (Refer to A 395). 2. The facility failed to ensure one (1) of nine (9) sampled Registered Nurses (RN 4), had completed orientation and competencies according to facility’s policy and procedure (P&P) for an RN working in the assigned units (Labor & Delivery [L&D - specialized unit to prepare a woman’s body to give birth to a baby] and Obstetric (OB) triage (a specialized unit where pregnant mothers were examined to determine the disposition of the woman and her fetus on arrival in the facility). RN 4 had no orientation and competencies records completed to the units worked (L&D and OB triage) to ensure specialized qualifications were met to provide care for the patients in the units worked. This deficient practice had the potential for RN 4 and other nurses working in the L&D and OB units without completed orientation and competencies, not qualified to care for the type of patients in the different units and patients were at risk for not getting proper care met. (A 397). 3. The facility failed to follow a physician order of applying a sequential compression device (SCD [a device that prevents the pooling of blood in the legs by gently squeezing the legs from the ankles up to the knee]) on two (2) of thirty (30) sampled patients (Patient 18 and 28). The deficient practice resulted to physician order not followed and had the potential to result on Patient 18 and 28 having pooling of blood and developing blood clots (clumps of blood) in the legs due to no movements and stimulation. (Refer to A 398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38310 Based on interview and review, the facility failed to ensure two of thirty sampled patients (Patient 13 and Patient ?), were screened for potential abuse. This deficient practice had the potential for being in an abusive situation. Findings: 42937 Based on interview and review, the facility failed to ensure one (1) of thirty sampled (Patient 13) was screened for potential abuse. This deficient practice had the potential for Patient 13 and other patients not assessed of being in an abusive situation. Findings: On 12/1/2023, at 3:15 PM, during concurrent interview with Registered Nurse Informaticist (RN I) and record review of Patient 13’s nursing notes, dated 1/4/2023 to 1/6/2023, RN I stated there was no documentation that Patient 13 was assessed for the screening questions for abuse. RN I stated Patient 13 should have been screened for abuse after being admitted to the hospital, on 1/4/2023. RN I stated patients admitted to the nursing unit should be interviewed and assessed for signs of abuse. A review of facility Pre-Employment Background Check policy, dated 6/30/2022, indicated the following: 1. Pre-employment background checks will be conducted on all prospective new hires and monthly government sanctions/ exclusion screenings on all employees. 2. Background investigation will include references, current and/or past employment, education, criminal or police reports, sexual offender, other public records, and credit checks. A review of facility’s Elder/Dependent Abuse and Neglect policy, dated 1/20/2023, indicated the following: 1. All hospital employees must report suspected abuse or neglect, when acting in their professional capacity or within the scope of their employment. 2. All licensed hospital personnel may be responsible for recognition and reporting, and are considered, “mandated reporters” (a person who is legally required to report observed or suspected abuse). 3. Any employee suspecting abuse is required to file an Adult Protective Services (APS - agency to help elder adults and dependent adults who are suspected of being victims of abuse) report and should contact the social worker assigned to that hospital unit, who can assist with assessment and reporting. 4. A copy of the APS form is placed in the patient’s medical record and a copy is on file in the social services office. A review of facility’s Employee Handbook, dated 11/29/2023, indicated the following: 1. The new employee orientation is designed to provide information necessary to acquaint employees with their job, the hospital, and the necessity of working, including receipt of important information regarding the hospital’s policies and procedures, programs, regulations, benefits, and safety. 2. Facility employees are expected to promote and protect the rights of diverse patient populations, including respecting the patient’s dignity, worth, attributes, and human rights. 3. Employees are urged to be alert to the entry of unauthorized persons in any area and should report any suspicious activity to security.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42937 Based on interview and record review the facility failed to evaluate and document psychosocial assessment (the evaluation screen on domestic violence, abuse history and suicidal tendency of a patient) on one (1) of thirty sampled patients (Patient 17). The deficient practice has the potential of failing in identifying Patient 17 and other patients, who are at risk of domestic violence, abuse, and/or suicide. Findings: A review of Patient 17’s “Face Sheet,’’ undated, indicated Patient 17 was admitted to the facility, on 08/30/2023 at 11:58 p.m. A review of Patient 17’s, “Admission Screen Psychosocial”, dated 08/31/2023, at 00:38(12:30 p.m.), indicated no entry (blank) of Patient 17 evaluation question on domestic violence, abuse, and/or suicide. During an interview, with the Manager of Women Services (MWS), on 11/30/2023, at 11:48 a.m., the MWS stated the admitting nurse failed to complete and document Patient 17 psychosocial assessment which includes asking Patient 17’s domestic violence, abuse, and suicide history. The MWS stated it (psychosocial assessment) was important for a nurse to complete. The MWS patient psychosocial assessment helps identify Patient 17’srisk of domestic violence, abuse and/or suicide. The MWS stated admitting nurse was responsible to complete the assessment and document the psychosocial assessment in Patient 17’s Electronic Health Record (EHR). A review of the facility’s policy and procedure (P&P), titled, “Assessment, Reassessment and interprofessional plan of care”, revised date 5/2021, indicated the roles and responsibilities of the nurse was to collect and analyze data to produce information, formulate discipline-specific treatment plans and recommendations within their scope of practice. The nurse was also expected to document patient information (assessments), and care provided in the Electronic Health Record (EHR).”

“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: 38310 Based on interview and record review, the facility failed to ensure one (1) of nine (9) sampled Registered Nurses (RN 4), had completed orientation and competencies according to facility’s policy and procedure (P&P) for an RN working in the assigned units (Labor & Delivery [L&D - specialized unit to prepare a woman’s body to give birth to a baby] and Obstetric (OB) triage (a specialized unit where pregnant mothers were examined to determine the disposition of the woman and her fetus on arrival in the facility). RN 4 had no orientation and competencies records completed to the units worked (L&D and OB triage) to ensure specialized qualifications were met to provide care for the patients in the units worked. This deficient practice had the potential for RN 4 and other nurses working in the L&D and OB units without completed orientation and competencies, not qualified to care for the type of patients in the different units and patients were at risk for not getting proper care met. Findings: On 12/1/2023, at 4:59 PM, during a concurrent interview with Labor and Delivery Manager (L&D Mgr.) and record review of RN 4’s employee file, L&D Mgr. stated RN 4’s employee file had no documentation of RN 4’s orientation training to L&D and OB Triage, where RN 4 was hired to work. L&D Mgr. stated there were no documented competencies for RN 4 for L&D and OB Triage units, where RN 4 was hired to work. L&D Mgr. stated RN 4 should have had documented competencies for the units RN 4 worked (L&D and OB Triage). L&D Mgr. Stated RN 4 was an RN who conducted Medical Screening Examination (MSE - evaluation by a physician or to the extent permitted by applicable law, by other health professionals, to determine if an emergency medical condition, psychiatric emergency medical condition, and/or active labor exists). On 12/1/2023, at 4:59 p.m., during a concurrent interview with L&D Mgr. and record review of facility’s P&P titled, “Medical Screening Examination (MSE) by a Registered Nurse I Women’s Services; Standard Procedure,” revised date 1/27/2022, indicated the following: 1. Qualified L&D RNs are authorized to perform MSE for labor evaluation and pregnancy related complaints in consultation with a medical staff (physician). 2. Qualifications and training included ability to perform standard procedures that included, “The licensed RN must have completed all OB triage RN orientation requirements: A. Assessment of obstetric patient including high risks conditions. B. Point of Care Testing (POCT) including Urine dipstick, Amnio test (check fluid in the womb surrounding the fetus [baby]), C. Advance fetal monitoring (checking the condition of fetus in the womb) competency.” 3. Evaluation of RN competency in the performance of standard procedure functions will be performed in the following manner: a. . Successful completion of an orientation period in the OB triage and L&D. b. Validation of nursing skills required for performing an OB MSE. c. Demonstrated competence in the performance of vaginal examination of the pregnant patient to include dilation (opening of the cervix the lower, narrow of the uterus [womb]), status of the membranes [layer of tissue holds in the fluid the surrounds the baby in the womb), and station (how far down a baby’s head had descended into the pelvis). d. Demonstrate competency in fetal heart rate monitoring. e. Demonstrate competency in the performance of a MSE and supervised by a designated evaluator. A review of facility’s Employee Handbook, dated 11/29/2023, indicated the new employee orientation was designed to provide information necessary to acquaint employees with their job, the hospital, and the necessity of working, including receipt of important information regarding the hospital’s policies and procedures, programs, regulations, benefits, and safety.”

“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: 42937 Based on interview and record review the facility failed to follow a physician order of applying a sequential compression device (SCD [a device that prevents the pooling of blood in the legs by gently squeezing the legs from the ankles up to the knee]) on two (2) of thirty (30) sampled patients (Patient 18 and 28 ). The deficient practice resulted to physician order not followed and had the potential to result on Patient 18 and 28 having pooling of blood and developing blood clots (clumps of blood) in the legs due to no movements and stimulation. Findings: 1. A review of Patient 18’s Electronic Medical Record (EMR - the systematized collection of patient and population electronically stored health information in a digital format, which can be shared across different health care settings) indicated Patient 18 had a physician order to apply SCD when given an epidural (an injection to a patient’s back to stop them from feeling pain in certain part of their body). Patient 18 was given an epidural on 8/30/23 at 1159 p.m. There was no documentation that an SCD was applied on Patient 18. During an interview, with the Manager of Women Services (MWS) on 12/01/2023, at 3:27 p.m., MWS stated that the nurse failed to document and apply an SCD on Patient 18 as ordered by the physician. The MWS, the nurse providing care and treatment to patient must follow physician orders and document treatment provided. A review of the facility’s policy and procedure (P&P), titled, “Assessment, Reassessment and interprofessional plan of care,” revised date 5/2021, indicated that part of the roles and responsibilities of the nurse is to provide care, treatment, and services as defined by their job description, professional license, laws, and regulations. It is also expected that Nurse document patient information/data collected, and care provided in the Electronic Health Record (EHR). 2. A review of Patient 28’s Electronic Medical Record (EMR) indicated that Patient 28 had a physician order to apply SCD when given an epidural (an injection to a patient’s back to stop them from feeling pain in certain part of their body). Patient 28 was given an epidural on 6/30/23 at 1:00 p.m. There was no documentation that an SCD was applied on Patient 28. During an interview, with the Manager of Women Services (MWS) on 12/01/2023, at 3:27 p.m., MWS stated that the nurse failed to document and apply the SCD on Patient 28 as ordered by the physician. The MWS, the nurse providing care and treatment to patient must follow physician orders and document treatment provided. A review of the facility’s policy and procedure (P&P), titled, “Assessment, Reassessment and interprofessional plan of care,” revised date 5/2021, indicated that part of the roles and responsibilities of the nurse is to provide care, treatment, and services as defined by their job description, professional license, laws, and regulations. It is also expected that Nurse document patient information/data collected, and care provided in the Electronic Health Record (EHR).”

“UPDATED EXAM CFR(s): Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (ii) An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration when the medical history and physical examination are completed within 30 days before admission or registration and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure one of thirty sampled patients (Patient 6) had an updated physical examination for any changes in patient’s condition, that was completed and documented, within 24 hours after patient was admitted. This deficient practice had the potential for adverse events during or after surgery. Findings: On 11/30/2023, at 11:48 AM, during concurrent interview with Clinical Educator (Educator) and record review of Patient 6’s Informed Consent for cesarean section (the surgical delivery of a baby through a cut made in the mother’s abdomen and uterus), dated 10/8/2023, indicated patient was pregnant with twins, and recommended surgery to get the babies out. Concurrently, Educator stated patient had a history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 10/3/2023, which indicated the following: 1. Pregnancy was at 33 6/7 weeks and not near term, which is 40 weeks. 2. Patient was in preterm labor. 3. Patient had twins. Concurrently, Director of Quality (DOQ) stated there should have been an update to the patient’s H&P, to indicate there were no significant changes in Patient 6’s condition, prior to patient’s cesarean section delivery. A review of facility’s Pre-Op Assessment Prior to Surgery policy, dated 10/7/2020, indicated the following: 1. A completed history and physical (H&P - the most formal and complete assessment of the patient and the problem), within 30 days and an updated patient assessment documented 24 hours prior to surgery. 2. A complete preoperative H&P assessment prior to any operative (surgery)/ invasive procedure (a deliberate access to the body by an incision, puncture by a needle or instrument through a natural orifice) will be performed, including any indicated laboratory and radiographic examinations appropriate to the patient’s condition, consented procedure, and documented in the patient’s medical record. 3. The minimum elements documented in the medical record, prior to operative/ invasive procedure include assessment of the heart and lungs, documentation of vital signs (clinical measurements of the pulse rate, temperature, respiratory rate, and blood pressure), examination of the operative/ invasive procedure site, venous access, chest x-ray, documentation of recent bathing, and a surgeon’s note regarding the emergent necessity for the surgery or procedure. A review of the facility’s Medical Staff Rules and Regulations, dated 10/26/2017, indicated the following: 1. All inpatients and outpatients must have a H&P completed prior to surgery or major invasive procedure. 2. If the H&P is performed more than 24 hours prior to admission or surgery, any subsequent changes in the patient’s status must be reflected in an interval H&P note recorded in the medical record within 24 hours of admission or not more than 24 hours prior to surgery. 42937 Based on interview and record review, the facility failed to ensure one (1) of thirty sampled patients (Patient 6) had an updated physical examination for any changes in patient’s condition, that was completed and documented, within 24 hours after patient was admitted. This deficient practice had the potential for adverse events during or after surgery. Findings: On 11/30/2023, at 11:48 AM, during concurrent interview with Clinical Educator (Educator) and record review of Patient 6’s Informed Consent for cesarean section (the surgical delivery of a baby through a cut made in the mother’s abdomen and uterus), dated 10/8/2023, indicated patient was pregnant with twins, and recommended surgery to get the babies out. Educator stated Patient 6 had a history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 10/3/2023, which indicated the following: 1. Pregnancy was at 33 weeks and 6 days. Patient 6 was not near full term (40 weeks of pregnancy). 2. Patient was in preterm labor. 3. Patient had twins. On 11/30/2023, at 11:48 AM, during an interview, Director of Quality (DOQ) stated there should have been an update to the Patient 6’s H&P, to indicate there were no significant changes in Patient 6’s condition, prior to patient’s cesarean section delivery. A review of facility’s Pre-Op Assessment Prior to Surgery policy, dated 10/7/2020, indicated the following: 1. A completed history and physical (H&P - the most formal and complete assessment of the patient and the problem), within 30 days and an updated patient assessment documented 24 hours prior to surgery. 2. A complete preoperative H&P assessment prior to any operative (surgery)/ invasive procedure (a deliberate access to the body by an incision, puncture by a needle or instrument through a natural orifice) will be performed, including any indicated laboratory and radiographic examinations appropriate to the patient’s condition, consented procedure, and documented in the patient’s medical record. 3. The minimum elements documented in the medical record, prior to operative/ invasive procedure include assessment of the heart and lungs, documentation of vital signs (clinical measurements of the pulse rate, temperature, respiratory rate, and blood pressure), examination of the operative/ invasive procedure site, venous access, chest x-ray, documentation of recent bathing, and a surgeon’s note regarding the emergent necessity for the surgery or procedure. A review of the facility’s Medical Staff Rules and Regulations, dated 10/26/2017, indicated the following: 1. All inpatients and outpatients must have a H&P completed prior to surgery or major invasive procedure. 2. If the H&P was performed more than 24 hours prior to admission or surgery, any subsequent changes in the patient’s status must be reflected in an interval H&P note recorded in the medical record within 24 hours of admission or not more than 24 hours prior to surgery.”