St Bernardine Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47394 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of care for the contracted services for two of 37 sampled patients (Patient 23 and 31), when 1. For Patient 23, the responsible physician did not evaluate Patient 23’s condition in a timely manner with continuous rise in blood pressure (BP-how strongly blood is pushing through arteries. When top number above 130 is considered as high blood pressure that can cause damage to body). (Refer to A-0084) 2. For Patient 31, the responsible physician did not ensure the vaginal packing (gauze that was inserted into the vagina to stop bleeding) was fully removed from Patient 31 after a vaginal delivery. (Refer to A-0084) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47394 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide Quality Assessment and Performance Improvement (QAPI-identify, analyzes, addresses performance issues in the facility) program for 37 of 37 sampled patients as evidenced by: 1. The facility did not ensure an ongoing program to monitor patients’ abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood), nursing assessment, neurological assessment (an assessment used to determine brain function and nerve control by checking the alertness, orientation, speech, movement, strength, sensation, and pupils of a patient), monitoring effectiveness of medications, internal department hand off communications, oxygen weaning, retained foreign body (an object such as sponge unintentionally left inside patient’s body after a procedure) assessment before the patient is discharged and timely escalation of patient’s change of condition. (Refer to A-0273). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care in a safe environment and had the potential to cause adverse health outcomes including death of patients.”

“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: 51269 Based on interview and record review the facility failed to maintain effective and organized nursing services for 12 of 37 sampled patients (Patient 1, 6, 7, 9, 12, 14, 17, 18, 19, 23, 27, and 31) when: 1. For one patient (Patient 23), the nursing staff did not provide ongoing nursing surveillance and timely response to a change in patient condition when Registered Nurse (RN) did not initiate a “safety net” (an emergency intervention called when a patient shows early signs of clinical deterioration such as changes in vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood), mental status (a description of how awake, alert and mentally aware a patient is)) for elevated blood pressure readings. (Refer to A-0395) 2. For two patients (Patient 1 and 9), there was no documented evidence of a completed Ticket to Ride (TTR- a form provided by the nursing staff to the transporter, used when a patient leaves the unit without a nurse, to inform any staff members of important safety information like oxygen needs, last set of VS, and last medications given as per the facility’s policy and procedure (P&P)). (Refer to A-0398) 3. For one patient (Patient 1), the nursing staff did not document a complete neurological assessment (an assessment used to determine brain function and nerve control by checking the alertness, orientation, speech, movement, strength, sensation, and pupils of a patient) for the shift. (Refer to A-0398) 4. For four patients (Patient 7, 12, 14 and 19), the nursing staff did not document vital signs as indicated in the facility’s P&P. (Refer to A-0398) 5. For one patient (Patient 17), the nursing staff did not document restraints (device used to stop a patient from moving freely to prevent them from hurting themselves or others) discontinuation. (Refer to A-0398) 6. For one patient (Patient 18), the nursing staff did not document the reduction (weaning) of oxygen therapy in accordance with the facility’s P&P. (Refer to A-0398) 7. For one patient (Patient 27), who was hemodynamically unstable (a person’s blood circulation is failing, resulting in dangerously low blood pressure or irregular heart rates that cannot properly supply oxygen to vital organs) the nursing staff did not use two Registered Nurse’s (RN) during repositioning as per the P&P resulted in an endotracheal tube (ETT- a flexible plastic tube inserted into the trachea (the tube in the neck that carries air from throat to the lungs) through the mouth to maintain an open airway, deliver oxygen and protect the lungs) dislodgement. (Refer to A-0398) 8. For one patient (Patient 31), the nursing staff did not ensure the vaginal packing (gauze that was inserted into the vagina to stop bleeding) was fully removed from patient after a vaginal delivery.. (Refer to A-0398) 9. For one patient (Patient 1), the nursing staff did not provide appropriate monitoring, before and after Lorazepam (Ativan- a medication that calms the brain and body and can make a person feel drowsy (sleepy or having trouble staying awake), relaxed, and can slow down the breathing) was given. (Refer to A-0405) 10. For one patient (Patient 6), intravenous (IV- given through a tube directly into the blood stream) Hydromorphone (Dilaudid- medication used to treat pain) was administered for the wrong indication (reason to administer a medication). (Refer to A-0405) The cumulative effects of these systemic problems resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, evaluation, and treatment which jeopardized the health and safety of the patients.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 47394 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to ensure an effective oversight of the contracted physician services responsible for two of 37 sampled patients (Patient 23 and 31) when: 1. For Patient 23, the responsible physician did not respond and evaluate Patient 23’s condition in a timely manner with continuous rise in blood pressure (BP-how strongly blood is pushing through arteries. When top number above 130 is considered as high blood pressure that can cause damage to body). This failure resulted in delayed response to Patient 23’s change in health condition that contributed to multiple “code blue” (an emergency in which patient has a life-threatening event and a team of people from different expert areas including doctors come for help) episodes and subsequent death. 2. For Patient 31, the responsible physician did not ensure the vaginal packing (gauze that was inserted into the vagina to stop bleeding) was fully removed from Patient 31 after a vaginal delivery. This failed practice resulted in Patient 31’s readmission to the hospital (after one day of discharge) to remove the retained vaginal packing subjected her to discomfort, risk for infection, and delayed bonding with the newborn and healing of the wound which could jeopardize health and safety. Findings: 1. During a review of Patient 23’s “face sheet” (FS-demographic data), the FS indicated, Patient 23 was admitted to the facility on February 4, 2026, with the diagnoses of epigastric pain (pain in upper abdomen), acute cholecystitis (a condition in which the gall bladder is inflamed), and acute respiratory failure (a condition in which lungs does not function properly). During a concurrent interview and record review on April 15, 2026, at 2:10 PM, with the Medical Surgical Director (MSD), Patient 23’s “electronic health record” (EHR- an electronic health record where patient’s health details are documented) under “Vital signs Flowsheet” (VSFS), dated February 4, 2026, was reviewed. The VSFS indicated as follows: On February 4, 2026, at 3:00 AM, BP was 197/82 On February 4, 2026, at 4:00 AM, BP was 191/78 On February 4, 2026, at 5:00 AM, BP was 165/76 On February 4, 2026, at 8:00 AM, BP was 179/107. The MSD verified that Patient 23 had high BP consistently and it should have been addressed to the physician for immediate care. During a concurrent interview and record review on April 15, 2026, at 2:10 PM, with the MSD, Patient 23’s EHR under “Event,” dated February 4, 2026, was reviewed. Registered Nurse (RN 5) documented the “Events” as follows: On February 4, 2026, at 3:24 AM, Patient 23 came to the Medical Surgical Unit (MSU- a unit in which patients are treated for health and surgery problems) with shortness of breath. On February 4, 2026, at 4:16 AM, RN 5 attempted to reach the Physician (P1) via phone, call was not answered and went to voicemail. On February 4, 2026, at 6:54 AM, RN 5 documented that she texted P1 to update the Patient 23’s status and PP ordered to discontinue intravenous (into the vein) fluid (IVF- a hydration method of delivering fluid through vein). (2 hours and 38 minutes when RN able to receive instruction). On February 4, 2026, at 7:47 AM, Patient 23 was transferred to the Intensive Care Unit (ICU- unit where patients with critical condition are treated). The MSD stated, as per Pateint 23’s “Event” RN 5 tried calling the physician multiple times for Resident 23. The MSD further stated, the nursing staff always have problems in reaching out to P1. A review of Patient 23’s “Code Blue Record”, dated February 4, 2026, indicated, Patient 23 had a “code blue” on February 4, 2026, at 7:15 AM, when Patient 23 was found unresponsive covered with emesis and no heart rate. During an interview on April 16, 2026, at 12:32 PM, with the Director of Quality (DQ), the DQ stated, P1 is a contracted independent physician and he has the privilege for patient care in the facility. During an interview on April 17, 2026, at 12:45 PM, with the interim Chief Excecutive Officer (I CEO), DQ, and Chief Nursing Officer (CNO), the I CEO stated that the incident was brought up to the GB and P1 was referred for the peer review (an evaluation process of a physician’s performance). The I CEO further stated, the GB is responsible for the independent physician and are responsible for all patients who receive care in the facility. 2. During a review of Patient 31’s “Admission Record” (contains demographic and medical information), undated, the “Admission Record” indicated Patient 31 returned to the facility on February 3, 2026, to the Emergency Room for evaluation of retained vaginal foreign body (a piece of medical equipment such as sponge, is accidentally left inside a patient’s body after surgery or a procedure) following delivery of a baby through vaginal delivery on January 30, 2026. Patient 31 was admitted with diagnosis that included vaginal foreign body. A review of Patient 31’s “ED [Emergency Department] Physician Note,” dated February 3, 2026, indicated “Packing was partially removed until resistance felt. Attempt was stopped. Contacted OBGYN (Obstetrician-Gynecologist-a physician specializing in female reproductive health, pregnancy, and childbirth) who is familiar with patient ... OB-GYN able to remove the remainder of the packing and evaluated vaginal vault [expanded region of the vaginal canal at the internal end of the vagina] ...” During an interview on April 16, 2026, at 11:30 AM, with the Medical Staff Coordinator (MSC), the MSC stated that the OB-GYN is a contracted physician in the facility. During a concurrent interview and record review on April 17, 2026, at 8:01 AM, with the OB-GYN, Patient 31’s “Physician Note,” dated January 31, 2026, was reviewed. The “Physician Note” indicated, “Deflated Bakri balloon [a silicone, catheter-based device designed for the temporary management of severe postpartum hemorrhage (PPH- heavy dangerous bleeding after childbirth] by 300 cc [cubic centimeter-a unit of volume equal to 1 milliliter or 1 ml] at 19:30 [7:30 PM] and observed for increased bleeding which did not happen. Removed Bakri ballon at 21:00 [9:00 PM]; patient stable to go to Postpartum Unit [a specialized hospital department where parents and newborns stay after delivery, typically for 1-4 days].” The OB-GYN stated it was uncommon to have vaginal packing with a Bakri ballon, and further stated she failed to properly inspect the vaginal canal after removal of the Bakri ballon. During an interview on April 17, 2026, at 12:45 PM, with the I CEO, DQ and CNO, the CNO stated, Patient 31 was initially (during the first admission) in the Intensive Care Unit (ICU- a unit where critical ill patients are taken care of) and Registered Nurse (RN) was not trained for taken care of pregnancy related patients. The I CEO stated, the incident was brought to the GB, and investigations for the physician are still ongoing and the physician will be referred to Medical Executive Committee for peer review. The I CEO further stated, the GB is responsible for the independent physician and are responsible for all patients who receive care in the facility. During a concurrent interview and record review on April 17, 2026, at 1:00 PM, with the I CEO, CNO and DQ, the facility document titled, “Bylaws of the Board of community advisors”, dated September 2025, was reviewed. The “Bylaws of the Board of community advisors”, indicated, “ ....2.2.2 .... (k) assuring that Medical staff (1) participates in the assessment, and improvement of clinical and non-clinical processes affecting patient care and (2) takes a leadership role when clinical processes are the primary responsibility of the physicians”. The I CEO acknowledged that the GB is responsible for all the activities in the facility and I CEO stated, that the bylaws were not followed as there are multiple issues which affected the patient care.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47394 Based on interview and record review, the facility did not ensure an effective and ongoing Quality Assessment and Performance Improvement (QAPI-is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for 37 of 37 sampled patients when the facility failed to monitor, collect and analyze quality data regarding monitoring and notification of patients’ abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood), nursing assessment, neurological assessment (an assessment used to determine brain function and nerve control by checking the alertness, orientation, speech, movement, strength, sensation, and pupils of a patient), monitoring effectiveness of medications, internal department hand off communications, oxygen weaning (gradual process of reducing, and eventually stopping, supplemental oxygen therapy to help a patient breathe on their own), retained foreign body (an object such as sponge unintentionally left inside patient’s body after a procedure) assessment before the patient is discharged and timely escalation of patient’s change of condition. These failures had resulted in the missed opportunity to identify patient safety issues and changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: During an interview on April 17, 2026, at 12:15 PM, with three members of the QAPI including the Director of Quality (DQ), Quality Manager (QM), and Chief Nursing Officer (CNO), the DQ stated, each department manager collects data and send to the QAPI team twice a week and monthly meetings are held for the QAPI to discuss the concerns and performance improvement plans. During a review of facility’s “QAPI committee meeting minutes” (QAPI CMM), dated February 26, 2026, the QAPI CMM indicated, the facility had discussed the topic on emergency department triaging (a process of categorizing patients depending on the severity of illness), fall prevention, supply management, and high risk medication (drugs that have potential to cause significant harm to patients if misuse). A follow up review of facility’s “QAPI CMM”, dated March 26, 2026, the facility had discussed about the topic on emergency department triaging, fall prevention, supply management, high risk medication, operation room retained foreign body object , and isolation precautions (safety rules used in hospitals to stop the spread of germs from an infected patient to others.) During an interview on April 17, 2026, at 12:18 PM, with the member of the QAPI team including the Director of Quality (DQ), Quality Manager (QM), and Chief Nursing Officer (CNO), the CNO stated, the QAPI team is auditing each department issues, but facility is having gaps in the data collection, because the team is missing some components of tracking details like restraints (device used to stop a patient from moving freely) follow up . During an interview on April 17, 2026, at 12:20 PM, with the DQ and CNO, the survey team brought up the summary of findings including missing vital signs, neurological assessment, weaning of oxygen, ticket to ride (a form provided by the nursing staff to the transporter, used when a patient leaves the unit without a nurse, to inform any staff members about patient’s current status) document, medication effects follow ups, restraint (device used to stop a patient from moving freely) discontinuation documentation, improper handling for patient during repositioning as per policy, nurse’s responsibility on escalation for change of condition, and retained foreign body. The CNO stated that the facility had no tracking or analysis for the survey findings. The CNO further stated, the facility started tracking for retained foreign body since March 2026, after the incident of patient [Patient 31] returned with retained foreign body but the data collected was limited. During a concurrent interview and record review on April 17, 2026, at 12:45 PM, with the DQ and CNO, the facility’s document titled “QAPI Plan FY26 [Fiscal Year 2026]”, dated August 28, 2025, was reviewed. The “QAPI Plan FY26” indicated, “Purpose: the purpose of the organizational performance improvement plan (PI Plan) is to ensure that governing body, medical staff, and professional service staff demonstrate A consistent endeavor to deliver safe, effective and optimal patient care and services and then environment of minimal risk ....1. Integrate quality assessment and performance improvement systems, processes and activities into department and program functions throughout the facility ....6. Plan and implement processes for conducting thorough and credible event reviews and root cause analysis, focusing on process and system factors in response to Sentinel events and other critical incidents as defined by the hospital .... QAPI committee ....1. Identifying and prioritizing core organizational process/outcome indicators as well as appropriate benchmarks, reviewing indicators data to assess performance, determining the effectiveness of improvement/problem solving activities, and coordinating follow up and communication to ensure the effectiveness of these effort”. The CNO stated, QAPI had gaps as the facility was not tracking all the components of data analysis.”

“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: 47394 Based on interview and record review, the facility failed to ensure nursing staff provided ongoing nursing surveillance and timely response to a change in patient condition for one of 37 sampled patients (Patient 23), when Registered Nurse (RN 5) did not initiate a “safety net” (an emergency intervention called when a patient shows early critical signs of condition changes) for high blood pressure (BP-how strongly blood is pushing through arteries. When top number above 130 is considered as high blood pressure that can cause damage to body) readings. This failure resulted in delayed recognition and response of Patient 23’s deteriorating condition and which may have contributed to multiple “code blue” (an emergency in which patient has a life-threatening event and a team of people from different expert areas including doctors come for help) episodes and subsequent death. Findings: During a review of Patient 23’s “face sheet” (FS-demographic data), the FS indicated, Patient 23 was admitted to the facility on February 4, 2026, with the diagnoses of epigastric pain (pain in upper abdomen), acute cholecystitis (a condition in which the gall bladder is inflamed), and acute respiratory failure (a condition in which lungs does not function properly). During a concurrent interview and record review on April 15, 2026, at 2:10 PM, with the Medical Surgical Director (MSD), Patient 23’s “electronic health record” (EHR- an electronic health record where patient’s health details are documented) under “Vital signs Flowsheet” (VSFS), dated February 4, 2026, was reviewed. The VSFS indicated as follows: On February 4, 2026, at 3:00 AM, BP was 197/82 On February 4, 2026, at 4:00 AM, BP was 191/78 On February 4, 2026, at 5:00 AM, BP was 165/76 On February 4, 2026, at 8:00 AM, BP was 179/107. The MSD verified that Patient 23 had high BP consistently and it should have been addressed to the physician for immediate care. During a concurrent interview and record review on April 15, 2026, at 2:10 PM, with the MSD, Patient 23’s EHR under “Event,” dated February 4, 2026, was reviewed. RN 5 documented the “Events” as follows: On February 4, 2026, at 3:24 AM, Patient 23 came to the Medical Surgical Unit (MSU- a unit in which patients are treated health and surgery problems) and had shortness of breath. On February 4, 2026, at 4:16 AM, RN 5 attempted to reach Physician 1 (P1) via phone, call was not answered and went to voicemail. On February 4, 2026, at 4:18 AM, RN 5 attempted to reach P1 via phone, call was not answered and went to voicemail, charge nurse informed. On February 4, 2026, at 4:40 AM, RN 5 attempted to reach P1 via phone, call was not answered and went to voicemail. On February 4, 2026, at 6:24 AM, RN 5 attempted to reach P1 via phone, call was not answered and went to voicemail (1 hour and 44 minutes from last attempt). On February 4, 2026, at 6:54 AM, RN 5 documented that she texted P1 to update Patient 23’s status and PP ordered to discontinue intravenous (into the vein) fluid (IVF- a hydration method of delivering fluid through vein). On February 4, 2026, at 7:47 AM, Patient 23 was transferred to the Intensive Care Unit (ICU- unit where patients with critical condition are treated). The MSD stated, RN 5 tried calling P1 multiple times. The MSD further stated, the nursing staff always have problems in reaching out P1. The MSD confirmed that the nursing staff did not call “safety net” and should have where patient’s condition could have been taken care of. A review of Patient 23’s “Code Blue Record”, dated February 4, 2026, indicated, Patient 23 had a “code blue” on February 4, 2026, at 7:15 AM, when Patient 23 was found unresponsive covered with emesis and no heart rate. During an interview on April 16, 2026, at 7:35 AM, with RN 5, RN 5 stated, she remembered Patient 23 and tried to call P1 to get order for any BP medication as Patient 23 had multiple high BP readings. RN 5 further stated, she escalated or reported the situation with the unit charge nurse and the response she got was to keep trying to reach P1. During a phone interview on April 17, 2026, at 8:02 AM, with Charge Nurse (CN), CN stated, she got the information regarding Patient 23 from RN 5 and escalated the situation to house supervisor (HS- a person in charge of the hospital nursing unit) where HS guided to repeatedly call P1. CN further confirmed, RN 5 did not call “safety net” and should have called for “safety net” to get help for Patient 23. During an interview on April 17, 2026, at 8:38 AM, with HS, HS stated, she does not recall Patient 23, and she does not document anywhere in Patient 23’s charts. HS further stated, if the nurses could not reach P1, then usually, she would escalate the situation to the supervisor and other in charge doctors, but the nurses should have initiated “safety net” for getting help for the patient. A review of Patient 23’s “EHR nursing progress notes”(EHR NPN), dated February 4, 2026, at 11:50 AM , the EHR NPN indicated, Patient 23 arrived to the Intensive Care Unit (ICU) on February 4, 2026, at 8:47 AM, without heart rate, “ code blue” was called and Patient 23 had total of 6 “code blue” in the ICU and subsequently Patient 23 expired. During a concurrent interview and record review on April 17, 2026, at 10:30 AM, with the Chief Nursing Officer (CNO), the facility’s policies and procedures (P&P) titled, “Safety Net: Utilization of”, dated June 5, 2024, was reviewed. The P&P indicated, “ ...Purpose: To provide assessment and appropriate intervention in the deteriorating patient by a critical care RN, including transfer to a higher level of care if necessary. Policy: adolescent and our adult patients exhibiting signs and symptoms of deteriorating conditions, including respiratory distress/threatened airway/change in breathing pattern, acute changes in HR or BP, acute changes in level of consciousness, decrease urine output, etc, will be assessed by a critical RN. This includes contacting the physician and transfer to a higher level of care if necessary.” The CNO stated that the policy was not followed as the nurses did not initiate a “safety net” for the patient. During a concurrent interview and record review on April 17, 2026, at 10:40 AM, with the CNO, the facility’s undated, document titled, “Job Description of Medical surgical RN” (JD MS RN), was reviewed. The JD MS RN indicated, “ ... Communicate changes in patient condition with physician and other members of the health care team. Contact the physician promptly with significant changes in patients condition, collaborates professionally for required orders and follow up with the revised care period document these events and constantly report to the charge nurse.” The CNO stated, the JD MS RN was not followed as they nurses could have called for the safety net.”

“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: 51269 Based on interview and record review, the facility failed to ensure all licensed nurses adhered to the facility’s policies and procedures (P&P), to provide adequate supervision and evaluation for 10 of 37 sampled patients (Patient 1, 7, 9, 12, 14, 17, 18, 19, 27 and 31) when: 1. For two patients (Patient 1 and 9), there was no documented evidence of a completed Ticket to Ride (TTR- a form provided by the nursing staff to the transporter, used when a patient leaves the unit without a nurse, to inform any staff members of important safety information like oxygen needs, last set of vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood), mental status (a description of how awake, alert and mentally aware a patient is), and last medications given as per the facility’s policy and procedure (P&P). 2. For one patient (Patient 1), the nursing staff did not document a complete neurological assessment (an assessment used to determine brain function and nerve control by checking the alertness, orientation, speech, movement, strength, sensation, and pupils of a patient) for the shift. 3. For four patients (Patient 7, 12, 14 and 19), the nursing staff did not document vital signs as indicated in the facility’s P&P. 4. For one patient (Patient 17), the nursing staff did not document restraints (device used to stop a patient from moving freely to prevent them from hurting themselves or others) discontinuation. 5. For one patient (Patient 18), the nursing staff did not document the reduction (weaning) of oxygen therapy in accordance with the P&P. 6. For one patient (Patient 27), who was hemodynamically unstable (a person’s blood circulation is failing, resulting in dangerously low blood pressure or irregular heart rates that cannot properly supply oxygen to vital organs) the nursing staff did not use two Registered Nurse’s (RN) during repositioning as per the P&P causing an endotracheal tube (ETT- a flexible plastic tube inserted into the trachea (the tube in the neck that carries air from throat to the lungs) through the mouth to maintain an open airway, deliver oxygen and protect the lungs) dislodgement. These failures resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed monitoring, evaluation, treatment, deterioration of patient conditions, prolonged hospitalization, unsafe patient care, and lead to actual patient harm or death. 7. For one patient (Patient 31), the nursing staff did not ensure the vaginal packing (gauze that was inserted into the vagina to stop bleeding) was fully removed from patient after a vaginal delivery. This failed practice resulted in Patient 31’s readmission to the hospital (after one day of discharge), and to remove the retained vaginal pack subjected her to discomfort, risk for infection, and delayed bonding with the newborn and healing of the wound which could jeopardize the health and safety. Findings: 1a. During a review of Patient 1’s “History and Physical” (H&P- a document containing demographic information), dated January 23, 2026, at 12:40 PM, the H&P indicated, Patient 1 was admitted to the facility for weakness, hyperkalemia (high potassium (electrolyte (mineral) in body that helps the heart, muscles and nerves work properly) levels in the blood that can cause abnormal heart rhythms), and new diagnosis of ascites (fluid buildup in the abdomen). Patient 1 had history of diabetes (DM-high blood sugar), hypertension (HTN-high blood pressure), and end stage renal disease (ESRD- kidneys are no longer removing the waste and extra fluid from the body and can cause electrolyte imbalance). During a review of Patient 1’s “Orders,” dated January 26, 2026, the “Orders” indicated, “MRI [Magnetic Resonance Imaging - medical imaging that uses magnets, radio waves and computers to produce a detailed image of soft tissue, organs, and bones used to diagnose conditions] Brain .... reason for exam: left facial droop ...MRI C-spine [cervical spine-the neck region that support the skull] ...reason for exam: upper cervical [the neck portion of the spine] epidural [the area between the bones of the spine and the protective covering of the spinal cord] mass [tumor/growth]/collection [fluid buildup, such as blood or pus].” During a telephone interview on April 16, 2026, at 8:30 AM, with the presence of the Director of Telemetry (DOT), and Manager of Telemetry (MOT)Registered Nurse (RN 1), RN 1 stated, the TTR is a requirement and RN 1 “believes” he provided one to the Radiologist Assistant (RA- transporters) on January 26, 2026, when Patient 1 was transported to MRI. During an interview on April 16, 2026, at 9:30 AM, with RA 1, RA 1 stated, typically the RNs provide her with a ticket to ride and sign it if the patients are being transported without a nurse. RA 1 further stated however, on January 26, 2026, during Patient 1’s MRI transport, “I forgot to get a ticket to ride.” 1b. During a review of Patient 9’s H&P, dated April 11, 2026, at 5:14 AM, the H&P indicated, Patient 9 was admitted to the facility for weakness and dizziness. Patient 9 had history of HTN and hyperlipidemia (HLD- high fat levels in the blood). During a review of Patient 9’s “Orders,” dated April 10, 2026 to April 15, 2026, the “Orders” indicated Patient 9 had an order for “MRI Brain ....” Dated April 10, 2026 and “MRI MRCP” [magnetic resonance cholangiopancreatography a MRI scan of the bile ducts (tubes from the liver and gallbladder) and pancreas) ...dated April 15, 2026 ....” During an interview on April 16, 2026, at 11:15 AM with the Respiratory Therapy Manager (RTM), the RTM stated that the facility did not have a TTR for Patient 1 or Patient 9. During an interview on April 16, 2026, at 11:40 AM, with RA 2, RA 2 stated the TTR is important because if a patient does not look well, the hospital staff can look further to review the code status, last VS, oxygen, and pertinent patient information. During an interview on April 16, 2026, at 12:07 PM, with the Chief Nursing Officer (CNO), the CNO stated, the TTR contains a patient’s isolation status (special precautions to prevent the spread of infection between patients), last VS, intravenous (IV- medications or fluids given through a tube directly into the blood stream) access and the purpose of the TTR is to provide the radiology departments [a part of the hospital that uses imaging to help diagnose and treat medical problems] with hand off [ transfer of patient care responsibility from one health care professional to another] of a patient since the radiology does not call to get report. During a concurrent interview and record review on April 17, 2026, at 11:18 AM, with the Director of Quality (DQ) and the CNO, the facility’s P&P titled “Radiology Patient Transportation,” dated January 28, 2026, was reviewed. The P&P indicated, “ ...4. transporters will obtain a ticket to ride from Registered Nurse Prior to transporting the patient ...” The CNO verified that the policy was not followed and stated that the facility is unable to provide any documentation of a TTR for Patient 1 or Patient 9. 2. During a review of Patient 1’s H&P, dated January 23, 2026, at 12:40 PM, the H&P indicated, Patient 1 was admitted to the facility for weakness, hyperkalemia, and new diagnosis of ascites. Patient 1 had history of DM, HTN, and ESRD. During a telephone interview on April 16, 2026, at 8:22 AM, with RN 1, and in the presence of the Director of Telemetry (DOT), and Manager of Telemetry (MOT), RN 1 stated the nursing staff is expected to complete a head to toe assessment (a full body check from the top of the head down to the feet of a patient) including neurological assessment at the start of the shift. During an interview on April 17, 2026, at 9:10 AM, with RN 2, RN 2 stated, it is important to do the neurological assessment at the start of the shift to ensure you obtain a baseline of the patient’s and can notice a change in condition. During a concurrent interview and record review on April 17, 2026, at 9:58 AM, with the DOT and MOT, Patient 1’s “Neurological assessment” (NA), dated January 26, 2026, from 7:00 PM to 10:27 PM was reviewed. The NA indicated that there was no documented evidence to indicate a neurological assessment was performed by RN 1 on January 26, 2026. The DOT and MOT confirmed and stated that the nursing staff are expected to do the neurological assessments at the start of each shift to identify any change in condition within the shift. During a concurrent interview and record review on April 17, 2026, at 11:20 AM, with the DQ and the CNO the facility’s P&P titled “[name of company] Health Core Nursing Standards of Practice,” dated February 25, 2026, was reviewed. The P&P indicated, “ ...g. Physical assessment should be completed ...within 4 hours of the start of each shift ...i. Neurologic...1. neurologic assessment includes but is not limited to: level of consciousness [loc- how aware, aware and responsive a person is], orientation status [whether a person is aware of who they are, the time, where they are, and what is happening around them], pupillary reaction to light [how the pupils react to light], facial symmetry [face looks even on both sides], sensory [testing how well someone can feel touch, pain, and other sensations in different parts of the body] and motor function [ how well a person can move their muscles and control their body movements], and notion of speech [how clear and normal the way someone talks is]...” The CNO confirmed the policy was not followed and should have to identify throughout the shift if there are any deficits. 3a. During a review of Patient 7’s H&P, dated March 12, 2026, at 1:24 PM, the H&P indicated, Patient 7 was admitted to the facility for severe mitral valve regurgitation [MVR-blood in the heart leaks backwards instead of moving forwards properly]. Patient 7 had history of HTN and HLD. During a review of Patient 7’s “Orders,” dated April 12, 2026, the “Orders” indicated, “ ...Discharge ...home with home health ...” During an interview on April 17, 2026, at 9:15 AM, with RN 2, RN 2 stated, if a patient is going to be discharged from the facility, the nursing staff should obtain a set of VS at least 30 minutes prior to leaving to ensure that the patient is safe for discharge. During a concurrent interview and record review on April 17, 2026, at 10:00 AM, with the DOT and MOT, Patient 7’s “Electronic Health Record Vital Signs” (EHR VS- vital signs located in the electronic medical record) dated April 14, 2026, was reviewed. Patient 7’s EHR VS indicated, Patient 7 was discharged on April 14, 2026, at 5:36 PM, and the last set of VS were at 3:00 PM (2 hours and 36 minutes prior to discharge). The DOT and MOT verified and stated that the nursing staff is expected to take VS within the last hour of discharge to ensure the patient is in the same condition and stable for discharge. 3b. During a review of Patient 12’s H&P dated April 10, 2026, at 12:12 PM, the H&P indicated, Patient 12 was admitted to the facility for hematemesis (throwing up blood). Patient 12 had history of HLD, and Abdominal Aortic Aneurysm (AAA-a weak spot in the main vessel in the stomach that has stretched outward like a balloon that can be life threatening) with thrombus (a blood clot). During a review of Patient 12s “Orders,” dated April 15, 2026, the “Orders” indicated, “ ...Discharge ...home ...” During an interview on April 17, 2026, at 9:15 AM, with RN 2, RN 2 stated, if a patient is going to be discharged from the facility, the nursing staff should obtain a set of VS at least 30 minutes prior to leaving to ensure that the patient is safe for discharge. During a concurrent interview and record review on April 17, 2026, at 10:03 AM with the DOT and MOT, Patient’s 12’s EHR VS, dated April 15, 2026, were reviewed. Patient 12’s EHR VS indicated, Patient 12 was discharged on April 15, 2026, at 1:49 PM, and the last set of VS were at 11:00 AM (2 hours and 49 minutes prior to discharge). The DOT and MOT verified and stated that the nursing staff is expected to take VS within the last hour of discharge to ensure the patient is in the same condition and stable for discharge. During a concurrent interview and record review on April 17, 2026, at 11:21 AM, with the DQ and the CNO, the facility’s P&P titled “[name of company] Health Core Nursing Standards of Practice,” dated February 25, 2026, was reviewed. The P&P indicated, “ ...iii. vital sins should be obtained within 1 hour prior to patient transfer or discharge ...” The CNO verified that the policy was not followed for Patient 7 and 12. The CNO stated it was important to obtain discharge vital signs to ensure that the patient is stable for discharge. 47394 3c. During a review of Patient 14’s H&P, dated April 10, 2026, the H&P indicated Patient 14 was admitted to the facility on April 10, 2026, with the diagnoses of DM and HTN. During a concurrent interview and record review on April 14, 2026, at 3:20 PM, with the Medical Surgical Director (MSD), Patient 14’s EHR VS was reviewed. The EHR VS indicated, Patient 14’s VS as follows: On April 11, 2026, at 9:00 PM - VS checked and documented. On April 12, 2026, at 3:00 PM - VS checked and documented (18 hours from the last VS). The MSD verified there was no documented evidence to indicate Patient 14’s EHRVS for 18 hours. The MSD further stated, nurses are expected to check vitals as per unit policy to make sure patient health status is not deteriorating. 3d. During a review of Patient 19’s H&P, dated April 10, 2026, the H&P indicated that Patient 19 was admitted to the facility on April 9, 2026, with the diagnosis of abdominal pain. During a concurrent interview and record review on April 15, 2026, at 9:20 AM, with the MSD, Patient 19’s EHR VS, dated from April 10, 2026, through April 15, 2026, was reviewed. The EHR VS, indicated as follows: On April 10, 2026, at 11:00 PM, VS checked and documented. On April 11, 2026, at 11:00 PM, VS checked and documented (24 hours from the last VS) The MSD verified and acknowledged that the VS was missing. The MSD stated this was not acceptable practice to miss the VS for the 24 hours. During a concurrent interview and record review on April 17, 2026, at 10: 30 AM, with the CNO, the facility’s P&P titled “[Name of the corporate] Health Core Nursing Standard of Practice”, dated April 10, 2023, was reviewed. The P&P indicated, “Standard of Care Standard 1: Nursing Process 1. Assessment ...c. Vital signs should be obtained within 30 minutes of admission and monitored approximately every 8 hours thereafter unless patient’s condition and/or LIP [Licensed Independent Practitioner] order require more frequent monitoring. i. Vital signs include temperature, heart rate, respiratory rate, blood pressure, and pulse oximeter. ii. Telemetry patient vital signs should be monitored every four hours while awake, with a minimum frequency of every six hours to allow for uninterrupted sleep. iii. Vital signs should be obtained within one hour prior to patient transfer or discharge ...” The CNO stated, the policy was not followed as there was fall out on documentation. 4. During a review of Patient 17’s H&P, dated April 6, 2026, the H&P indicated, Patient 17 was admitted to the facility on April 6, 2026, with the diagnoses of atrial fibrillation (a condition with irregular and fast heartbeats), seizure disorder (a neurological condition known as epilepsy), DM and HTN. During a concurrent interview and record review on April 15, 2026, at 8:45 AM, with the MSD, Patient 17’s EHR for “restraint”, dated April 10, 2026, through April 11, 2026, was reviewed. The “restraint” indicated, Patient 17 was started with “soft limb restraints” (a type of restraint used) on April 10, 2026, at 7:00 AM, and was continued until April 11, 2026, at 5:00 AM. The MSD verified there was no documented evidence to indicate the discontinuation of restraints and patient’s response for restrain discontinuation. The MSD stated, nurses should have documented. During a concurrent interview and record review on April 17, 2026, at 10:40 AM, with the CNO, the facility’s P&P titled “Restraints, use of”, dated August 28, 2020, was reviewed. The P&P indicated, “ ...General provisions ...4. Early release-Restraints will be discontinued by the RN or physician when the behavior or condition which was the basis for the order is resolved, regardless of the duration of the original order. 2. Order: b. If clinically indicated a registered nurse may apply a restraint and then obtain a telephone order from the physician within one hour of application. i. The registered nurse will document in EHR initiation and discontinuation time of restraints”. The CNO stated, that the P&P was not followed as there was no discontinuation documentation for restrains. 5. During a review of Patient 18’s H&P, dated December 20, 2025, the H&P indicated Patient 18 was admitted to the facility on December 20, 2025, with the diagnosis of abdominal pain. During a review of Patient 18’s EHR “Pulmonary Progress Notes” (EHR PPN), dated December 25, 2025, the EHR PPN indicated, Patient 18 had acute hypoxic respiratory failure (a condition in which the lungs do not have enough oxygen), secondary to atelectasis (a condition in which the lung collapse) or pneumonia ( a condition in which fluid is collected in lungs and impaired gas exchange happens ) and Patient 18 currently on 4 Liter (L -a unit of measurement) of oxygen (O2). During a concurrent interview and record review on April 15, 2026, at 9:00 AM, with the MSD, Patient 18’s EHR VS, dated April 20, 2026, through April 26, 2026, was reviewed. The EHR VS indicated, Patient 18’s oxygen delivery method was as follows: On December 25,2025, at 12:00 AM, Patient 18’s oxygen method was on “room air” (without oxygen support) On December 25,2025, at 4 :00 AM, Patient 18 was “nasal canula” (a plastic tube by which oxygen was delivered to the patient) with 5 L of O2. On December 25,2025, at 8 :00 AM, Patient 18 was on “nasal canula” with 5 L of O2. On December 25,2025, at 12:00 PM, Patient 18 on “room air” On December 25,2025, at 4:00 PM, Patient 18 on “nasal canula” at 2 L of O2. On December 25,2025, at 7:00 PM, Patient 18 on “nasal canula” but no oxygen measurement documented On December 25,2025, at 9:25PM, Patient 18 on “room air” On December 26,2025, at 12:00 AM, Patient 18 on “room air” On December 26,2025, at 4:00 AM, Patient 18 on “nasal canula” at 5 L of O2. On December 26,2025, at 8:00 AM, Patient 18 on “nasal canula” at 2 L of O2. On December 26,2025, at 12:00 PM, Patient 18 on “room air” MSD verified the oxygen method and confirmed that there was no documented evidence of O2 weaning (reducing) or patient’s response to weaning. MSD stated, that she is not sure about what the nurses were doing with the oxygen therapy as there was no clear documentation for weaning and placing the patient on room air. MSD further stated, the documentation was confusing and had no supporting documentation for the different methods of O2 weaning. During a concurrent interview and record review on April 16, 2026, at 8:30 AM, with RN 7, Patient 18’s “EHR VS”, dated December 20, 2025, through December 26, 2025, was reviewed. The EHR VS indicated, Patient 18 had multiple O2 dekivery methods with hours. RN 7 stated, she was the primary nurse for Patient 18 for couple of days and she said by checking her documentation on the chart, RN 7 was unable to explain the reason for Patient 18’s weaning of O2 and verified that there was no documented evidence to indicate reason. During a concurrent interview and record review on April 17, 2026, at 10:45 AM, with the CNO, the facility’s P&P titled “Oxygen protocol”, dated January 28, 2022, was reviewed. The P&P indicated, “ ... Protocol:1. Oxygen saturation lesser than 92 percentage on room air or current level of oxygen being delivered to the patient.2. Initiate oxygen therapy or increase current oxygen delivery as follows: a. Nasal cannula: 1- 6 liters per minute ....4. Is the patient saturation greater than 92 percent a. If yes, continue oxygen therapy at present level ....6. For patients with oxygen above 98 percentage fractions of inspired oxygen (FIO2- concentration of oxygen a person inhales) Device or liter per minute gradually.” The CNO stated, the policy was not followed. 51828 6. During a review of Patient 27’s “Admission Record” (contains demographic and medical information), undated, the “Admission Record” indicated Patient 27 was admitted to the facility on January 18, 2026 to the Intensive Care Unit (ICU-specialty department with critically ill patient) on Mechanical Ventilator (a life-support machine that assists or replaces breathing by pushing oxygen-enriched air into the lungs), with diagnoses that included pontine hemorrhage (a severe, often fatal, bleed within the brainstem’s pons, typically triggered by chronic, uncontrolled high blood pressure or vascular malformations), and intracranial hemorrhage (a life-threatening medical emergency involving bleeding inside the skull, acting as a stroke or resulting from trauma) During an interview on April 16, 2026, at 1:05 PM, in the facility’s conference room, with RN 4. RN 4 acknowledged intubated (a plastic tube (endotracheal tube) has been inserted through a patient’s mouth or nose into the trachea (windpipe) to keep the airway open and deliver oxygen, typically using a ventilator to breathe for them) patients in the ICU requires two-to-three-person assist whenever moving or repositioning patients to secure airway. During a continuous concurrent interview and record review on April 16, 2026, at 3:50 PM, with the Manager of Intensive Care (MOI), Patient 27’s “Nursing Progress Note,” dated January 23, 2026, was reviewed. The “Nursing Progress Note” on January 23, 2026, at 2:20 AM indicated “Unplanned extubation (the medical procedure of removing an endotracheal tube (breathing tube) from a patient’s airway, marking the end of mechanical ventilation) occurred during bath, RT [Respiratory Therapist] immediately available, physician notified, RT removed ETT to facilitate ventilation. Physician to bedside, pt [patient] intubated.” During facility’s internal investigation the DQ stated, RN 8 disclosed she attempted to reposition Patient 27 alone. The MOI validated RN 8 was attempting to reposition Patient 27 alone and acknowledged RN 8 failed to use the two-to-three-person method when repositioning Patient 27, to ensure patient’s airway remained secured. RN 8 was unable to interview as RN 8 was placed on administrative leave. During an interview and record review on April 17, 2026, at 9:50 AM, in the Chief Nursing Officer (CNO)’s office, with the CNO and the Director of Quality (DQ). Patient 27’s admission record, dated January 18, 2026, was reviewed. The “admission record” indicated, Patient 27 weighed123kg (kilogram - the standard unit for measuring body weight, dosage calculations, and nutritional assessment.) The CNO and DQ verified Patient 27’s weight to be 123 kg. A continuous interview and record review April 17, 2026, at 9:52 AM, with the CNO and DQ, the facility’s policy and procedure (P&P) titled, “Intensive Care Unit (ICU) Standards of Practice”, dated August 2023, was reviewed. The policy indicated “Patient weighs > [greater than] 91kg (200Ib): use an FRD [Friction-Reducing Device] (e.g., slide board or slide sheet) and at least three team members or more.” The CNO, and DQ acknowledged the policy was not followed by RN8 during repositioning of Patient 27 and should have been. 7. During a review of Patient 31’s initial “Admission Record,” dated January 29, 2026, the “Admission Record” indicated Patient 31 delivered a male baby via spontaneous vaginal delivery on January 30, 2026. Patient 31 experienced a uterine inversion (a rare, life-threatening obstetric emergency where the uterus turns inside out, partially or completely, usually during the third stage of labor) and hemorrhage (severe, rapid blood loss, either internal (inside the body) or external (through a wound). A review of Patient 31’s “Operative Report,” dated January 30, 2026, indicated, Patient 31 “was taken to the operating suit for exploratory laparotomy (a surgical procedure that uses one large incision in the abdominal wall to directly examine the organs) with repositioning and suspension of the uterus and placement of Bakri tamponade balloon (a silicone, catheter-based device designed for the temporary management of severe postpartum hemorrhage (PPH- heavy dangerous bleeding after childbirth) caused by uterine atony, often utilized when uterotonic [medications that stimulate uterine muscle contractions, used primarily to induce labor, manage miscarriage, and prevent or treat postpartum hemorrhage] drugs fail). During a concurrent interview and record review on April 16, 2026, at 8:54 AM, in the facility’s conference room, with Registered Nurse (RN6), RN6 acknowledged witnessing removal of some vaginal packing from Patient 31’s vaginal canal by Obstetrician-Gynecologist (OB-GYN) doctor (a physician specializing in female reproductive health, pregnancy, and childbirth) during Patient 31’s hospitalization in the ICU on January 31, 2026. RN 6 further stated, she did not receive any formal training of what to look for or how to ensure vaginal packing had been completely removed when caring for Patient 31 in the ICU. During a review of Patient’s 31’s “Discharge Summary,” dated February 2, 2026, indicated “Patient 31 was discharged home in stable condition following removal of the Bakri ballon” During a review of Patient 31’s second “Admission Record,” (contains demographic and medical information), undated, the “Admission Record” indicated Patient 31 returned to the facility on February 3, 2026, to the Emergency Room for evaluation of retained vaginal foreign body (a piece of medical equipment such as sponge, is accidentally left inside a patient’s body after surgery or a procedure) following delivery of a baby through vaginal delivery on January 30, 2026. Patient 31 was admitted with diagnosis that included vaginal foreign body. A review of Patient 31’s “ED Physician Note,” dated February 3, 2026, indicated “Packing was partially removed until resistance felt. Attempt was stopped. Contacted OBGYN who is familiar with patient ... OB-GYN able to remove the remainder of the packing and evaluated vaginal vault with bimanual (requiring or using both hands simultaneously) exam.” A continuous concurrent interview and record review on April 17, 2026, at 8:01 AM, with the OB-GYN (doctor who removed the Bakri ballon), Patient 31’s “Physician Note,” dated January 31, 2026, was reviewed. The “Physician Note” indicated, “Deflated Bakri ballon by 300 cc [a unit of volume equal to 1 milliliter or 1 ml] at 7:30 PM and observed for increased bleeding which did not happen. Removed Bakri ballon at 9:00 PM; patient stable to go to Postpartum Unit” (a specialized hospital department where parents and newborns stay after delivery, typically for 1-4 days.) The OB-GYN stated it was uncommon to have vaginal packing with a Bakri ballon, and further stated she failed to properly inspect the vaginal canal after removal of the Bakri ballon. During a concurrent interview and record review on April 17, 2026, at 9:50 AM, in the CNO’s office, with the CNO and the DQ, the facility’s P&P titled, “Prevention of Retained Surgical Items,” dated March 21, 2021, was reviewed. The policy indicated “Section M: part b (i) Intra-operative orifice packing is usually used in the setting of hemorrhage. The most common site is the vagina. The packing is removed in the postoperative period when the patient has left the OR. Post-operative instruction involving multiple stakeholders is required to ensure the safe management and timely removal of the packing” The DON, and DQ acknowledged the policy was not followed by the care team during removal of Patient 31’s vaginal packing and should have been.”

“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: 51269 Based on interview and record review, the facility failed to ensure that medications were administered in accordance with the physician orders and accepted standards of practice for two of 37 sampled patients (Patient 1 and 6) when: 1. For Patient 1, the nursing staff did not provide appropriate monitoring before or after Ativan (lorazepam- a medication that calms the brain and body and can make a person feel drowsy (sleepy or having trouble staying awake), relaxed, and can slow down the breathing) was given. This failure had the potential to contribute to adverse outcomes, including unrecognized respiratory depression, clinical deterioration, and may have contributed to Patient 1’s death. 2. For Patient 6, intravenous (IV- given through a tube directly into the blood stream) hydromorphone (dilaudid- medication used to treat pain) was administered for the wrong indication (reason to administer a medication). This failure placed Patient 6 at risk for ineffective medication management and had the potential to result in Patient 6’s safety from preventable medication errors with discrepancy which could negatively affect patients’ health, safety, prolonged hospitalization, and lead to actual harm or death. Findings: 1. During a review of Patient 1’s “History and Physical” (H&P- a document containing demographic information), dated January 23, 2026, at 12:40 PM, the H&P indicated, Patient 1 was admitted to the facility for weakness, hyperkalemia (high potassium (electrolyte or mineral in body that helps the heart, muscles and nerves work properly) levels in the blood that can cause abnormal heart rhythms), and new diagnosis of ascites (fluid buildup in the abdomen). Patient 1 had history of diabetes (high blood sugar), hypertension (high blood pressure), and end stage renal disease (ESRD- kidneys are no longer removing the waste and extra fluid from the body and can cause electrolyte imbalance). A review of Patient 1’s “Orders,” with the start date January 23, 2026, to January 26, 2026, indicated, “LORazepam (Ativan) Inj [injection] ...1 mg [milligram-unit dosing medication] IV push ...q [every] 2hr [hours] ... PRN [as needed] agitation ...” During an interview on April 15, 2026, at 3:18 PM, with the MRI Technician (MRIT 1), MRIT 1 stated, if a patient goes to MRI without a nurse and “off tele [off telemetry- no heart monitoring],” no one has the responsibility of monitoring or assessing the sedation level or vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)), of the patient because the MRIT’s are focused on doing the scan. MRIT 1 stated, when she went to pick up Patient 1 for the MRI scan she told the Registered Nurse (RN 1) “are you sure the patient can come down because it doesn’t [does not] look like the patient is doing too well” and added Patient 1 was curled up next to the side rail and the RN 1 proceeded to administer the Ativan. During a telephone interview on April 16, 2026, at 8:20 AM, with RN 1, with the presence of the Director of Telemetry (DOT), and Manager of Telemetry (MOT), RN 1 stated, before and after the administration of Ativan, RN should check mentation, alertness, behavior, and VS of a patient. RN 1 stated, for Patient 1, Ativan was given right before patient left to MRI for agitation and he could not assess the patient after administration since the patient left for the MRI scan with the MRIT and transporter. RN 1 stated VS were performed by dialysis (a treatment that cleans your blood and removes waste and extra fluids when the kidneys are not working) RN when the dialysis was done and was unable to recall a neurological assessment (NA- an evaluation to determine mental status, motor strength, and reflexes) being documented. During an interview on April 16, 2026, at 9:20 AM, with Radiologist Assistant (RA 1), RA 1 stated that when she went to pick up Patient 1 for the MRI scan, RA 1 and MRIT 1 asked RN 1 if Patient 1 would be able to tolerate the scan because “the patient appeared lethargic [a state of severe fatigue, lack of energy], just lying there on his side”. RA 1 stated the RN proceeded to give the Ativan. During an interview on April 17, 2026, at 9:03 AM, with RN 2, RN 2 stated, any time a patient is going to receive Ativan, she checks the VS right before administration and a neurological assessment to obtain baseline. RN 2 added, if it is the patient’s first time receiving the medication during the stay, she would monitor closely for at least 15 minutes after administering the medication for adverse effects [AE- unwanted/ unintended occurrence after medication] like changes to neurologic assessment, lethargy, or changes to VS. During a concurrent interview and record review on April 17, at 9:52 AM, with the DOT and MOT, Patient 1’s NA, dated January 26, 2026, “MAR” (medication administration record- document containing medications administered to the patients), dated January 23, 2026, to January 26, 2026, “Events,” dated January 26, 2026, and “Electronic Health Record Vital Signs” (EHR VS), dated January 26, 2026, were reviewed. The MAR indicated, “Ativan ...1 mg IV push ...administered ...1/26/2026 [January 26, 2026] 22:24 [10:24 PM] ... reason for medication ... agitation ...” (first administration throughout stay) The NA indicated, “awake, alert” and was performed on January 26, 2026, at 8:52 PM by the dialysis (a procedure done to clean the blood from waste and extra fluid when the kidney’s no longer work) RN (1 hour and 32 minutes prior to the administration of Ativan). The EHR VS indicated that the last set of VS were performed at 8:52 PM, as follows: HR: 75 (normal 60 to 100 beats per minute) BP: 132/75 (normal BP: 120/80: the top number measures the pressure in the arteries (blood vessels that carry blood away from the heart to the rest of the body) when the heart beats. The bottom number indicates the pressure in the arteries between heartbeats.) (1 hour and 32 minutes prior to administration of Ativan). The “Events” indicated, “pt [Patient] to MRI ...01/26/2026 [January 26, 2026] 22:27 [10:27 PM] ...” (3 minutes after Ativan was given) The DOT and MOT verified and confirmed that RN 1 did not do baseline VS, or a baseline neurological assessment, and did not watch for changes in condition after the medication administration as Patient 1 left the unit three minutes after the administration of Ativan without a nurse. A review of Patient 1’s “Discharge Summary,” dated January 26, 2026, at 11:50 PM indicated, “ ...at night MRI [Magnetic Resonance Imaging-medical imaging that uses magnets, radio waves and computers to produce a detailed image of soft tissue, organs, and bones used to diagnose conditions] brain and C spine [cervical spine-the neck region that support the skull] were done and showed epidural abscess [a rare, serious, and potential fatal infection near the spine]. Pt became altered in MRI ...and expired [died] ...” During a concurrent interview and record review on April 17, 2026, at 11:08 AM, with the Director of Quality (DQ) and Chief Nursing Officer (CNO), the facility’s “[Name] IV Medication Administration” (facility protocol and education for the nursing staff regarding administration of IV medication), undated, was reviewed. The “[Name] IV Medication Administration” indicated, “take steps to avoid interruptions and distractions when getting medications ready ...8. Obtain baseline vital signs ...review medication reference information pertinent to the medication’s action, purpose, onset of action [the time required for a drug to begin procedure its effect after administration] and peak action [ the time for a medication to reach its maximum effect], normal dose and common side effects and implications ...watch the patient for adverse and allergic reactions to the medication ...” The CNO stated, the expectation is that nurses watch a patient for about 15 minutes after the administration of IV Ativan if it is the first time the patient is receiving the medication for any reaction and that the nurses did not follow the facility’s protocol and should have. A review of the facility’s policy and procedure (P&P) titled, “Medication Administration, Barcode Medication Administration (BCMA) & [and] Emar [electronic medical administration record] use,” dated October 2, 2025, indicated, “ ... IV) Appropriate precautions and/or instructions for administration will be included as appropriate for each drug ...” 2. During a review of Patient 6’s H&P, dated March 31, 2026, the H&P indicated Patient 6 was admitted to the facility for pain in the right lower abdomen with nausea and vomiting. Patient 6 had a history of asthma (a long-term breathing condition where the tubes that carry air in and out of your lungs become narrowed, swollen and filled with mucus, making it harder to breathe.) During a review of Patient 6’s “HYDROmorphone order”, dated April 9, 2026, to May 9, 2026, indicated “HYDROmorphone (Dilaudid) 1 mg ... IV Push ...q 3 h PRN ... reason ...breakthrough pain ...” During a review of Patient 6’s “Acetaminophen-HYDROcodone [Norco-a combination of medication to treat pain] order” (Norco order), dated April 9, 2026, to May 9, 2026, the Norco order indicated, “Acetaminophen-HYDROcodone 5-325 MG [hydrocodone 5 mg and acetaminophen 325 mg] oral [by mouth] tablet ...1 [one tablet] ... q4h PRN ...reason ... pain 4-6 [A tool to assess the severity of pain, typically 0-10 scale, 0-is no pain, 10 is the worst pain] ...” During a review of Patient 6’s Norco order, dated March 31, 2026, to April 30, 2026, the Norco order indicated “Acetaminophen-HYDROcodone 5-325 MG oral tablet ...2 [two tablets] ...q6h PRN ...reason ... pain 7-10 ...” During an interview on April 17, 2026, at 9:10 AM, with RN 2, RN 2 stated a “breakthrough” pain medication is used when a patient’s pain is not controlled after the administration of other pain medications. RN 2 stated it is important to try to give the other pain medications before the “breakthrough medications” to have effective pain management. During a concurrent interview and record review on April 17, 2026, at 10:22 AM, with the DOT and MOT, Patient 6’s “MAR,” dated April 13, 2026, to April 15, 2026, and “Nursing Notes” dated April 11, 2026, to April 13, 2026, were reviewed. The MAR indicated Dilaudid was administered as follows: On April 13, 2026, at 4:44 AM: “Pain intensity: 7” On April 13, 2026, at 10:31 AM: “Pain intensity: 8” On April 13, 2026, at 3:41 PM: “Pain intensity: 7” On April 13, 2026, at 7:44 PM: “Pain intensity: 6” On April 13, 2026, at 11:35 PM: “Pain intensity: 6” The MAR did not indicate that from April 13, 2026, to April 15, 2026, Norco was administered to Patient 6 by the nursing staff. The “Nursing Notes” from April 11, 2026, to April 13, 2026, did not indicate rationale for the administration of Dilaudid. The DOT and MOT verified and stated that the nursing staff did not administer the medication for the correct indication and should have administered the Norco first and if that did not control the pain then changed to the Dilaudid. During a concurrent interview and record review on April 17, 2026, 11:15 AM, with the DQ and the CNO, the facility’s P&P titled, “Medication Administration, Barcode Medication Administration (BCMA) & Emar use,” dated October 2, 2025, the P&P indicated, “ ...Prior to administration ....1) assess patient for appropriateness of the medication to be given ...3) ensure that the correct medication to be given has been selected based on the medication order ....” The CNO stated that the policy was not followed and should have been. The CNO added, it was important for the nursing staff to follow the orders to be working within their scope of practice.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 51269 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of care for a universe of 35 sampled patients, when the GB did not ensure an effective quality improvement measures implemented for infection prevention and control practices including the storage of Endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach), appropriate usage of protective personal equipment (PPE-equipment worn to minimize exposure to hazard such as mask, gowns, eye protection) monitoring of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist needs to run the cardiopulmonary (C/P- heart-lung) machine), and cleanliness of hand held brushes after each case in the sterile processing department. (Refer to A-0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in preventing the transmission of infection among patients from infection control practices. The inappropriate oversight could cause spread of microorganisms, exposure to infectious agents, and compromise vulnerable populations within the facility.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51269 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 35 sampled patients, when, 1. QAPI failed to monitor, collect and analyze quality data when Endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach) were not stored in accordance with the manufacture’s instruction for use, appropriate PPE (protective personal equipment such as mask, gowns, eye protection) was not donned (put on) by staff. Additionally, there was inadequate oversight of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist needs to run the cardiopulmonary (C/P- heart-lung) machine), hand held brushes not being cleaned after each case in the sterile processing department , and a plastic toy bird was found hanging from the C/P machines. (Refer to A-0273) 2. The facility failed to identify the collected data to utilize the opportunities for improvement to measure its success, and track performance to ensure that improvements are sustained when oversight within the infection surveillance program did not ensure the Endoscopes were not stored in accordance with the manufacture’s instruction for use. (Refer to A-0283) The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care and infection control services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) which could interfere with the patients’ medical care and may jeopardize the health and safety of other patients.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 39723 Based on observation, interview, and record review, the facility failed to ensure the Infection Prevention and Control and Antibiotic Stewardship Programs were met when, 1. The Infection Prevention and Control Program (IPCP) failed to ensure that endoscopes (a reusable instrument used to inspect and treat the interior portions of the body) were stored safely and according to the manufacturer’s instruction for use (IFU) for 14 of 35 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) (Refer to A0750). 2. The IPCP failed to ensure appropriate gloves were worn when manually cleaning endoscopes for one of two sampled gastroenterology (GI, the study, diagnosis, and treatment of disorders that deal with the digestive system) technicians (GI Tech 1) (Refer to A0750). 3. The IPCP failed to ensure decontamination (the process of removing or neutralizing germs) sinks were disinfected after manual cleaning (a process used to remove germs from soiled instruments) flexible endoscope for one of three decontamination sinks (Sink 3) (Refer to A0750). 4. The IPCP failed to ensure bronchoscopes (a flexible tube with a camera on the end used to inspect and treat the lungs and airways) were manually cleaned prior to performing high-level disinfection (a process used to kill almost all germs) for one of two sampled surgical technicians (Surg Tech 1) (Refer to A0750). 5. The IPCP failed to ensure multiple reusable surgical instruments (a device intended for repeated use on different patients) were not clean or were damaged and were available for patient use for one of one sampled sterile processing departments (SPD, a dedicated area within a healthcare facility that cleans, prepares, processes, and stores medical devices) (Refer to A0749). 6. The IPCP failed to ensure an effective separation between the decontamination workroom and the clean workroom for one of one sampled sterile processing departments (Refer to A0749). 7. The IPCP failed to ensure handheld reusable cleaning brushes used to scrub surgical instruments were cleaned between cases in accordance with the manufacturer’s instruction for use (MIFU) for one of two sampled sterile processing technicians (SPD Tech 3) (Refer to A0749). 8. The IPCP failed to ensure appropriate eye-protection equipment was worn when performing manual cleaning (a process used to remove germs from soiled instruments) of endocavity probes (medical device that contacts mucous membranes or non-intact skin) in accordance with the MIFU for one of three sampled ultrasound technicians (US Tech 1) (Refer to A0749). 9. The Infection Prevention and Control Leadership (IPCL) failed to ensure harmful chemicals were not stored with medications and medical supplies for one of two sampled cardiopulmonary (heart and lung) perfusion (the flow of blood to tissues and organs) carts (CP Cart 1) (Refer to A0772). 10. The IPCL failed to ensure safe injection (given into the blood stream) practices were followed, and single-dose medication bottles (bottles containing medication that are intended for a single patient) were observed stored for multidose (a container of liquid medication, intended for injection or infusion, that contains more than one dose) injections for two of two sampled cardiopulmonary perfusion carts (CP Cart 1 and CP Cart 2) (Refer to A0772). 11. The IPCL failed to ensure equipment was properly cleaned and disinfected after each patient procedure for one of two sampled cardiopulmonary machines (CP Machine 1) (Refer to A0772). 12. The IPCL failed to ensure appropriate attire was worn in restricted areas (area where access and traffic are limited to authorized personnel and where special attire is required) and facial hairs was not exposed in the operating room for one of two sampled nurse managers (ORNM) (Refer to A0772). The cumulative effects of these systemic problems resulted in the hospital’s inability to provide an effective hospital wide infection control program and to provide patient care in a safe and effective manner to meet the Condition of Participation Infection Prevention and Control and Antibiotic Stewardship Programs.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51269 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to identify and ensure a safe environment and provide quality of care for 14 of 35 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14), when the GB did not provide oversight on: the Quality Improvement Committee (QIC also known as QAPI) with the tracking system for the storage of Endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach), usage of protective personal equipment (PPE-equipment worn to minimize exposure to hazard such as mask, gowns, eye protection) monitoring of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist needs to run the cardiopulmonary (C/P- heart-lung) machine), and cleanliness of hand held brushes. These failures had resulted in the facility’s failure to identify the problem prone areas and deliver care with the GB oversight and to provide a safe patient care environment causing risk for acquiring hospital infection which could jeopardize the health and safety of the patients and prolonged the hospitalization. Findings: A review of the facility document titled, “[Facility name] Hospital Community Board and Medical Staff Quality Committee Ad Hoc Meeting” dated September 16, 2025, was reviewed. The “[Facility name] Hospital Community Board and Medical Staff Quality Committee Ad Hoc Meeting” indicated, “Quality, Patient safety, Risk Management and Patient experience reports” was not monitoring the Endoscopes storage, appropriate usage of PPE being donned by staff, monitoring of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist needs to run the cardiopulmonary (C/P- heart-lung) machine), and cleanliness of hand held brushes. During the Relicensing Survey (RLS) conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the ICPM and the Director of Perioperative (the care provided to patients before, during, and after a surgical procedure) Services (DOR) on November 17, 2025, at 11:15 AM, in the endoscope storage room. 14 endoscopes were observed in the cabinet and were labeled “Clean.” One endoscope had an expiration date of November 14, 2025; Three endoscopes were not hanging freely; One incontinent absorbent pad (a product used to absorb and hold moisture away from the skin) was observed covering the cabinet’s drip tray (a cleanable tray used to collect access moisture) and the endoscope’s distal ends (tip) were in contact with the incontinence absorbent pad. RLS lead to a complaint validation. A concurrent record review and interview were conducted of patients who underwent endoscopic procedures with potentially contaminated endoscopes from November 4, 2025, to November 17, 2025, with the Director of Medical Surgical Services (DOMS) on November 21, 2025, at 9:30 AM, in the conference room. The DOMS confirmed that the following records were reviewed on November 19, 2025, at 3:50 PM. The findings were as follows: -Patient 1’s clinical record indicated, Patient 1 was admitted to the hospital on November 14, 2025, and underwent an esophagogastroduodenoscopy procedure (EGD, an endoscopy procedure) on November 17, 2025. -Patient 2’s clinical record indicated, Patient 2 was admitted to the hospital on November 10, 2025, and underwent an EGD procedure on November 11, 2025. - Patient 3’s clinical record indicated, Patient 3 was admitted to the hospital on October 26, 2025, and underwent an EGD procedure on November 11, 2025. -Patient 4’s clinical record indicated, Patient 4 was admitted to the hospital on November 10, 2025, and underwent an EGD procedure on November 12, 2025. -Patient 5’s clinical record indicated, Patient 5 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 13, 2025. -Patient 6’s clinical record indicated, Patient 6 was admitted to the hospital on November 12, 2025, and underwent an EGD procedure on November 13, 2025. -Patient 7’s clinical record indicated, Patient 7 was admitted to the hospital on November 4, 2025, and underwent an EGD procedure on November 7, 2025. -Patient 8’s clinical record indicated, Patient 8 was admitted to the hospital on November 3, 2025, and underwent an EGD procedure on November 4, 2025. -Patient 9’s clinical record indicated, Patient 9 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 12, 2025. -Patient 10’s clinical record indicated, Patient 10 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 17, 2025. -Patient 11’s clinical record indicated, Patient 11 was admitted to the hospital on November 6, 2025, and underwent an EGD procedure on November 7, 2025. -Patient 12’s clinical record indicated, Patient 12 was admitted to the hospital on November 6, 2025, and underwent an EGD procedure on November 10, 2025. -Patient 13’s clinical record indicated, Patient 13 was admitted to the hospital on October 24, 2025, and underwent an EGD procedure on November 5, 2025. - Patient 14’s clinical record indicated, Patient 14 was admitted to the hospital on November 5, 2025, and underwent an EGD procedure on November 11, 2025. During an interview on November 21, 2025, at 2:21 PM, in the conference room, with four members of the GB: Director of Quality (DOQ), Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Quality Manager (QM), the DOQ stated, the Governing body has a meeting every other month with Quality Assurance and Performance Improvement (QAPI-A program used to continuously maintain and improve the quality of care, safety of patients) to discuss problems such as quality of care for patients , environment of care, and patient safety matters. The DOQ stated that the quality department oversees infection control issues. The DOQ added that the governing body is responsible for the oversight of QAPI. During an interview on November 21, 2025, at 2:35 PM, in the conference room, with four members of the GB: DOQ, COO, CNO, and QM, the survey team brought up some issues identified during survey including Endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach) were not stored in accordance with the manufacture’s instruction for use, appropriate Personal protective equipment (PPE-equipment worn to minimize exposure to hazard such as mask, gowns, eye protection) was not donned by staff, failed oversight of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist, needs to run the cardiopulmonary (C/P- heart-lung) machine), hand held brushes used to scrub surgical instruments not being cleaned after each case in the sterile processing department, and a plastic toy bird was found hanging from the C/P machine. During an interview on November 21, 2025, at 2:37 PM, with the GB members, The DOQ stated in relation to the PPE, when the Infection prevention (ICPM) does rounds they monitor PPE. The DOQ stated that any time the Infection Prevention Manager (ICPM) observes someone who is not wearing appropriate PPE, the director of the department will get notified and the staff will get real time education. The DOQ stated that QAPI has not identified the use of appropriate PPE as an area of concern hence not brought it up to GB. During an interview on November 21, 2025, at 2:40 PM, with the GB members, the GB was not made aware that perioperative services were collecting observations and data regarding the storage of endoscopes, however the data was not being tracked or analyzed. The COO stated it was not acceptable to have data collected but not analyzing it to help with the oversight of the operation. The COO added that the gap in multiple issues identified during the survey were that the infection preventionist did not inform the director of the problems occurring and hence the concerning issues were not brought up during QAPI nor GB. A review of the facility’s policy and procedure (P&P) titled “Quality Assurance and Performance Improvement Plan - FY [Fiscal year (July 2025- June 2026)]” dated 2026, the P&P indicated “ ...The governing body: has the overall responsibility for the safety, quality and performance improvement activities within the organization ...” A review of the “Bylaws of the [name of board] Board of community advisors” dated October 1, 2025, indicated, “Quality, Safety, and Patient Experience: The board of community advisors duties and responsibilities with respect to quality, safety, and patient experience at each market hospital Shall include (a) assuring the health care services provided are of high quality, safe and effective, efficient, and consistent with community standards; (b) approving ongoing quality assessment, performance improvement, patient safety, and utilization management, activities; (c) assuring that quality and patient safety issues are addressed and resolved timely and appropriately; (d) Assuring that quality assessment, Performance improvement, patient safety, and Utilization management activities are consistent with the standards, policies and procedures established by the Board of Community Advisors ... ...(g) communicating quality and safety concerns and reporting significant safety events, identified safety metrics, and potential performance measures to address such events with hospital leadership ....(i) holding hospital leadership accountable for maintaining accreditation .... (L) Participates in the measurement, assessment and improvement of clinical and non-clinical processes affecting patient care and (2) takes a leadership role when clinical processes are the primary responsibility of physicians ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51269 Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI) program for a universe of 35 sampled patients, to monitor, collect and analyze quality data regarding some infection control issues identified such as Endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach) were not stored in accordance with the manufacture’s instruction for use, appropriate PPE (protective personal equipment such as mask, gowns, eye protection) was not donned (put on) by staff. Additionally, there was inadequate oversight of the perfusionist cart (a specialized cart that hold supplies, equipment and emergency items that the perfusionist needs to run the cardiopulmonary (C/P- heart-lung) machine), hand held brushes not being cleaned after each case, and a plastic toy bird was found hanging from the C/P machines. These failures resulted in the hospital’s inability to identify the problems prone (likely to cause errors) areas and created changes to improve patients’ health outcomes and had the potential to cause preventable adverse patient outcomes that could negatively affect patients’ health and safety. Findings: During an interview on November 21, 2025, 8:45 AM, in the conference room with the Infection Prevention Manager (ICPM), the ICPM stated rounds in high level disinfection areas (Operating room, sterile processing department, and gastrointestinal lab [ GI lab- area in hospital where doctors perform test and procedures to examine the esophagus, stomach, intestines, liver, pancreas and colon]) are being conducted and documented on the “High Level Disinfection” sheet. The ICPM added that perioperative services also keep a log of the endoscopes signed off by staff , however it is not an item that gets tracked by infection control. During an interview on November 21, 2025, at 2:21 PM, in the conference room with the QAPI team that consists of the Director of Quality (DOQ), Chief Nurse Officer (CNO), Chief Operating Officer (COO), and Quality Manager (QM). The DOQ stated the process with issues identified in infection control is as follows: the infection preventionist will identify the issue, escalate it to the director of the department where the issue was found, and, if needed, escalate it further to QAPI. A continued interview on November 21, 2025, at 2:22 PM, with the QAPI team, the QM stated that the focus for infection control was on hospital acquired infections (HAI’s- an infection during the hospital stays). The QM added, infection control concerns are communicated with QAPI by an executive management group where they communicate via email thread. The COO stated they also perform daily safety huddles and will then follow up on issues identified. During a concurrent interview and record review on November 21, 2025, at 2:25 PM, with the QAPI team the “Quality Improvement Committee” dated September 25, 2025, and October 30, 2025, was reviewed. The “Quality Improvement Committee” document indicated the meeting minutes and the quality measures discussed with data collected from department directors. The survey team brought up some issues identified during survey including Endoscopes were not stored in accordance with the manufacture’s instruction for use, Appropriate PPE was not donned by staff, failed oversight of the perfusionist cart, hand held brushes used to scrub surgical instruments were not being cleaned after each case in the sterile processing department , and a plastic toy bird was found hanging from the C/P machines. The QM was unable to provide quality measures regarding action plans, trends, interventions, and evaluations regarding the survey team’s findings. The QM stated that the issues had not been identified or escalated to QAPI. The COO stated, they had lack of oversight on multiple levels including infection preventionist not identifying the issues and not informing the directors, and hence not being escalated to QAPI. During a review of the facility’s policy and procedure (P&P) titled “Quality Assurance and Performance Improvement Plan - FY [Fiscal year July 2025- June 2026] 2026” dated 2026, the P&P indicated, “The Quality/ Patient Safety Improvement Committee (QIC) ...this is done through the following: ...1. identifying and prioritizing core organizational process/ outcome indicators as well as appropriate benchmarks, reviewing indicator data to assess performance, determining the effectiveness of improvement/problem-solving activities and coordinating follow up and communication to ensure the effectiveness of these efforts ... the Quality management, patient safety, risk management, and infection prevention and control departments ... 4. Provide data abstraction, collection, management, analysis, and consultative services to support performance improvement activities ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 51269 Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 35 patients, when the facility failed to identify the collected data related to facility issues and work on the opportunities for improvement. Specifically, the endoscopes (a long, thin, flexible tube with a light and camera on the end that goes through the mouth to see the stomach) storage was not identified as a focus area by QAPI, and the meeting minutes did not include an action plan to measure success, track performance and to ensure that improvements are sustained. This failure resulted in the facility’s inability to identify the problem prone areas and set priorities to improve infection control and ensure a safe environment for their patients and the improvements are sustained. Findings: During an interview on November 21, 2025, at 8:41 AM, with the Infection Prevention Manager (ICPM), the ICPM stated that on the outside of the endoscope cabinet there is a log with staff daily checks. The ICPM stated the log was not tracked by infection control, however it was accessible during environmental rounds. During a concurrent interview and record review on November 21, 2025, at 8:50 AM, with the ICPM the “Infection Control Committee” for June 11, 2025, and September 9, 2025, was reviewed. The “Infection Control Committee” indicated, the infection prevention and control indicators did not include the endoscope storage and cleaning. The ICPM stated that the storage and cleaning of endoscopes had not been identified as an issue. During an interview on November 21, 2025, at 10:20 AM, with the Perioperative Director (DOR), the DOR stated that the log containing the processing of the scopes is not escalated to infection preventionist. The DOR stated the log is accessible during environmental rounds but is not audited by the infection preventionist. During a concurrent interview and record review on November 21, 2025, at 2:25 PM, with the QAPI team the “Quality Improvement Committee” dated September 25, 2025, and October 30, 2025, was reviewed. The “Quality Improvement Committee” indicated the meeting minutes and the quality measures discussed with data collected from the department directors. The survey team brought up some issues identified during survey including Endoscopes that were not stored in accordance with the manufacture’s instruction for use. The QM stated that the issues had not been identified or escalated to QAPI. The COO stated, they had lack of oversight on multiple levels including infection preventionist not identifying the issues and not informing the directors, and hence not being escalated to QAPI. During a review of the facility’s policy and procedure (P&P) titled “Quality Assurance and Performance Improvement Plan - FY [Fiscal year- started July 2025- June 2026] 2026” dated 2026, the P&P indicated, “The Quality/ Patient Safety Improvement Committee (QIC) ...this is done through the following: ...1. identifying and prioritizing core organizational process/ outcome indicators as well as appropriate benchmarks, reviewing indicator data to assess performance, determining the effectiveness of improvement/problem-solving activities and coordinating follow up and communication to ensure the effectiveness of these efforts ... the Quality management, patient safety, risk management, and infection prevention and control departments ... 4. Provide data abstraction, collection, management, analysis, and consultative services to support performance improvement activities ...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 39723 Based on observation, interview, and record review, the facility’s infection prevention and control program (IPCP) failed to establish and implement hospital wide policies and procedures (P&P) on methods to prevent and control infections among patients, personnel, and visitors as evidenced by, 1. Multiple reusable surgical instruments (a device intended for repeated use on different patients) were not clean or were damaged and were available for patient use for one of one sampled Sterile Processing Departments (SPD, a dedicated area within a healthcare facility that cleans, prepares, processes, and stores medical devices). 2. Ineffective separation between the decontamination (the process of removing or neutralizing germs) workroom and the clean workroom for one of one sampled sterile processing departments (SPD, a dedicated area within a healthcare facility that cleans, prepares, processes, and stores medical devices). 3. Handheld reusable cleaning brushes used to scrub surgical instruments were not cleaned between cases in accordance with the manufacturer’s instruction for use (MIFU) for one of two sampled sterile processing technicians (SPD Tech 3). 4. Appropriate eye-protection equipment was not worn when performing manual cleaning (a process used to remove germs from soiled instruments) of endocavity probes (medical device that contacts mucous membranes or non-intact skin) in accordance with the manufacturer’s instruction for use (MIFU) for one of three sampled ultrasound technicians (US Tech 1). These failures resulted in unsafe infection control and prevention practices, creating an increased risk of cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect), avoidable disease transmission, and poor health outcomes to patients, staff, and visitors. Findings: 1. An interview was conducted with the Infection Prevention Manager (ICPM) on November 21, 2025, at 9:20 AM, in the conference room. The ICPM stated the hospital followed the following nationally recognized infection prevention and control guidelines: A. Centers for Disease Control and Prevention (CDC, the national public health agency of the United States); B. Association of periOperative [the care provided to patients before, during, and after a surgical procedure] Registered Nurses (AORN, a nationally recognized infection control guideline for perioperative areas), C. Occupational Safety and Health Administration (OSHA, a large regulatory agency of the United States Department of Labor), D. ANSI/AAMI ST91: 2021 American National Standards/Association for the Advancement of Medical Instrument: Flexible and semi-rigid endoscope processing in health care facilities E. ANSI/AAMI ST79, American National Standards/Association for the Advancement of Medical Instrument: Comprehensive Guide to Steam Sterilization [the process of making reusable surgical instruments free of germs] and Sterility Assurance in Healthcare Facilities; and F. The Association for Professionals in Infection Control (APIC, a professional association for individuals working in the field of infection prevention). The ICPM stated the hospital did not have a written policy and procedures (P&P) on inspecting surgical instruments. The ICPM stated the hospital followed “AAMI” standards for inspecting instruments. During the Relicensing Survey (RLS) conducted on November 17, 2025, through November 20, 2025, a concurrent interview and inspection were conducted with SPD Tech 1, the ICPM, and the Director of Perioperative Services (DOR) on November 18, 2025, at 7:50 AM, in the SPD’s clean workroom. Two surgical tray sets were inspected. SPD Tech 1 stated the surgical tray sets contained reusable surgical instruments that had been previously reprocessed and were ready for patient use. The following were observed: -Tray Set 1 contained 75 surgical instruments, dated November 17, 2025. 21 of 75 sampled instruments were of concern upon inspection of the surgical tray set. One instrument contained fuzzy white matter; two instruments contained brown staining; four instruments contained scattered water stains; three instruments were not functioning properly; three instruments had multiple scratches; two instruments were discolored; four instruments contained nicks (imperfections); and two instruments contained etchings (an engraving on the surface of the instrument); and -Tray Set 2 contained 77 surgical instruments, dated November 17, 2025. Eight of 77 sampled instruments were of concern upon inspection of the tray set. One instrument contained water spots; two instruments contained white residue; one instrument had multiple scratches; and four instruments contained nicks. SPD Tech 1 stated the instruments that were observed with scratches and nicks should have been removed from the tray sets for repair. SPD Tech 1 stated the instruments that were observed with etchings were missed in the inspection process and should have been discarded. SPD Tech 1 stated the three instruments that were observed not to be functioning properly should have been lubricated prior to sterilization to reduce friction. SPD Tech 1 stated the white fuzzy matter was “lint” and if one reprocessed instrument in a tray set was potentially contaminated, the entire tray set would not be acceptable for patient use and the surgical tray set would have to be returned to the SPD’s decontamination workroom for reprocessing. A concurrent interview and inspection were conducted with the DOR and SPD Tech 1 on November 21, 2025, at 11:15 AM, in the SPD’s clean workroom. SPD Tech 1 confirmed the RLS finding on November 18, 2025, at 7:50 AM, related to Tray Set 1 and Tray Set 2. Tray Set 3 was inspected. SPD Tech 1 stated Tray Set 3 contained reusable surgical instruments that had been previously reprocessed and were ready for patient use. The following were observed: -Tray Set 3 contained 42 surgical instruments, dated November 20, 2025. Five of 42 sampled instruments were of concern upon inspection of Tray Set 3. One instrument contained scattered water spots; two instruments contained nicks; one instrument had multiple scratches; and one instrument contained etching. SPD Tech 1 stated scratches, nicks, and etchings can trap germs and prevent proper sterilization. SPD Tech 1 stated the instruments that were observed with etchings, scratches, and nicks should have been removed from the tray set during the inspection process. SPD Tech 1 stated Tray Set 1, Tray Set 2, and Tray Set 3 were not ready for patient use. The review of the facility’s document titled “ANSI/AAMI ST79: 2017/A2: 2020, Comprehensive guide to steam sterilization and sterility assurance in health care facilities” was conducted. The document indicated, “Amendment 2: Inspection of insulated instruments: 8.2 Inspection of instruments: Each time a medical device is processed, it should be visually inspected for cleanliness and integrity ...Upon inspection, medical devices with retained soil or residue should be subjected to repeated cleaning and decontamination processes until the device is completely clean. Damaged instruments should be removed from service ...” 2. During the RLS conducted on November 17, 2025, through November 20, 2025, an observation of the pass-through window (a system used to separate the decontamination area from the clean area) was conducted with the ICPM and the DOR on November 18, 2025, at 7:39 AM, in the SPD’s clean workroom. The pass-through window was observed between the clean workroom and the decontamination workroom. The pass-through window was observed open and the window was not in active use. An interview was conducted with the DOR on November 21, 2025, at 10:55 AM, in the SPD’s clean workroom. The DOR confirmed the RLS finding on November 18, 2025, regarding the open pass-through window. The DOR stated the pass-through window separated the clean workroom procedures from the decontamination workroom procedures. The DOR stated the facility did not follow the P&P on the pass-through system and the window should have remained closed to prevent cross-contamination. A review of the facility’s policy and procedure (P&P) titled “Decontamination of Soiled Instruments and Devices,” dated February 23, 2023, was reviewed. The P&P indicated “Manual Cleaning: ...4.9. The pass-through window must be kept closed at all times unless passing through items ... Miscellaneous: 10. Doors and windows to the decontamination area are kept closed at all times.” 3. During the RLS conducted on November 17, 2025, through November 20, 2025, an observation was conducted of the SPD’s decontamination workroom with the ICPM and the DOR on November 17, 2025, at 9:45 AM, there were three decontamination sinks (Sink 1, Sink 2, and Sink 3) observed. SPD Tech 3 was observed standing at Sink 1. A concurrent observation and interview were conducted with SPD Tech 3 on November 17, 2025, at 9:59 AM, in the SPD’s decontamination workroom. One hand-held general cleaning brush was observed on top of Sink 1. SPD Tech 3 stated cleaning brushes were not cleaned between surgical cases, and the brushes were disinfected at the end of the shift. An interview was conducted with SPD Tech 3 and the DOR on November 21, 2025, at 12:01 PM, in the SPD’s decontamination workroom. SPD Tech 3 confirmed the RLS finding on November 17, 2025, regarding cleaning and disinfecting hand-held brushes. SPD Tech 3 stated the MIFU was not followed on November 17, 2025. SPD Tech 3 stated hand-held brushes should have been cleaned after each use. The review of the hospital’s document titled, “General Instrument Cleaning Brushes,” dated 2023, was conducted. The document indicated, “Cleaning & Disinfection [a cleaning process using chemicals to kill germs]: Clean brushes after each use and disinfect between cases or daily, at a minimum...” 4. During the RLS conducted on November 17, 2025, through November 20, 2025, an interview was conducted with US Tech 1 and the ICPM on November 17, 2025, at 1:35 PM, in the radiology (a branch of medicine that uses pictures to diagnose and treat disease) department. US Tech 1 stated manually cleaning a contaminated (the presence of potentially harmful germs in or on reuseable medical devices) endocavity probe could splash blood, body fluids, or potentially infectious materials from the probe into her eyes. US Tech 1 stated she would wear her prescription eyeglasses to protect her eyes from potential contamination. An interview was conducted with the ICPM on November 21, 2025, at 9:23 AM, in the conference room. The ICPM confirmed the RLS finding on November 17, 2025, regarding eye protection and the use of Super Sani-Cloth (germicidal disposable wipes) when handling blood or body fluids. The ICPM stated eyeglasses and contact lens were not approved for eye protection. The ICPM stated the hospital had approved face shields and goggles as appropriate types of eye protection. The ICPM stated the facility did not follow the P&P on appropriate eye protection. A review of the manufacturer’s label, titled, “Super Sani-Cloth: Germicidal Disposable Wipes” dated 2020, was conducted. The label indicated “Personal protection: When using this product, wear disposal gloves, protective gowns, mask and eye coverings when handling ... body fluids.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 39723 Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control needs of all patients requiring surgical services and gastroenterology (GI, the study, diagnosis, and treatment of disorders that deal with the digestive system) services including the storage of flexible endoscopes (a reusable instrument used to inspect and treat the interior portions of the body) were met when, 1. The Infection Prevention and Control Program (IPCP) did not ensure that endoscopes (a reusable instrument used to inspect and treat the interior portions of the body) were stored safely and according to the manufacturer’s instruction for use (IFU) for 14 of 35 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). 2. The IPCP did not ensure appropriate gloves were worn when manually cleaning endoscopes for one of two sampled gastroenterology technicians (GI Tech 1). 3. The IPCP did not ensure decontamination (the process of removing or neutralizing germs) sinks were disinfected after manual cleaning (a process used to remove germs from soiled instruments) flexible endoscope for one of three decontamination sinks (Sink 3). 4. The IPCP did not ensure bronchoscopes (a flexible tube with a camera on the end used to inspect and treat the lungs and airways) were manually cleaned prior to performing high-level disinfection (a process used to kill almost all germs) for one of two sampled surgical technicians (Surg Tech 1). These failures resulted in unsafe reprocessing (a process carried out on a used device in order to allow its safe reuse) practices, creating an increased risk of cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect), prolonged hospitalization for 14 of 35 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14), and jeopardize the health and welfare of other patients requiring surgical procedures. Findings: 1. An interview was conducted with the Infection Prevention Manager (ICPM) on November 21, 2025, at 9:20 AM, in the conference room. The ICPM stated the hospital followed the following nationally recognized infection prevention and control guidelines: A. Centers for Disease Control and Prevention (CDC, the national public health agency of the United States), B. Association of periOperative [the care provided to patients before, during, and after a surgical procedure] Registered Nurses (AORN, a nationally recognized infection control guideline for perioperative areas), C. Occupational Safety and Health Administration (OSHA, a large regulatory agency of the United States Department of Labor), D. ANSI/AAMI ST91: 2021 American National Standards/Association for the Advancement of Medical Instrument: Flexible and semi-rigid endoscope processing [a process carried out on a used device in order to allow its safe reuse] in health care facilities, E. ANSI/AAMI ST79, American National Standards/Association for the Advancement of Medical Instrument: Comprehensive Guide to Steam Sterilization [the process of making reusable surgical instruments free of germs] and Sterility Assurance in Healthcare Facilities, and F. The Association for Professionals in Infection Control (APIC, a professional association for individuals working in the field of infection prevention). During the Relicensing Survey (RLS) conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the ICPM and the Director of Perioperative (the care provided to patients before, during, and after a surgical procedure) Services (DOR) on November 17, 2025, at 11:15 AM, in the endoscope storage room. 14 endoscopes were observed in the cabinet and were labeled “Clean.” One endoscope had an expiration date of November 14, 2025; Three endoscopes were not hanging freely; One incontinent absorbent pad (a product used to absorb and hold moisture away from the skin) was observed covering the cabinet’s drip tray (a cleanable tray used to collect access moisture) and the endoscope’s distal ends (tip) were in contact with the incontinence absorbent pad. An observation and interview were conducted with GI Tech 1 on November 17, 2025, at 11:21 AM, in the endoscope storage room. GI Tech 1 stated the incontinent absorbent pad was used to absorb excess water from the scopes and the cabinet’s drip tray. GI Tech 1 stated he did not know the amount of water that accumulated in the scope cabinet’s drip tray. GI Tech 1 stated the endoscopes should have been thoroughly dried before placing the endoscopes into the storage cabinet to prevent germs from multiplying inside the instrument’s channels or on the surfaces. GI Tech 1 stated the endoscope’s distal end should have been hanging freely but the endoscopes were long, and the distal end touched the pad. GI Tech 1 was observed rearranging the scopes in the storage cabinet. GI Tech 1 stated that there was not “enough” space between and around the endoscopes to prevent the scopes from “hitting” one another. GI Tech 1 confirmed the endoscope’s seven-day storage time (hang-time, the maximum amount of time scopes can be safely stored before needing to be reprocessed) had expired. GI Tech 1 stated the expired endoscope was “missed” during the daily inspection of storage cabinet and the scope should have been reprocessed on or before November 14, 2025 (three days ago). A concurrent interview and observation were conducted with the DOR on November 20, 2025, at 4:56 PM, in the endoscope storage room. The DOR confirmed the RLS findings on November 17, 2025, related to the handling and storage of endoscopes, the endoscope storage cabinet was observed. 13 endoscopes were observed in the cabinet and were labeled “Clean.” Four endoscopes were not hanging freely. The DOR stated the endoscopes should have been hanging freely. The DOR confirmed that an incontinent absorbent pad was observed on November 17, 2025, covering the drip tray of the endoscope cabinet. The DOR stated she did not know if the incontinent absorbent pads were made of lint-free material (tiny lint fibers can trap germs and contaminate an endoscope that was previously clean making it unsafe for use). A concurrent record review and interview were conducted of patients who underwent endoscopic procedures with potentially contaminated endoscopes from November 4, 2025, to November 17, 2025, with the Director of Medical Surgical Services (DOMS) on November 21, 2025, at 9:30 AM, in the conference room. The DOMS confirmed that the following records were reviewed on November 19, 2025, at 3:50 PM. The findings were as follows: -Patient 1’s clinical record indicated, Patient 1 was admitted to the hospital on November 14, 2025, and underwent an esophagogastroduodenoscopy procedure (EGD, an endoscopy procedure) on November 17, 2025. -Patient 2’s clinical record indicated, Patient 2 was admitted to the hospital on November 10, 2025, and underwent an EGD procedure on November 11, 2025. - Patient 3’s clinical record indicated, Patient 3 was admitted to the hospital on October 26, 2025, and underwent an EGD procedure on November 11, 2025. -Patient 4’s clinical record indicated, Patient 4 was admitted to the hospital on November 10, 2025, and underwent an EGD procedure on November 12, 2025. -Patient 5’s clinical record indicated, Patient 5 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 13, 2025. -Patient 6’s clinical record indicated, Patient 6 was admitted to the hospital on November 12, 2025, and underwent an EGD procedure on November 13, 2025. -Patient 7’s clinical record indicated, Patient 7 was admitted to the hospital on November 4, 2025, and underwent an EGD procedure on November 7, 2025. -Patient 8’s clinical record indicated, Patient 8 was admitted to the hospital on November 3, 2025, and underwent an EGD procedure on November 4, 2025. -Patient 9’s clinical record indicated, Patient 9 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 12, 2025. -Patient 10’s clinical record indicated, Patient 10 was admitted to the hospital on November 11, 2025, and underwent an EGD procedure on November 17, 2025. -Patient 11’s clinical record indicated, Patient 11 was admitted to the hospital on November 6, 2025, and underwent an EGD procedure on November 7, 2025. -Patient 12’s clinical record indicated, Patient 12 was admitted to the hospital on November 6, 2025, and underwent an EGD procedure on November 10, 2025. -Patient 13’s clinical record indicated, Patient 13 was admitted to the hospital on October 24, 2025, and underwent an EGD procedure on November 5, 2025. - Patient 14’s clinical record indicated, Patient 14 was admitted to the hospital on November 5, 2025, and underwent an EGD procedure on November 11, 2025. An interview was conducted with GI Tech 1 and the DOR, on November 21, 2025, at 10:25 AM. GI Tech 1 confirmed the RLS findings on November 17, 2025, regarding the expired endoscope’s maximum safe storage time; the storage of the incontinent pad observed in the drip tray; improper hanging of the scopes, and the endoscope’s distal ends were in contact with the incontinence absorbent pad. GI Tech 1 stated “The endoscopes need a larger storage cabinet.” A review of the facility’s undated document titled, “[Brand NAME]: Endoscope Reprocessing Manual” was conducted. The document indicated, “Warning: A. To keep the endoscope storage cabinet clean, store only properly reprocessed endoscope and accessories in the cabinet. If the endoscope storage cabinet becomes contaminated it could pose a risk of infection. B. Before storing the endoscope and accessories, thoroughly dry external and internal surfaces (lumen). If an endoscope or accessory that is not sufficiently dried is stored, microorganisms [germs] may proliferate [multiply] and may pose a risk of infection C. Store the properly reprocessed endoscope and accessories in an appropriate storage environment. If they are not stored in an appropriate storage cabinet, they may become damaged or re-contaminated ...” A review of the facility’s document titled, “2025 Infection Control and Prevention Plan” was conducted. The document indicated “Infection Control Goals: The goal of the infection prevention and control program include, but not limited to: ...Minimizing the risk of transmitting infections during the use of medical equipment and medical devices ...” 2. During the RLS conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the ICPM and the DOR on November 17, 2025, at 10:25 AM, in the sterile processing department (SPD, a dedicated area within a healthcare facility that cleans, prepares, processes, and stores medical devices) decontamination (the process of removing or neutralizing germs) workroom. GI Tech 1 was observed performing manual cleaning at Sink 3. GI Tech 1 was observed wearing examination gloves (gloves used for routine patient care). An interview was conducted with GI Tech 1 on November 17, 2025, at 10:40 AM, in the SPD’s decontamination workroom. GI Tech 1 confirmed that he used examination gloves for manually cleaning contaminated endoscopes. GI Tech 1 stated the heavy-duty decontamination gloves were thick and he preferred to wear examination gloves. The DOR stated staff handling contaminated endoscopes should wear gloves that provide extra protection and are fitted above the wrist. An interview was conducted with GI Tech 1 and the DOR on November 21, 2025, at 10:45 AM, in the SPD’s decontamination workroom. GI Tech 1 confirmed the RLS finding on November 17, 2025, regarding not wearing appropriate gloves when manually cleaning soiled instruments. GI Tech stated, “I understand, I should wear heavy-duty utility gloves.” A review of the facility’s policy and procedure (P&P) titled, “Decontamination of Soiled Instruments and Device,” effective October 4, 2023, was conducted. The P&P indicated, “2. Personnel assigned to Decontamination must wear personal protective equipment (PPE) including: ...2.4. Extra protection gloves (Decontamination gloves).” 3. During the RLS conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the ICPM and the DOR on November 17, 2025, at 10:25 AM, in the SPD’s decontamination workroom. GI Tech 1 was observed performing manual cleaning at Sink 3. GI Tech 1 completed the manual cleaning process and GI Tech 1 was not observed to disinfect Sink 3 after use. An interview was conducted with GI Tech 1 on November 17, 2025, at 10:40 AM, in the SPD’s decontamination workroom. GI Tech 1 stated he had used Sink 3 to manually clean a flexible endoscope. GI Tech 1 confirmed that he had not disinfected Sink 3 after use. GI Tech 1 stated he was not aware that the decontamination sink should have been disinfected after each use. An interview was conducted with GI Tech 1 and the DOR on November 21, 2025, at 10:50 AM, in the SPD’s decontamination workroom. GI Tech 1 confirmed the RLS finding on November 17, 2025, regarding cleaning and disinfecting the decontamination sink after each use. GI Tech 1 stated the decontamination sink should have been cleaned and disinfected after each use. The review of the facility’s document titled, “ANSI/AAMI ST91 (2021) Flexible and semi-rigid endoscope processing in health care facilities” was conducted. The document indicated “7.6 Manual Cleaning Steps ...S. Sinks should be cleaned, disinfected, and rinsed between uses with a disinfectant approved by a multidisciplinary team [healthcare professionals who specialize in different fields and work together] and in accordance with the IFUs for the disinfectant and the sink.” 4. During the RLS conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the DOR on November 17, 2025, at 10:55 AM, in the SPD’s decontamination workroom. Surg Tech 1 was observed placing the bronchoscope into the automatic endoscope reprocessor (AER, a machine designed for the purpose of disinfecting endoscopes). Surg Tech 1 was not observed performing manual cleaning on the bronchoscope prior to performing high-level disinfection. An interview was conducted with the DOR on November 21, 2025, at 10:55 AM, in the SPD’s decontamination workroom. The DOR confirmed the RLS finding on November 17, 2025, regarding the technician not manually cleaning the bronchoscope prior to performing high-level disinfection. DOR stated the bronchoscope was a loaned instrument and should have been manually cleaned prior to high-level disinfection in accordance with the MIFU. During a review of the facility’s document titled, “Endoscope EB-580 Series,” was conducted. The document indicated “8.1 Methods of High-Level Disinfection: ...Prior to high-level disinfection, these instruments must be pre-cleaned and manually cleaned in accordance with this manual.” During a review of the facility’s P&P titled, “SPD Management of Loaner/Vendor Instruments and Trays” effective April 11, 2024, was conducted. The P&P indicated “Purpose: Management of loaner instrumentation and non-sterile implants for specialty operative procedures requires proper inventory, cleaning and sterilization according to the manufacturer’s written instructions ...””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 39723 Based on observation, interview, and record review, the facility’s Infection Prevention and Control Leadership (IPCL) failed to provide adequate oversight to ensure that hospital-wide infection surveillance, prevention, and control policies and procedures were followed and were consistent with nationally recognized guidelines for one of three sampled departments (Surgical Services) when, 1. The IPCL did not ensure harmful chemicals were not stored with medications and medical supplies for one of two sampled cardiopulmonary (heart and lung) perfusion (the flow of blood to tissues and organs) carts (CP Cart 1). 2. The IPCL did not ensure safe injection (given into the blood stream) practices were followed, and single-dose medication bottles (bottles containing medication that are intended for a single patient) were observed stored for multidose (a container of liquid medication, intended for injection, that contains more than one dose) injections for two of two sampled cardiopulmonary perfusion carts (CP Cart 1 and CP Cart 2). 3. The IPCL did not ensure equipment was properly cleaned and disinfected after each patient procedure for one of two sampled cardiopulmonary machines (CP Machine 1). 4. The IPCL did not ensure appropriate attire was worn in restricted areas (area where access and traffic are limited to authorized personnel and where special attire is required) and facial hairs was not exposed in the operating room for one of two sampled Operating Room Nurse Managers (ORNM). These failures resulted in a lack of infection prevention and control oversight consistent with nationally recognized guidelines, thereby creating an increased risk for cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect), prolonged hospitalization, and death, to patients experiencing open-heart surgery (a procedure where the chest is surgically opened to access and operate on the heart). Findings: 1. An interview was conducted with the Infection Prevention Manager (ICPM), on November 20, 2025 at 3:00 PM, in the conference room, the ICPM confirmed the hospital followed the following nationally recognized guidelines: A. Centers for Disease Control and Prevention (CDC, the national public health agency of the United States); B. Association of periOperative [the care provided to patients before, during, and after a surgical procedure] Registered Nurses (AORN, a nationally recognized infection control guidelines for perioperative areas); C. Occupational Safety and Health Administration (OSHA, a large regulatory agency of the United States Department of Labor); D. ANSI/AAMI ST79 (2017) American National Standards/Association for the Advancement of Medical Instrument: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities; and E. The Association for Professionals in Infection Control (APIC, a professional association for individuals working in the field of infection prevention). During the Relicensing Survey (RLS) conducted on November 17, 2025, through November 20, 2025, an observation was conducted with the Director of Perioperative (the care provided to patients before, during, and after a surgical procedure) Services (DOR) and the ICPM on November 18, 2025, at 10:45 AM, in Operating Room 7 (OR 7). A can of penetrating lubricant was observed wrapped in a soiled blue towel and was stored in the third drawer of CP Cart 1. Grey fuzzy matter was observed throughout the drawer. The DOR removed the towel, and brown residue was observed scattered across the can’s surface. The DOR removed the white cap from the can and the spray nozzle, and the inside of the cap was observed covered with a brown, oily substance. The can of penetrating lubricant oil was observed stored between an opened bottle of injectable medication (medication introduced directly into the bloodstream) and clean medical supplies. The review of the facility’s document titled “Safety Data Sheet [a document that provides information about the hazards of a chemical product and instructions for its safe handling, storage, and emergency procedures]: Win Pen Non-Flammable Penetrating Oil” dated January 15, 2015, was conducted. The document indicated the penetrating lubricant oil was carcinogenicity (the ability of a substance, agent, or exposure to cause cancer), fatal if swallowed, and excessive inhalation [the act of breathing] may cause unconsciousness or death. An interview was conducted with the Director of Facilities (DOF) on November 20, 2025, at 5:30 PM, in the conference room. The DOF stated that he was aware of the RLS finding on November 18, 2025, regarding the unsafe storage of the penetrating lubricant oil can. The DOF stated the brown substance observed on the can’s surface and inside of the can’s cap had potentially leaked from the spray can and the chemical product produced harmful vapors and residue. The DOF stated repairs requiring hazardous chemical should have been performed in well-ventilated workspaces and the operating room did not meet the standard for releasing hazardous vapors into the clean environment. The DOF stated chemicals should be stored safely to prevent unintentional cross-contamination and harm. An interview was conducted with the Director of Pharmacy (DOP) on November 21, 2025, at 8:05 AM, in the conference room. The DOP confirmed a can of penetrating lubricant oil was observed stored with injectable medications on November 18, 2025. The DOP stated penetrating lubricant oil stored with intravenous medication posed a risk of leaking, aerosolizing (turning into a fine mist or spray containing minute [very small] particles), and transferring harmful residue onto medications. The DOP stated contaminated (the presence of potentially harmful germs in or on an object) intravenous medication increased the risk of blood stream infections and exposure to harmful compounds that were not intended for injections. An interview was conducted with the Cardiopulmonary Perfusionist (CP 1) on November 21, 2025, at 8:30 AM, in the conference room. CP 1 confirmed the RLS finding on November 18, 2025, regarding the handling and storage of the penetrating lubricant oil can. CP 1 stated CP Cart 1’s lock was not functioning properly, and he took the can of penetrating lubricant from the environmental service closet. CP 1 stated he sprayed the key with the lubricant oil, and the key did not function properly. CP 1 stated he sprayed CP Cart 1’s lock and placed a towel under the lock to “catch” the residue. CP 1 stated he wiped the excess lubricant oil with the towel then proceeded to wrap the can in the blue towel and placed the can into CP Cart 1’s drawer. CP 1 stated he stored the can of lubricant oil in CP Cart 1’s drawer for future use. CP 1 stated he did not realize that the lubricant oil could not safely be stored in CP Cart 1 or that the penetrating oil could contaminate medications and medical supplies. An interview was conducted with the ICPM on November 21, 2025, at 9:25 AM, in the conference room. The ICPM stated hazardous chemicals should not have been stored in CP Cart 1 with medications or clean medical supplies to prevent cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect). A review of the facility’s policy and procedures (P&P) titled, “Medication Storage,” dated October 5, 2022, was conducted. The P&P indicated, “Policy: 1. Medications will be stored under appropriate conditions to maintain medication integrity [quality, purity, safety, and effectiveness] ...2. All medications will be stored in accordance with applicable laws and regulations and manufacturers’ guidelines. A review of the facility’s P&P titled, “Hazardous Materials and Waste Storage,” dated April 1, 2024, was conducted. The P&P indicated, “ Policy Statement: Departments where hazardous materials are used must provide adequate storage for their hazardous chemicals and waste. Appropriate equipment must be used to safely handle hazardous chemicals and waste. Employees must receive training in the safe handling and storage of hazardous materials and waste ...” A review of the facility’s document titled, “2025 Infection Control and Prevention Plan” was conducted. The document indicated “Infection Control Goals: The goal of the infection prevention and control program include, but not limited to: ...Maintaining a sanitary environment to minimize transmission of infections and communicable [capable of being easily transmitted or spread] diseases ...” 2. During the RLS conducted on November 17, 2025, through November 20, 2025, an inspection was conducted with the ICPM, and the DOR on November 18, 2025, at 10:45 AM, in the cardiopulmonary operating rooms (OR). Two CP Carts were inspected. The following were observed: -CP Cart 1, An opened 250 milliliter (ml, a unit of measurement) glass bottle of injectable (given directly into the bloodstream) nitroglycerine (medicine used during surgery to control the heart and blood vessels) was observed stored in a green light-protective bag. The medication was stored in CP Cart 1’s third drawer and the drawer contained grey fuzzy matter. CP Cart 2, An opened 250 ml glass bottle of injectable nitroglycerine was observed stored in a green light-protective bag. The medication was stored in CP Cart 2’s third drawer. An interview was conducted with the DOP on November 20, 2025, at 4:02 PM, in OR 7. The DOP stated all pharmaceuticals (the production and sale of drugs and medicines) were managed by the pharmacy department, and he did not know who had designated CP Cart 1 and CP Cart 2 as medication storage units. The DOP stated the pharmacy department was not aware that CP Cart 1 and CP Cart 2 contained medications, and the carts were not inspected monthly to ensure proper medication storage. A follow-up interview was conducted with the DOP on November 21, 2025, at 8:15 AM, in the conference room. The DOP confirmed the RLS finding on November 18, 2025, regarding opened glass bottles of injectable nitroglycerine stored on CP Carts. The DOP stated the nitroglycerin was in single-dose bottles and approved for single-patient use. The DOP stated single-dose vials do not contain antimicrobial preservatives (ingredients added to some medications to stop germs from growing in them) and can increase the risk of infection if they are not used according to the manufacturer’s instruction for use (MIFU). The DOP stated the facility’s P&P on medication storage was not followed and any remaining medication should have been properly discarded. An interview was conducted with the DOR and CP 1 on November 21, 2025, at 8:45 AM, in the conference room. CP 1 confirmed the RLS finding on November 18, 2025, regarding storing and administering (given) single-dose injectable nitroglycerine for multidose injections. CP 1 stated that he had placed the nitroglycerin bottles into CP Cart 1 and CP Cart 2 several weeks ago. CP 1 stated he had administered the medication to patients who had undergone heart surgeries and he could not recall the identity of the patients. CP 1 stated he could not confirm the amount of nitroglycerin that was administered from the bottles. CP 1 stated “I usually give three to five mls, depending on the patient’s response.” CP 1 stated he did not document the nitroglycerine that he had administered, and he could not confirm how much nitroglycerine remained in the medication bottles. CP 1 stated that the bottles of nitroglycerin in the CP Carts were stored for future patient use. CP 1 stated that he did not know whether the nitroglycerine was in single-dose bottles. CP 1 stated, “I did not read the bottle” [manufacturer’s instruction for use, MIFU]. CP 1 stated the infection control and prevention concerns associated with administering medications intended for a single patient to multiple patients “should not be done.” The review of the facility’s P&P titled, “Medication Storage,” dated October 5, 2022, was conducted. The P&P indicated, “Policy: ... 2. All medications will be stored in accordance with applicable laws and regulations and manufacturers’ guidelines.” The review of the Center for Disease Control and Prevention (CDC) recommendation titled “Preventing Unsafe Injection Practices,” dated March 26, 2024, was conducted. The recommendation indicated, “Unsafe injection practices put patients and healthcare providers at risk. This harm is preventable. A single-dose vial of liquid medication intended for injection or infusion is only approved for use in a single patient for a single case, procedure or injection. Single-dose vials are labeled by the manufacturer and typically lack an antimicrobial preservative. They can serve as a source of infection when used inappropriately or contaminated. Never use medications packaged as single-dose vials for more than one patient ...” 3. A review of the facility’s document titled “2025 Infection Control and Prevention Plan,” was conducted. The document indicated, “Purpose: The purpose of the [Name of Facility] Infection Control Plan (The Plan) is to establish, maintain and ensure the implementation of an Infection Control Program that encompasses all facility departments and involve all employees and care providers in meeting the hospital’s mission of providing quality health care ...the plan provides oversight to the following: ...3. Development of surveillance plan based on review of infection control data and services provided ...Scope: ... The Infection Control Plan is hospital wide including, but not limited to the following ...Perioperative Services ... Cardiac Services ...” A record review and interview were conducted with the ICPM on November 21, 2025, at 9:20 AM, in the conference room. The facility documents titled, “High Level Disinfection” dated January 2, 2025, to October 20, 2025, were reviewed. There were no documentation or logs observed that indicated the ICPM conducted active infection prevention rounds in the cardiopulmonary perfusion areas. The ICPM confirmed the RLS findings on November 18, 2025, regarding the handling and storage of the can of penetrating lubricant oil being used in the OR and stored between medications and medical supplies; storing and administering single-dose injectable nitroglycerine for multidose injections; and cleaning and disinfecting the perfusion equipment after each patient procedure. The ICPM stated she did not conduct specific infection prevention and control rounds in the cardiopulmonary perfusion areas. An interview was conducted with CP 1 on November 21, 2025, at 12:10 PM, in OR 7. CP 1 confirmed on November 20, 2025, in OR 7, the toy bird was attached to CP Machine 1. CP 1 stated the toy bird had been stored on CP Machine 1 for several weeks. CP 1 stated the bird was decoration and did not serve a clinical purpose. CP 1 stated that the toy bird was not cleaned and disinfected after each patient procedure, and he did not know how to clean and disinfect the bird. A review of the AORN’s Guidelines for Perioperative Practice titled, “Environmental Cleaning,” dated January 13, 2020, was conducted. The regulatory requirement indicated, “4.2 Operating and procedure rooms must be cleaned and disinfected after each patient procedure.” The review of the facility’s P&P titled, Environmental Cleaning in Procedural Areas,” dated July 12, 2024, was conducted. The P&P indicated “ ... 3. Between patient Cleaning: ...111. Clean and disinfect items used during patient care after each patient use ...” A review of the facility’s document titled, “2025 Infection Control and Prevention Plan” was conducted. The document indicated “Infection Control Goals: The goal of the infection prevention and control program include, but not limited to: ...Maintaining a sanitary environment to minimize transmission of infections and communicable diseases ...” 4. A concurrent observation and interview were conducted with the ORNM on November 20, 2025, at 3:55 PM, in OR 7. The ORNM’s mustache was observed. The ORNM stated that facial hair must be covered in restricted areas to prevent cross-contamination. The ORNM stated his facial hair should have been covered prior to entering the operating room. A review of the facility’s P&P titled, “Surgical Attire,” dated October 2, 2024, was conducted. The P&P indicated, “ ...7. Head and Facial Coverings: ...b. Facial hair must be covered while in restricted areas ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 46696 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of patient care for 215 of 215 patients admitted on August 25, 2025, when: 1.The GB did not ensure an effective quality improvement program and did not provide effective oversight on proper patient transport techniques for Patient 31, which led to a fall. (Refer to A0049). 2.For Patient 15,accurate fall risk assessment (a tool used to determine the patient is at high risk for falling, scoring from 0-20 no risk or low risk, 25 -44 medium risk, 45 or more is a high-risk score), may have contributed the health care team to not identifying the correct fall risk score and assessment during each shift resulted in sustaining a fall during the procedure which lead to a brain bleed and jeopardized the health and safety of patients. (Refer to A0049). 3. For Patient 20, initiation of care plans (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) for a high fall risk patient. (Refer to A0049). 4. For Patient 17, unsafe patient care environment in procedure areas that led to a fall. (Refer to A0049). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51099 Based on observation, interview, and record review, the facility failed to protect and promote patient’s rights in accordance with acceptable standards of practice for three of 31 sampled patients (Patient 15, 17, and 2), when: 1. Patient 15 was not securely strapped in bed during the procedure in Interventional Radiology (IR - doctor uses x-rays, scans, or ultrasound like a GPS to guide small tools inside the body to treat problems without needing big surgery cuts) (Refer to A0144). 2. Patient 17 was not properly secured in bed during the procedure in the Cardiac Catheterization Laboratory (CCL - where doctors use tiny tubes, x-rays, and dye to see and fix heart arteries without opening the chest) (Refer to A0144). 3. The nursing staff did not ensure that sharp and blood contaminated objects (needles) were disposed of safely when it was left on the patient’s bedside table for Patient 2 (Refer to A0144). The cumulative effect of these systemic problems resulted in the facility’s failure to deliver quality care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 46696 Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for 215 of 215 patients admitted on August 25, 2025, when 1.The facility did not ensure proper patient transport techniques were used, for Patient 31 leading to a fall. (Refer to A0283). 2. The facility did not document accurate fall risk assessment (a tool used to determine the patient is at high risk for falling, scoring from 0-20 no risk or low risk, 25- 44 medium risk, 45 or more is a high-risk score), for Patient 15 (Refer to A0283). 3. The facility did not ensure a care plan (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) for falls was initiated and implemented for a high-fall risk patient for Patient 20 (Refer to A0283). 4. The facility did not ensure a safe patient care environment in procedure areas that led to a fall for Patient 15 and Patient 17 (Refer to A0283). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify the problem prone areas to ensure the provision of quality nursing care and patient safety and had the potential to cause adverse health outcomes which could interfere with the patient’s medical care and may jeopardize health and safety.”

“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: 46696 Based on interview, and record review, the facility failed to maintain an organized Nursing Services for three of 31 sampled patients (Patient 15, 20, and 31), as evidenced by: 1. For Patient 20, the Nursing staff did not ensure a care plan (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) for falls was initiated and implemented for a high-fall risk patient. (Refer to A0396) 2. For Patient 31, the nursing staff did not ensure patient bed was locked during transfer, which resulted in a fall. (Refer to A0398) 3. For Patient 15, a “Fall Risk Assessment” (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk, 25-44 medium risk, 45 or more is a high risk score ), misidentified a high fall risk to a low fall risk, which led to a low fall intervention was implemented during the procedure and patient sustained a fall to the ground (Refer A0398). The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and quality nursing care in a safe environment and potentially resulted inadequate patient monitoring prolonged discomfort, infection and delayed healing which significantly jeopardized health and safety.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 46696 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to ensure the quality of care was provided for 215 of 215 patients admitted on August 25, 2025, when the GB did not have an effective oversight on : 1.For Patient 31, had an improper patient transport techniques were used for , leading to a fall. 2. For Patient 15, inaccurate fall risk assessment (a tool used to determine the patient is at high risk for falling, scoring from 0-20 no risk or low risk, 25 -44 medium risk, 45 or more is a high-risk score) . 3.For Patient 20, an initial care plan (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) for falls was initiated and implemented for a high-fall risk patient . 4. For Patient 15 and Patient 17, unsafe patient care environment in procedure areas that led to a fall. These failures had resulted in the facility to deliver care without the GB oversight and failure to provide a safe patient care environment causing inadequate fall prevention leading to falls which jeopardized the health and safety of the patients and lead to prolonged hospitalization. Findings: During an interview on August 28, 2025, at 12:00 PM, in the conference room, with the Chief Executive Officer (CEO), the survey findings were discussed including lack of effective oversight on proper patient transport techniques, inaccurate risk assessment, lack of initiation of care plans for a high fall risk patient, and unsafe care environment in procedure areas were discussed. The CEO stated the Quality Department report to the board each meeting as noted in the GB minutes; improvement opportunities and interventions were discussed at each GB meeting. The GB was aware of the plans of quality, including the post fall review, the GB tasks the Quality Department with these plans. The CEO confirmed the GB has an oversight responsibility of the hospital. During a review of the facility “Hospital Community Board Minutes” dated August 6, 2025, the “Hospital Community Board minutes” indicated, Quality and risk manager report presented by the Director of Quality (DQ). During a concurrent interview and record review on August 28, 2025, at 11:39 AM, with the DQ, the facility’s “Quality Improvement Committee meeting minutes,” dated June 26, 2025, was reviewed. The “Quality Improvement Committee meeting minutes” indicated, Performance Improvement Monitoring (PIMS) report: PIMS were developed for monitoring corrective action effectiveness, resulting from regulatory and licensing surveys. Nursing Fall precautions: All areas were at 100 percent (%) for June 2025, except Emergency department, Unit 4 North and South monitoring can be discontinued. The DQ acknowledged and stated, Quality Assessment and Performance Improvement (QAPI) were already tracking falls and nursing fall prevention with the Quality Committee and PIMS since this was a finding from a previous complaint validation survey (survey cycle from September 27, 2024, to February 10,2025), survey, however Quality were still seeing falls with an increase in falls in July 2025. During a review of the facility’s “Quality management Plan FY2025,” dated 2025, the “Quality management plan FY2025” indicated, “The scope of the organizations Quality Assessment and Performance Improvement (QAPI) program, established by the medical staff and an interdisciplinary Quality/Patient Safety Committee with the support and approval of the Community Governing Board, encompasses organization-wide activities related to performance measurement, assessment, improvement and control of patient care and support services...Improvement opportunities are identified though data analysis activities and assessments. Actions to improve is initiated for priorities identified by organizational leaders. The efficacy of performance improvement activities is assessed to determine whether changes made have resulted in improvement. Action is taken when improvement is not achieved or sustained.” During a review of the facility’s document titled, “Medical Staff Bylaws,” dated June 2025, the “Medical Staff Bylaws” indicated “ ... a quality assurance plan for maintaining quality of care within the Hospital. This plan may include mechanisms to ... F. submit regular confidential reports to the executive committee on the quality of care provide and the quality review activities conducted.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 51099 Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe environment for three of 31 sampled patients (Patient 15, 17, and 2), when: 1. Patient 15 was not securely strapped in bed during the procedure in Interventional Radiology (IR - doctor uses x-rays, scans, or ultrasound like a GPS to guide small tools inside the body to treat problems without needing big surgery cuts). This failure resulted in Patient 15 sustaining a fall to the ground and suffering with hematoma (collection of blood under the skin or in the tissues) in the brain, subsequently placed on life saving machine and may have contributed to prolonged hospitalization and jeopardized the health and safety. 2. Patient 17 was not properly secured in bed during the procedure in the Cardiac Catheterization Laboratory (CCL - where doctors use tiny tubes, x-rays, and dye to see and fix heart arteries without opening the chest). This failure had resulted in Patient 17 sustaining falls to the ground and had the potential to complications such as a hematoma (collection of blood under the skin or in the tissues) fracture (broken bone) and prolonged hospitalization. 3. The nursing staff did not ensure that sharp and blood contaminated objects (used needles) were disposed of safely when it was left on the bedside table for Patient 2. This failure had the potential to result in patients, staff, and visitors being exposed to bloodborne pathogens (germs that live in human blood or body fluids that can cause disease) through accidental needlesticks (to be accidentally poked or stuck by a needle that was already used on a patient) leading to serious infection, illness, or death. Findings: 1. During a review of Patient 15’s face sheet (contains demographic and medical information), undated, the face sheet indicated, Patient 15 was admitted to the facility on June 20, 2025, with diagnoses which included multiple syncopal events (fainting or passing out), fall causing hematoma (collection of blood under the skin or in the tissues), and chronic heart failure (heart is not pumping as strong as it should be over a long period of time). A review of Patient 15’s “Assessment Documentation” (contains patient’s health, condition, needs), dated June 20, 2025, indicated, Patient 15 had an initial fall risk assessment (a tool used to determine the patient is a high risk for falling; scoring from 0-5 is low risk, 6-13 is moderate risk, 14 and above is high risk) of 4, which indicated a low fall risk score. A review of Patient 15’s “Assessment Documentation,” dated June 22, 2025, indicated, Patient 15 had a fall risk assessment score of 13, which indicated a moderate fall risk score. A review of Patient 15’s Computed Tomography (CT - x-ray test that takes many pictures of the inside of the body from different angles) scan of head dated June 20, 2025, at 12: 18 OM, indicated, there was no acute intracranial hemorrhage, mass effect, or shift. A review of Patient 15’s “Consent to Surgery or Special Procedure,” dated June 23, 2025, indicated, Patient 15 underwent a procedure in the IR for an image guided (video/picture assisted) temporary hemodialysis (treatment that cleans blood when kidneys cannot) catheter (special tube placed into a large vein to give doctors and nurses direct access to the bloodstream) placement. A review of Patient 15’s “Progress Note - Physician Note,” dated June 29, 2025, indicated, during the procedure, Patient 15 became agitated and rolled out of bed landing on his face. Patient was placed in cervical collar (neck brace or stiff support that goes around the nek to keep it still and straight) and received a Computed Tomography (CT) scan of head and neck. CT scan of the head demonstrated subacute subdural hematoma (slow brain bleed that builds up days or weeks after head injury) with some bleeding and small subarachnoid hemorrhage (bleeding in the space of the brain). Patient 15 was transferred to the Intensive Care Unit (ICU) where Patient 15 was intubated (having a breathing tube placed into the throat so it can help with breathing) for altered mental status. During an interview on August 25, 2025, at 10:40 AM, with Registered Nurse 5 (RN5), in the IR department, RN5 confirmed Patient 15 was not secured with any straps on the procedure bed. Patient 15 had two arm-board slats (a piece of equipment used to position and secure a patient’s arm for a procedure) that were inserted underneath the mattress, but the slats could easily be pushed out with a bit of force. RN5 stated the IR staff was not aware Patient 15 was a high fall risk because his fall risk score indicated 13, which was a moderate fall risk. RN5 further stated, if IR staff knew about Patient 15’s fall risk score, more safety prevention measures would have been implemented, such as possible straps or another staff to always be beside Patient 13 during the procedure. RN5 confirmed Patient 15 went to get a CT after the fall on June 23,2025,and the fall resulted in a subarachnoid hemorrhage. During a concurrent observation and interview on August 27, 2025, at 9:11 AM, with Unit Director 2 (UD 2), in the IR department, the IR bed was observed to be narrow and flat with a thin mattress pad the length of the bed. UD 2 stated, prior to Patient 15’s fall, the IR staff did not utilize straps to secure patients down to the IR bed. UD 2 further stated fall precautions were not consistently applied in the IR and should have been regardless of whether patients were alert or oriented. A follow-up interview on August 27, 2025, at 9:14 AM, with RN 5, in the IR room, RN5 stated, the IR department had no specific fall policies for the unit. RN5 further stated the use of restraints (tools or methods used to stop a patient from moving in a way that could hurt themselves or others) was only applicable to patients who were disoriented (confused and not fully aware of who they are, where they are, what time it is, and what is happening around) and could not follow commands. During a concurrent and record review on August 28, 2025, at 9:38 AM, with UD 2, the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated October 2, 2024, was reviewed. The P&P indicated, “ ...The patient rights and responsibilities are identified, by oversight entity, as follows ...The patient has the right to ...receive care in a safe setting ...” UD2 stated the facility did not follow the P&P. 2. During a review of Patient 17’s face sheet, the face sheet indicated, Patient 17 was admitted to the facility on August 21, 2025, with diagnoses including left distal foot gangrene (area at the end of their left foot where the skin and tissue have died), and critical limb ischemia (blood flow to a leg or foot is extremely blocked). A review of Patient 17’s “Assessment Documentation,” dated August 22, 2025, indicated, Patient 17 had a fall risk assessment score of 7, which indicated a moderate fall risk. A review of Patient 17’s “Procedure Note,” dated August 22, 2025, indicated, Patient 17 underwent an abdominal aortogram (x-ray test with dye that lets doctors see how blood flows through the main artery in the stomach, to check for blockages or weak spots), aortogram with iliofemoral runoff (AIF - dye test that shows how blood flows from the stomach artery into the legs), and left popliteal artery (big artery behind the left knee) percutaneous transluminal angioplasty (PTA - when doctors use a balloon inside the blood vessel to open up a blockage). During a concurrent observation and interview on August 27, 2025, at 2:09 PM, with UD3, in the CCL unit, the CCL room was observed to have a narrow bed with a thin mattress on top. No side railings were observed. UD3 demonstrated the use of arm board slates that could be tucked underneath the mattress but had no security to keep them in place. UD3 further stated the arm boards are held down primarily by a patient’s weight, but the arm boards can still move and fall out. There were no side railings or securements to prevent a patient from falling out of bed. UD3 stated, the CCL staff did not use restraints on patients who are alert, oriented and were able to follow commands. UD3 further stated, Patient 17 was oriented and able to follow commands, so staff did not strap him down or use restraints to secure him to the bed. During a concurrent observation and interview on August 28, 2025, at 8:15 AM, with Patient 17, Patient 17 was observed resting on his bed. There was no bruising observed on his face or head. Patient 17 stated, “Yeah, the hospital staff dropped me during the procedure. My back hurt a lot after that. I should’ve been safe during that, but I ended up falling.” Patient 17 further stated he sustained a bruise on his back after the fall. During an interview on August 28, 2025, at 8:30 AM, with RN 6, in the CCL unit, RN 6 confirmed that Patient 17 was placed on the procedure bed with arm board slats inserted underneath the mattress, but the arm board slats were not securely attached to the bed. RN 6 stated the CCL staff did not use restraints or straps for patients who are alert, oriented, and can follow commands. RN 6 also confirmed that Patient 17 was on moderate sedation (a condition that patients are awake but may be drowsy) during the time of the procedure. RN 6 stated staff monitored sedation levels throughout procedure and adjusted medication according to Patient 17’s responses. No other safety precautions were taken during the procedure. During a concurrent interview and record review on August 28, 2025, at 10:12 AM, with UD 3, the facility’s P&P, titled, “Patient Rights and Responsibilities,” dated on October 2, 2024, was reviewed. The P&P indicated, “ ...The patient rights and responsibilities are identified, by oversight entity, as follows ...The patient has the right to ...receive care in a safe setting ...” UD3 stated safety should always be possible in the procedural setting and Patient 17’s fall should have been prevented. UD 3 further stated the facility did not properly ensure patient safety during the procedure. A review of the facility’s job description, titled, “Tech Special Procedures - 75700 - Cardiac Catheterization Services,” updated March 19, 2015, indicated, “ ...Job Responsibilities ...1.9...Safely transports patient to procedure room and maintains the safety and comfort of the patient during a procedure. Maintains proper body alignment and uses safety restraint when appropriate ...” 3. During a review of Patient 2’s “History and Physical” (H&P-a comprehensive medical document created by a physician that details a patient’s medical history), dated August 24, 2025, the H&P indicated, “Patient was transferred from [facility name] for evaluation of abdominal pain and concern for gallstone (hard, mineral deposits that form in the gallbladder), and pancreatitis (an inflammation of the pancreas). During a concurrent observation and interview on August 25, 2025, at 10:39 AM, in Unit 4, with RN 1 and RN 2, RN 2 was observed an Intravenous Catheter (IV- A tube inserted into a vein for delivery of medications and fluids) starting on Patient 2. A used IV catheter with blood on it and a used needle were observed on Patient 2’s bedside table. RN 2 stated this was the second attempt. After the IV was successfully started, the nurse proceeded to clean up the IV site, disposing of the used equipment on the just placed IV, began to leave the room leaving the bloody IV and needle on Patient 2’s bedside table. When asked if the contaminated IV and needle should be left on Patient 2’s bedside, RN 1 stated, “I didn’t realize it had been left there good thing you said something, it should not be left on the patient’s bedside table.” During a concurrent interview and record review on August 27, 2025, at 10:30 AM, with the Manager of the Medical Surgical Unit (MSM), the facility’s P&P titled, “Infection Prevention, Blood Borne Pathogen Exposure Control Plan,” dated October 2, 2024, was reviewed. The P&P indicated, “ ...c. Work Practice Controls ... xxv. Disposable Sharps are not to be reused and should be placed in sharps containers immediately after use ...” The MSM stated that it is important for nurses to ensure that items are not left at the bedside. The MSM further stated, the nursing staff were responsible for cleaning up their areas, as patients, family members, and staff can potentially injure themselves on sharps. The MSM added, the staff did not follow this policy when sharp and contaminated needles were left at patient’s bedside and should be disposed of immediately. During an interview on August 28,2025 at 11:33 AM, with the Infection Control Practitioner (ICP), the ICP stated, if sharps are left at patient’s bedside, visitors could poke themselves, patients or anybody could which is an infection control risk. The ICP further stated, this is not the proper process.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 46696 Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide data driven Quality Assessment and Performance Improvement (QAPI) program for 215 of 215 patients admitted on August 25, 2025, when 1. The facility did not ensure proper patient transport techniques were used for Patient 31, leading to a fall. 2. The facility did not document accurate fall risk assessment (a tool used to determine the patient is at high risk for falling, scoring from 0- 20 no risk or low risk, 25 -44 medium risk, 45 or more is a high-risk score) for Patient 15. 3. The facility did not ensure a care plan (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) for falls was initiated and implemented for a high-fall risk patient (Patient 20). 4. The facility did not ensure a safe patient care environment in procedure areas that led to a fall for Patient 15 and Patient 17. These failures resulted in the hospital’s inability to identify the problem prone areas and create changes to improve patients’ health outcomes and had the potential to cause preventable adverse patient outcomes that could negatively affect patients’ health and safety of patients who sought care in the facility. Findings: 1.During a review of Patient 31’s History and Physical (H&P -a comprehensive medical document created by a physician that details a patient’s medical history) H&P, dated August 13,2025, the H&P indicated, “Patient 31 had medical history of hypertension (a chronic condition characterized by persistently elevated blood pressure levels) and fibromyalgia(a chronic condition characterized by widespread musculoskeletal pain, fatigue, and other symptoms). During a review of Patient 31’s “Operative Report,” dated August 13, 2025, at 2:58 PM, the “Operative report” indicated, “Operations: Laparoscopic (minimally invasive surgical procedure that allows surgeons to examine and operate on organs in the abdomen and pelvis through small incisions) robotic gastric bypass(a weight loss procedure that involves altering the digestive system to reduce calorie intake and absorption) ... Disposition: The patient was stable at the end of operation ...” During a review of Patient 31’s “Nursing Progress Note,” dated August 13, 2025, at 3:50 PM, the “Nursing Progress Note” indicated, “[Registered Nurse(RN 3)]: While moving patient from gurney to hospital bed with (transporter) using inflated glide sheet, hospital bed moved, and patient started sliding down between the bed and gurney. Unable to lift the patient to bed, lowered patient to floor with inflated glide sheet. No injuries noted ... With assistance from 4th floor personnel, patient moved to the bed with an appropriate size lift.” During an interview on August 28, 2025, at 12:30 PM, with RN 3, RN 3 stated, “The transporter was pulling, and I was pushing the patient to the new bed, and the bed moved. If the wheels were locked the bed should not be able to move ...Locking the bed should be part of the process but I am unsure if they were locked.” RN 3 further stated, “we probably should have had another person help us because of the size of the patient.” 2. During a review of Patient 15’s face sheet (contains demographic and medical information), the face sheet indicated, Patient 15 was admitted to the facility on June 20, 2025, with diagnoses which included multiple syncopal events (fainting or passing out); fall causing hematoma (collection of blood under the skin or in the tissues), and chronic heart failure (heart is not pumping as strong as it should be over a long period of time). During a review of Patient 15’s “Assessment Documentation” (contains patient’s health, condition, needs), dated June 20, 2025, the “Assessment Documentation” indicated, the initial fall risk assessment was 4, which indicated a low fall risk score. The fall risk assessment score did not include Patient 15’s history of more than one fall within six months before admission, which would automatically place Patient 15 as a high fall risk per protocol. A review of Patient 15’s “Consent to Surgery or Special Procedure,” dated June 23, 2025, indicated, Patient 15 underwent a procedure in the IR for an image guided (video/picture assisted) temporary hemodialysis (treatment that cleans blood when kidneys cannot) catheter (special tube placed into a large vein to give doctors and nurses direct access to the bloodstream) placement. A review of Patient 15’s “Progress Note - Physician Note,” dated June 29, 2025, indicated, during the procedure, Patient 15 became agitated and rolled out of bed landing on his face. Patient was placed in cervical collar (neck brace or stiff support that goes around the nek to keep it still and straight) and received a Computed Tomography (CT - x-ray test that takes many pictures of the inside of the body from different angles) scan of head and neck. CT scan of the head demonstrated subacute subdural hematoma (slow brain bleed that builds up days or weeks after head injury) with some bleeding and small subarachnoid hemorrhage (bleeding in the space of the brain). Patient 15 was transferred to the Intensive Care Unit (ICU) where Patient 15 was intubated (having a breathing tube placed into the throat so it can help with breathing) for altered mental status. 3.During a review of Patient 20’s face sheet (contains demographic and medical information), the face sheet indicated, Patient 20 was admitted to the facility on August 20, 2025, with diagnoses including shortness of breath (difficulty breathing), hypertension (high blood pressure - heart is pushing too hard on your arteries), and chronic heart failure (heart is not pumping as strong as it should be over a long period of time). A review of Patient 20’s “Assessment Documentation,” dated August 27, 2025, indicated the fall risk assessment score was 17, which indicated a high fall risk. During a concurrent interview and record review on August 27, 2025, at 8:42 AM, with Registered Nurse 4 (RN 4), in the Critical Care Unit (CCU - part of the hospital where the sickest patients go), Patient 20’s “Assessment Documentation,” dated August 27, 2025, was reviewed. RN 4 confirmed Patient 20’s fall risk score was 17, which indicated a high fall risk. RN 4 was unable to provide any documented evidence to show Patient 20’s care plan for falls. RN 4 stated every patient who deemed at risk of fall should have a care plan initiated and interventions should be implemented. 4.During a review of Patient 17’s face sheet, the face sheet indicated, Patient 17 was admitted to the facility on August 21, 2025, with diagnoses including left distal foot gangrene (area at the end of their left foot where the skin and tissue have died), and critical limb ischemia (blood flow to a leg or foot is extremely blocked). A review of Patient 17’s “Assessment Documentation,” dated August 22, 2025, indicated, Patient 17 had a fall risk assessment score of 7, which indicated a moderate fall risk. A review of Patient 17’s “Procedure Note,” dated August 22, 2025, indicated, Patient 17 underwent an abdominal aortogram (x-ray test with dye that lets doctors see how blood flows through the main artery in the stomach, to check for blockages or weak spots), aortogram with iliofemoral runoff (AIF - dye test that shows how blood flows from the stomach artery into the legs), and left popliteal artery (big artery behind the left knee) percutaneous transluminal angioplasty (PTA - when doctors use a balloon inside the blood vessel to open up a blockage). During a concurrent observation and interview on August 27, 2025, at 2:09 PM, with UD3, in the Cardiac Catheterization Laboratory (CCL - where doctors use tiny tubes, x-rays, and dye to see and fix heart arteries without opening the chest), the CCL room was observed to have a narrow bed with a thin mattress on top. No side railings were observed. UD3 demonstrated the use of arm board slates that could be tucked underneath the mattress but had no security to keep them in place. UD3 further stated the arm boards are held down primarily by a patient’s weight, but the arm boards can still move and fall out. There were no side railings or securements to prevent a patient from falling out of bed. UD3 stated that the CCL staff did not use restraints on the oriented patients who were able to follow commands. UD3 further stated, Patient 17 was oriented and able to follow commands, so staff did not strap him down or use restraints to secure him to the bed. During an interview on August 28, 2025, at 11:30 AM, with the Director of Quality (DQ), the survey team’s findings were discussed as follows: The facility did not ensure proper patient transport technique was used leading to a fall, the facility did not document an accurate fall risk assessment, the facility did not ensure a care plan for falls was initiated and implemented for a high fall risk patient, and the facility did not ensure a safe patient care environment in procedure areas that lead to a fall. The DQ acknowledged these findings and stated that the facility will work to correct these findings. During a concurrent interview and record review on August 28, 2025, at 11:39 AM, with the DQ, the facility’s “Quality Improvement Committee meeting minutes,” dated June 26, 2025, was reviewed. The “Quality Improvement Committee meeting minutes” indicated, Performance Improvement monitoring (PIMS) report: PIMS were developed for monitoring corrective action effectiveness, resulting from regulatory and licensing surveys. Nursing Fall precautions: All areas were at 100 percent (%) for June 2025, except Emergency department, Unit 4 North and South monitoring can be discontinued. The DQ acknowledged and stated, QAPI are already tracking falls and nursing fall prevention with the Quality Committee and PIMS since this was a finding from a previous complaint validation survey (survey cycle from September 27, 2024, to February 10,2025), however Quality department is still seeing falls, and an increase in falls in July 2025. During a review of the facility’s document titled, “Falls Task Force meeting minutes,” dated August 13, 2025, the “Falls Task Force meeting minutes” indicated, the facility reported falls as follows: January 2025: 23 falls February 2025: 15 falls March 2025: 20 falls April 2025: 15 falls May 2025: 14 falls June 2025: 12 falls July 2025 : 22 falls During an interview on August 28, 2025, at 11:40 AM, with the DQ, the DQ stated, the falls task force meets monthly reviewing aspects of falls like location time, unit, type, outcome and follow up. However, “QAPI still needs to do better to eliminate these falls from happening”. During a concurrent interview and record review on August 28, 2025, at 11:45 AM, with the DQ, the facility’s “Quality management Plan FY2025,” dated 2025, was reviewed, the “Quality management plan FY2025” indicated, “The scope of the organizations QAPI program, established by the medical staff and an interdisciplinary Quality/Patient Safety Committee with the support and approval of the Community Governing Board, encompasses organization-wide activities related to performance measurement, assessment, improvement and control of patient care and support services...Improvement opportunities are identified though data analysis activities and assessments. Actions to improve is initiated for priorities identified by organizational leaders. The efficacy of performance improvement activities is assessed to determine whether changes made have resulted in improvement. Action is taken when improvement is not achieved or sustained.” The DQ stated that the quality team has the overall responsibility for evaluating the problems, The facility has a fall task force in place, but the facility still needs to figure out how to stop falls from happening.”

“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: 51099 Based on interview, and record review, the facility failed to ensure nursing staff developed and maintained an individualized nursing care plan (a documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) as per the facility’s policy and procedure for one of 31 sampled patients (Patient 20) when the nursing staff did not develop the care plan for fall prevention management for Patient 20. This failure resulted in a lack of communication between the healthcare team of Patient 20’s current health status, which had the potential to result in inadequate treatment, monitoring and management and may lead to serious injury, which can jeopardize the health and safety of the patient. Findings: During a review of Patient 20’s face sheet (contains demographic and medical information), the face sheet indicated, Patient 20 was admitted to the facility on August 20, 2025, with diagnoses including shortness of breath (difficulty breathing), hypertension (high blood pressure - heart is pushing too hard on your arteries), and chronic heart failure (heart is not pumping as strong as it should be over a long period of time). A review of Patient 20’s “Assessment Documentation,” dated August 27, 2025, indicated the fall risk assessment (a tool used to determine the patient is a high risk for falling; scoring from 0-5 is low risk, 6-13 is moderate risk, 14 and above is high risk) score was 17, which indicated a high fall risk. During a concurrent interview and record review on August 27, 2025, at 8:42 AM, with Registered Nurse 4 (RN 4), in the Critical Care Unit (CCU - part of the hospital where the sickest patients go), Patient 20’s “Assessment Documentation,” dated August 27, 2025, was reviewed. RN 4 confirmed Patient 20’s fall risk score was 17, which indicated a high fall risk. RN 4 was unable to provide any documented evidence to show Patient 20 had a care plan for falls. RN 4 stated every patient who deemed at risk of fall should have a care plan initiated and interventions should be implemented. During a concurrent interview and record review on August 27, 2025, at 1:49 PM, with Unit Director 1 (UD1), in the CCU, the facility’s policy and procedure (P&P) titled, “[Corporate NAME] Health Core Nursing Standards of Practice,” dated June 2, 2021, was reviewed. The P&P indicated, “ ...4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes ....a. Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner ...h. Documents implementation, modifications and evaluation of goals; including changes or omissions, of the identified plan ...” UD1 stated the facility staff did not follow the P&P when Patient 20 did not have a fall risk care plan initiated.”

“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: 46696 Based on interview, and record review, the hospital failed to ensure that licensed nursing staff adhered to the facility’s policies and procedures (P&P) for patient care, for two of 31 sampled patients (Patient 15 and Patient 31) when: 1. For Patient 31, the nursing staff did not ensure patient bed was locked during transfer. 2. For Patient 15, a “Fall Risk Assessment” (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk, 25 - 44 medium risk, 45 or more is a high risk score ), misidentified a high fall risk to a low fall risk, so the correct fall intervention was not implemented. These failures resulted in patients fall from not being accurately assessed and not provided with appropriate fall prevention interventions, which could have contributed to a life-threatening complications, disability, or death. Findings: 1. During a review of Patient 31’s History and Physical (H&P -a comprehensive medical document created by a physician that details a patient’s medical history) H&P, dated August 13,2025, the H&P indicated, “Patient 31 had medical history of hypertension (a chronic condition characterized by persistently elevated blood pressure levels) and fibromyalgia(a chronic condition characterized by widespread musculoskeletal pain, fatigue, and other symptoms). During a review of Patient 31’s “Operative Report,” dated August 13, 2025, at 2:58 PM, the “Operative report” indicated, “Operations: Laparoscopic (minimally invasive surgical procedure that allows surgeons to examine and operate on organs in the abdomen and pelvis through small incisions) robotic gastric bypass (a weight loss procedure that involves altering the digestive system to reduce calorie intake and absorption) ... Disposition: The patient was stable at the end of operation ...” During a review of Patient 31’s “Nursing Progress Note,” dated August 13, 2025, at 3:50 PM, the “Nursing progress Note” indicated, “[Registered Nurse (RN 3)]: While moving patient from gurney to hospital bed with (transporter) using inflated glide sheet, hospital bed moved, and patient started sliding down between the bed and gurney. Unable to lift the patient to bed, lowered patient to floor with inflated glide sheet. No injuries noted ... With assistance from 4th floor personnel, patient moved to the bed with an appropriate size lift.” During a review of the facility’s policy and procedure (P&P) titled, “Radiology Patient Transportation, Departments: Radiology/ Imaging Departments, Nursing and Emergency Departments,” dated August 5, 2025, the P&P indicated , “ ...Transportation of patients to and from the Radiology Department will be conducted under strict safety guidelines to include but not limited to: ... c. utilization of safe and appropriate transportation equipment (wheel chairs, gurneys, or beds. D. Observation of body mechanics, e. the Transporter will seek assistance with the transport as deemed necessary and whenever patient safety may be compromised ...” During an interview on August 28, 2025, at 12:30 PM, with RN 3, RN 3 stated, “The transporter was pulling, and I was pushing the patient to the new bed, and the bed moved. If the wheels were locked the bed should not be able to move ...Locking the bed should be part of the process but I am unsure if they were locked.” RN 3 further stated, “we probably should have had another person help us because of the size of the patient.” 2. During a review of Patient 15’s face sheet (contains demographic and medical information), the face sheet indicated, Patient 15 was admitted to the facility on June 20, 2025, with diagnoses which included multiple syncopal events (fainting or passing out); fall causing hematoma (collection of blood under the skin or in the tissues), and chronic heart failure (heart is not pumping as strong as it should be over a long period of time). During a review of Patient 15’s “Assessment Documentation” (contains patient’s health, condition, needs), dated June 20, 2025, the “Assessment Documentation” indicated, the initial fall risk assessment was 4, which indicated a low fall risk score. The fall risk assessment score did not include Patient 15’s history of more than one fall within six months before admission, which would automatically place Patient 15 as a high fall risk per protocol. During a review of Patient 15’s “Assessment Documentation,” dated June 22, 2025, the fall risk assessment score was 13, which indicated a moderate fall risk score. No other fall risk assessment score was charted prior to Patient 15’s procedure on June 23, 2025. During a review of Patient 15’s “Consent to Surgery or Special Procedure,” dated June 23, 2025, the “Consent to Surgery or Special Procedure” indicated, Patient 15 was to undergo a procedure in Interventional Radiology (IR-doctor uses x-rays, scans, or ultrasound like a GPS to guide small tools inside the body to treat problems without needing big surgery cuts), for an image guided temporary hemodialysis (treatment that cleans blood when kidneys cannot) catheter (special tube placed into a large vein to give doctors and nurses direct access to the bloodstream) placement. During a further review of Patient 15’s “Progress Note - Physician Note,” dated June 29, 2025, the “Progress Note - Physician Note” indicated, during the procedure, Patient 15 became agitated and rolled out of bed landing on his face. Patient was placed in cervical collar and received a Computed Tomography (CT - x-ray test that takes many pictures of the inside of the body from different angles) scan of head and neck. CT of the head demonstrated subacute subdural hematoma (slow brain bleed that builds up days or weeks after head injury) with some bleeding and small subarachnoid hemorrhage (bleeding in the space of the brain). Patient was transferred to ICU where he was intubated for altered mental status. Discussion with patient’s daughter and son at bedside with nurse as well. Patient’s family approaches the ICU team requesting for Patient 15 to be placed on comfort measures. Family came to conclusion that family would like to proceed with comfort care. Code status: DNR [Do Not Resuscitate -a medical order not to provide chest compression or breathing measures when the heart and breathing stops/DNI [Do Not Intubate-physician order not to place on life saving measures when the breathing stops] comfort measures only. A review of Patient 15’s “Discharge Summary,” dated June 30, 2025, indicated, “ ...6/30 ...Patient extubated yesterday and transitioned to comfort care ...Patient was pronounced deceased at 1235 ...” During an interview on August 25, 2025, at 10: 45AM, with RN 5, in the IR department, RN 5 confirmed Patient 15 was not secured with any straps when he was on the procedure bed on June 23, 2025. Patient 15 had two arm-board slats that were inserted underneath the mattress, but the slats could easily be pushed out with a bit of force. RN 5 further stated the IR staff was not aware Patient 15 was a high fall risk because his fall risk score indicated 13, which was a moderate fall risk. According to RN 5, if staff knew about his high fall risk score, more safety prevention measures would have been implemented, such as possible straps or another staff to always be beside patient during procedure. During a concurrent interview and record review on August 28, 2025, at 8:05 AM, with Nurse Manager 1 (NM1), in the Medical Surgical floor, Patient 15’s Assessment Documentation,” dated June 20, 2025, and June 22, 2025, was reviewed. NM1 stated the fall assessment score needs to be accurate to assess patient safety and apply the most appropriate interventions for that patient. NM1 further stated, Patient 15’s fall risk score of 4 and 13 were inaccurate. NM1 confirmed Patient 15 should have had a high fall risk score of 34 because he was admitted for recent falls. NM1 stated patients who have a high fall risk score should have additional fall prevention interventions, such as high fall risk patient identification wristband and remaining besides patient when they get up and fall risk assessment on each shift. During a concurrent interview and record review on August 28, 2025, at 8:08 AM, with NM1 in the Medical Surgical floor, the facility’s P&P titled, “Fall Prevention and Management Policy & Procedure,” undated, was reviewed. The P&P indicated “ ...The policy of [facility NAME] is: ...To provide a safe environment for patients and to minimize their risk of falling ...Acute: ...a. Document fall risk score using appropriate Fall Risk Assessment Tool (FRAT) in the medical health record upon admission, every shift, upon transfer to another level of care or after a patient fall ...b. Document fall injury risk screen upon admission, every shift, and upon transfer to another level of care ...d. Document fall interventions on the appropriate fall risk assessment tool or fall injury screen section ...e. initiate and document plan of care ...” NM1 stated the P&P was not followed. During a review of the facility’s job description titled, “Clinical Nurse I - 61701 - Medical/Surg Acute 5NS TRN,” dated July 31, 2014, the job description indicated, “ ...Job Responsibilities ...1.3. Completes nursing assessment and consistently utilizes/develops initial care plan ...Recognizes patient’s/family’s capabilities and assists them to function at their optimal level ...1.15 Evaluates patient’s needs for safety precautions, such as: ...fall prevention ...””