John Muir Medical Center - Walnut Creek Campus

“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: 46658 Based on observation, interview and record review, the facility failed to ensure the governing body implemented a contract for a juice machine in the mother baby unit in a safe and sanitary manner when there were no responsible persons, policy or procedure to clean or maintain the juice machine for 8 years. This failure placed patients, family and any persons who drank from the juice machine at risk of foodborne illness. Findings: During a concurrent observation and interview with Nurse Manager 2 (NM 2), on 6/10/25, at 11:25 a.m., the juice machine in family nourishment room in the mother baby unit was inspected. The juice machine’s door which was meant to maintain juice below 50F was found open and could not be latched. Three partially full containers of juice were inserted into the dispensing nozzles. The three containers were warm to touch, and the interior surfaces contained tacky, dry residue. NM 2 stated environmental services (EVS) would wipe down the exterior surfaces of the machine, but did not know who cleaned the interior of the machine. NM 2 stated there were no logs of temperature, cleaning or maintenance of the machine, and there was no policy or procedure to clean or maintain the machine. During an interview with coordinator of accreditation and regulatory (CAR), on 6/10/25, at 12:40 p.m., the CAR stated facilities maintenance staff did not clean or service the juice machine. The CAR stated the mother baby unit was responsible for contacting [contractor] for service and maintenance of the juice machine. The CAR stated there was no policy or procedure regarding the juice machine. During a concurrent observation and interview with NM 2, on 6/10/25, at 12:50 a.m., the juice containers in the mother baby unit staff kitchen was inspected. Three containers of juice were in the kitchen and were stored at room temperature. Factory labels on the containers indicated the juice needed to be refrigerated after opening. NM 2 stated staff did not keep track of how long juice remained in the machine and did not have a policy or procedure to track juice usage. During the interview, a staff member and a hospital visitor entered the kitchen with the juice machine and the staff member instructed the visitor that patients and visitors can get juice from the machine. During an interview on 6/11/25, at 1:05 p.m., with Director of Nutrition Services (DNS) and Registered Dietitian 1 (RD 1), DNS stated the nutrition services department was not responsible for the cleaning or maintenance of the machine to manufacturer instructions. DNS and RD 1 stated the machine had been there since before “many of the staff” had worked there. DNS and RD 1 stated the nutrition services department was only responsible for delivering juice to the mother baby unit for the juice machine. During a concurrent observation and interview with DNS and RD 1, on 6/11/25, at 1:18 p.m., the juice machine in the mother baby unit was inspected. The juice machine door was ajar and could not be kept shut. After feeling the juice containers, DNS stated the juice was not cold and could not get cold if the door could not be latched shut. DNS stated juice which couldn’t maintain temperature control would only be good to drink for 4 hours. Upon removal of the juice containers to inspect the internal components, a stain red piece of cloth was discovered near one of the nozzles. DNS stated “I wouldn’t drink from it” and the juice was not safe to drink. A review of FDA (Food and Drug Administration) Food Code, dated 2022, indicated “if time without temperature control is used as the public health control up to a maximum of 4 hours: ...food shall have an initial temperature of 41 F (Fahrenheit, a unit of temperature measurement) or less when removed from cold holding temperature control.” During an interview on 6/12/25, with EVS manager (EVSM), the EVSM stated EVS staff were only allowed to clean the outer surfaces of the juice machine and did not know who was responsible for cleaning the machine according to manufacturer instructions. During a record review on 6/16/25, at 2:50 p.m., the [contractor] juice machine contract, dated 8/29/2017, was reviewed. The contract indicated, “customer agrees to use loaned equipment ...to conform to instructions for its use, including but not limited to keeping the equipment clean and following the sanitation directions posted.” During a review of facility policy and procedure (P&P) titled, “EOC - Nutrition Services Sanitation,” dated 3/27/24, the P&P indicated “all readily perishable ...beverages capable of supporting rapid and progressive growth of microoganisms shall be maintained at temperatures of 40 degrees F or below ...at all times ...all equipment ...will be cleaned ...when visibly soiled and/or immediately after any spill, and at the end of each shift until they are free of loose or stuck on debris, grime or build up.” The P&P indicated a cleaning schedule which indicated drink dispensers were cleaned daily. During a record review of manufacturer Juice machine instructions titled, “[Manufacturer] JDF-2S, JDF-4S Installation and Operating Guide,” dated 2018, the instructions indicated “this appliance must be installed in locations where it can be overseen by trained personnel ...Cleaning & Preventative Maintenance. Daily: Rinse Procedure ...Daily: Parts washing 1. Remove and wash the dispense nozzle(s), drip tray and drip tray cover in a mild detergent solution ...use brush ...to clean inside and o-ring area on dispense nozzles ...Weekly: Clean condenser coils and filter.””

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 49983 Based on observation, interview, and record review, the facility failed to ensure that Certified Nursing Assistants (CNAs) are maintaining their CNA license. This failure had the potential to lead to patient confusion and could result in reduced accountability for reporting incidents of unprofessional conduct or abuse. Findings: During a telephone interview on 6/12/25, at 3:52 p.m., with Nurse Manager 4 (NM4), NM4 stated that Certified Nursing Assistant 1 (CNA 1) did not currently have an active CNA license. NM4 stated the policy is that CNAs are required to have a license at the time they are hired, but they are not required to maintain their CNA license. During a record review of facility’s document, titled, “Job Description”, dated 1/1/24 - 12/31/24 for CNA1, the document indicated that CNA 1’s essential job functions include, “ ... demonstrates a basic knowledge of medical terminology and disease conditions .... performs medication reconciliation ... provides quality nursing care ... accurately takes patient vital signs ...” During a telephone interview on 6/13/25, at 9:55 a.m., with Human Resources Manager of Talent Acquisition (MHR), MHR stated that when CNAs are hired, they need to have an active CNA license. MHR stated the policy was changed several years ago to no longer require that CNAs keep their license active. MHR stated that their job description is as a “Nursing Assistant”, not “Certified Nursing Assistant.” During an interview and concurrent record review on 6/13/25, at 10:26 a.m., with Nurse Manager 2 (NM2), facility’s document titled, “Daily Assignment,” dated 6/13/25, was reviewed. NM2 stated the staffing sheets showed three CNAs assigned to the unit and included CNA2 and CNA3. NM2 stated CNA stands for “Certified Nursing Assistant”. During an interview on 6/13/25, at 10:35 a.m., with CNA2, CNA2 stated she is a Certified Nursing Assistant and her employee ID badge stated “CNA” in the corner. During an interview on 6/13/25, at 10:37 a.m., with CNA3, CNA3 stated she is a Certified Nursing Assistant and her employee ID badge stated “CNA” in the corner. During an interview on 6/16/25, at 8:39 a.m., with CNA1, CNA1 stated he is a Certified Nursing Assistant and his employee ID badge stated “CNA” in the corner. During an interview on 6/16/25, at 1:13 p.m., with Vice President, Clinical Nursing Officer (VPCNO), VPCNO stated that the policy about CNAs was created in 2018. VPCNO stated that the CNA badges and identification on staffing sheets was not looked at when the policy was changed and should have been. During a review of facility’s policy, titled, “HR - Nursing Assistant - Requirements”, with an origination date of 4/2018 and approval date of 7/29/24, the policy stated, “A. Certification is a minimum qualification upon hire for all nursing assistants. B. John Muir Health does not perform primary source verification or maintain records of certification expiration dates for nursing assistants after hire ... “”

“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: 49983 Based on interview and record review, the facility failed to accurately titrate Fentanyl medication for 2 out of 15 reviewed patients. This failure had the potential for patients to be over-sedated, which could interfere with checking for neurological symptoms and delay recovery. Findings: During a review of facility’s document titled, “Encounter”, dated June 12, 2025, for Patient 17, the document indicated Patient 17 was a 31 year old male who arrived at the hospital on 6/8/25 with a diagnosis of Pnuemocephalus (air or gas in the brain). During a review of facility’s document titled, “Medication Administration Record” (MAR, a document used to record medication administration), dated 6/8/25, the MAR indicated Patient 17 was given fentanyl 10mcg/mL standard concentrate infusion (a powerful narcotic with a potential for abuse given into the bloodstream in a continuous rate) at 50 mcg/hr on 6/8/25 at 13:24 and the dose was increased on 6/8/25 at 14:21 to 125 mcg/hr. In a review of facility’s document titled, “Medication”, dated 6/8/25 at 13:45, for Patient 17, the document indicated Patient 17 was prescribed Fentanyl 10 mcg/mL standard concentrate infusion with an administration dose of 0-150 mcg/hr, with administration instructions of “ ... Titrate by 25 mcg/hr every 5 min as needed to a maximum ordered dose to maintain parameters. May reduce rate by 50% every 30 min as tolerated while weaning to off”. In a concurrent interview and record review on 6/12/25, at 11:29 a.m., with Registered Nurse 1 (RN1), facility’s MAR for Patient 17 was reviewed. RN 1 stated the document indicated on 6/8/25, Patient 17 received 50 mcg/hr on 6/8/25 at 13:24 and the dose was increased on 6/8/25 at 14:21 to 125 mcg/hr. RN 1 stated the dose was titrated incorrectly and it should have been increased first to 75 mcg/hr, then if needed after 5 minutes, to 100 mcg/hr, then if needed after five minutes, to 125 mcg/hr. RN 1 stated the reason for titrating the medication is to find the lowest effective dose to control the patient’s pain, so that neurological symptoms are not masked and to not over-sedate the patient. In a concurrent interview and record review on 6/12/25, at 11:29 a.m., with RN 1, facility’s document titled, “Richmond Agitation Sedation Scale” (RASS, an instrument designed to assess the level of alertness and agitation in critically ill patients) for Patient 17 was reviewed. RN 1 stated the document indicated that on 6/8/25 at 13:23, Patient 17 had a RASS score of +1 (restless), and on 6/8/25 at 15:00, Patient 17 had a RASS score of -3 (Moderate Sedation). During a record review of facility’s document titled, “Encounter”, dated 6/12/25, the document indicated that Patient 21 was a 79 year old male who arrived at the facility on 6/6/25 at 11:52 am with a diagnosis of trauma. During a review of facility’s document titled, “Complex Assessment”, dated 6/11/25, for Patient 21, on 6/11/25 at 0:00 and 01:05, Patient 21’s Critical-Care Pain Observation tool (CPOT, a tool used to assess pain in critically ill patients who are unable to communicate their pain) was 0 (meaning no pain). During a review of facility’s document titled “Medication”, dated 6/10/25 at 23:55, Fentanyl 10mcg/mL standard concentration infusion was ordered for Patient 21, with administration instructions of: “Mild Pain (1-3): Initiate infusion at 12.5 mcg/hr; Moderate Pain (4-6): Initiate infusion at 25 mcg/hr; Severe Pain (7-10): Initiate infusion at 50 mcg/hr; Titrate by 25 mcg/hr every 5 min as needed to a maximum ordered dose to maintain parameters. May reduce rate by 50% every 30 min as tolerated while weaning to off.” The order also stated, “titrate to: Critical care pain observation tool rating of 0 to 2”. The order had a scheduled start time of 6/11/25 at 00:15. During a review of facility’s document titled, “MAR”, dated 6/11/25, for Patient 21, on 6/11/25 at 00:25, Patient 21 received the Fentanyl infusion started at a rate of 25 mcg/hr. During a concurrent interview and record review on 6/12/25, at 10:23 a.m., with RN 1, facility’s documents titled, “Complex Assessment”, dated 6/11/25, “MAR Report” dated 6/11/25, and “RASS”, dated 6/11/25 for Patient 21 were reviewed. RN 1 stated the documents indicated that on 6/11/25 at 0:00 a.m., Patient 21 had a CPOT of zero (no pain), an opioid sedation scale of 4 (somnolent), and a RASS of -3 (moderate sedation). RN1 stated on 6/11/25 at 00:25, a bag of fentanyl 10mcg/mL standard concentrate infusion was started for Patient 21 at a rate of 25 mcg/hr. RN 1 stated the fentanyl order did not indicate what rate to start an infusion for a patient with a CPOT of zero. During a concurrent interview and record review on 6/12/25, at 10:47 a.m., with the Director of Critical Care (DCC), facility’s document titled “Medication”, dated 6/10/25 for Patient 21 was reviewed. DCC stated the fentanyl orders entered on 6/10/25 for Patient 21 were part of an order set (a tool used to help doctors choose which medication and which dose to order), titled “JMH ICU IP CRITICAL CARE CONTINUOUS SEDATION INFUSION.” DCC stated the orders were unclear and the way the fentanyl order was written was incorrect and needed to be updated. DCC stated the fentanyl infusion order did not indicate how the infusion should be started if the patient had a CPOT of zero. DCC stated the orders needed to be re-written. During an interview and concurrent record review on 6/16/25, at 11:23 a.m., with DCC, facility’s order set, titled “JMH ICU IP CRITICAL CARE CONTINUOUS SEDATION INFUSION,” dated 1/14/19, were reviewed. DCC stated that as the orders were written, it was not clear if the fentanyl IV infusion should be started if a patient had a CPOT of zero. DCC stated the pain scale on the administration orders went up to 10, but the CPOT pain scale went up to 8, and this does not match, so it could create confusion for the nurses on what they should do. During a concurrent interview and record review on 6/16/25, at 10:34 a.m., with Pharmacy Manager (PM), facility’s order set titled, “JMH ICU IP CRITICAL CARE CONTINUOUS SEDATION INFUSION” was reviewed. PM stated that the order for the fentanyl infusion did not state what to do if the patient’s CPOT was zero and stated that based on how the orders were written, the fentanyl would not be started if the CPOT was zero. During a concurrent interview and record review on 6/12/25, at 10:23 a.m., with RN 1, facility’s documents titled, “Complex Assessment”, dated 6/11/25, “MAR Report” dated 6/11/25, and “RASS”, dated 6/11/25 for Patient 21 were reviewed. RN 1 stated the documents indicated on 6/11/25 at 1:05 a.m., Patient 21 had a CPOT of zero and an opioid sedation scale of 3. RN 1 stated there was a RASS score done on 6/11/25 at 00:24 a.m. which was -4 (deep sedation, no response to voice, but movement or eye opening to physical stimulation). RN 1 stated for a patient with an opioid sedation score of 3 and a CPOT of zero, it would be reasonable to decrease the opioid dose. RN 1 stated on 6/11/25 at 1:05 a.m., the fentanyl 10mcg/mL standard concentrate infusion was increased from 25 mcg/hr to 50 mcg/hr and it should not have been increased at that time because the patient was sedated and had a CPOT pain score of zero. During a review of facility’s policy titled, “Pain Management”, dated 1/26/22, the policy stated, “sedation level is assessed/reassessed using the Opioid Sedation Scale: Pasero Opioid-induced Sedation Scale (POSS).” The policy also stated, “In the critical care areas, patients may be on a continuous sedation infusion such as Propofol or Midazolam, in addition to receiving opioids for pain treatment. In the event that a patient is on a continuous sedative infusion in addition to receiving opioids, the RN will document the Richmond Agitation Sedation Scale (RASS) as the sedation scale in place of the Opioid Sedation Scale in order to ensure appropriate pain treatment .... The RASS should be documented upon receipt of the patient, every four hours and as indicated for titration of medication ...” The policy further indicated that a Pasero Opioid-induced Sedation Scale at a level of 3 would indicate that a sedation of 3 was “unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50% or notify prescriber ...””

“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: 46658 Based on observation, interview and record review, the facility failed to ensure staff followed adequate infection control practices when a juice machine in the mother baby unit was found to be unclean, unsanitary and was dispensing unrefrigerated juice because there were no staff who were trained or responsible for the manufacturer recommended cleaning, sanitization or maintenance instructions. This failure placed patients, family and any persons who drank from the juice machine at risk of foodborne illness. Findings: During a concurrent observation and interview with Nurse Manager 2 (NM 2), on 6/10/25, at 11:25 a.m., the juice machine in family nourishment room in the mother baby unit was inspected. The juice machine’s door which was meant to maintain juice below 50F was found open and could not be latched. Three partially full containers of juice were inserted into the dispensing nozzles. The three containers were warm to touch, and the interior surfaces contained tacky, dry residue. NM 2 stated environmental services (EVS) would wipe down the exterior surfaces of the machine, but did not know who cleaned the interior of the machine. NM 2 stated there were no logs of temperature, cleaning or maintenance of the machine, and there was no policy or procedure to clean or maintain the machine. During an interview with coordinator, accreditation and regulatory (CAR), on 6/10/25, at 12:40 p.m., the CAR stated facilities maintenance staff did not clean or service the juice machine. The CAR stated the mother baby unit was responsible for contacting [contractor] for service and maintenance of the juice machine. During a concurrent observation and interview with NM 2, on 6/10/25, at 12:50 a.m., the juice containers in the mother baby unit staff kitchen was inspected. Three containers of juice were in the kitchen and were stored at room temperature. Factory labels on the containers indicated the juice needed to be refrigerated after opening. NM 2 stated staff did not keep track of how long juice remained in the machine and did not have a policy or procedure to track juice usage. During the interview, a staff member and a hospital visitor entered the kitchen with the juice machine and the staff member instructed the visitor that patients and visitors could get juice from the machine. During an interview on 6/11/25, at 1:05 p.m., with Director of Nutrition Services (DNS) and Registered Dietitian 1 (RD 1), DNS stated the nutrition services department was not responsible for the cleaning or maintenance of the machine to manufacturer instructions. DNS and RD 1 stated the machine had been there since before “many of the staff” had worked there. DNS and RD 1 stated the nutrition services department was only responsible for delivering juice to the mother baby unit for the juice machine. During a concurrent observation and interview with DNS and RD 1, on 6/11/25, at 1:18 p.m., the juice machine in the mother baby unit was inspected. The juice machine door was ajar and could not be kept shut. After feeling the juice containers, DNS stated the juice was not cold and could not get cold if the door could not be latched shut. DNS stated juice which couldn’t maintain temperature control would only be good to drink for 4 hours. Upon removal of the juice containers to inspect the internal components, a stained red piece of cloth was discovered near one of the nozzles. DNS stated, “I wouldn’t drink from it” and the juice was not safe to drink. A review of FDA (Food and Drug Administration) Food Code, dated 2022, indicated “if time without temperature control is used as the public health control up to a maximum of 4 hours: ...food shall have an initial temperature of 41 F (Fahrenheit, a unit of temperature measurement) or less when removed from cold holding temperature control.” During an interview on 6/12/25, with EVS manager (EVSM), the EVSM stated EVS staff were only allowed to clean the outer surfaces of the juice machine and did not know who was responsible for cleaning the machine according to manufacturer instructions. During a record review on 6/16/25, at 2:50 p.m., the [contractor] juice machine contract, dated 8/29/2017, was reviewed. The contract indicated, “customer agrees to use loaned equipment ...to conform to instructions for its use, including but not limited to keeping the equipment clean and following the sanitation directions posted.” During a review of facility policy and procedure (P&P) titled, “EOC - Nutrition Services Sanitation,” dated 3/27/24, the P&P indicated “all readily perishable ...beverages capable of supporting rapid and progressive growth of microoganisms shall be maintained at temperatures of 40 degrees F or below ...at all times ...all equipment ...will be cleaned ...when visibly soiled and/or immediately after any spill, and at the end of each shift until they are free of loose or stuck on debris, grim or build up.” The P&P indicated a cleaning schedule which indicated drink dispensers were cleaned daily. During a record review of manufacturer Juice machine instructions titled, “[Manufacturer] JDF-2S, JDF-4S Installation and Operating Guide,” dated 2018, the instructions indicated “this appliance must be installed in locations where it can be overseen by trained personnel ...Cleaning & Preventative Maintenance. Daily: Rinse Procedure ...Daily: Parts washing 1. Remove and wash the dispense nozzle(s), drip tray and drip tray cover in a mild detergent solution ...use brush ...to clean inside and o-ring area on dispense nozzles ...Weekly: Clean condenser coils and filter.””

“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: 38534 Based on record review and interview the facility failed to do the pain assessment and re-assessment for one of 30 sample selected patients (Patient 23) when Patient 23 was in the Emergency Department (ED) for abdominal pain and Patient 23’s pain was not reassessed after the initial assessment. This failure had the potential to result in Patient 23 experiencing uncontrolled pain, delayed treatment, increased complications, and reduced satisfaction. Findings: A review of Patient 23’s History and Physical (H&P), dated 4/14/25, indicated Patient 23 was admitted to the hospital with abdominal pain. A review of Patient 23’s pain flowsheet record indicated, Patient 23’s abdominal pain score was six out of 10 on 4/14/25, at “14:11 (2:11 p.m.) in the Emergency Department (ED),” and the next time staff checked Patient 23’s pain score on 4/15/25 at “05:35 (5:35 a.m.),” which was15 hours and 24 minutes later, the pain score was four out of 10. During a consecutive record review and interview on 4/16/25, at 10:00 a.m., with the ED Manager (EDM), Patient 23’s pain flow sheet, Medication Administration Record (MAR), and nurses’ notes were reviewed. EDM confirmed the pain assessment delay, and stated Patient 23 was not re-assessed for pain and staff did not do any intervention for pain level six out of 10 at that time. Furthermore, EDM stated staff should re-assess patient’s pain at least once a shift which is every eight hours. A review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 12/22/21, indicated “ ...Patient Assessment/Reassessment: The registered nurse (RN) will assess the patient’s pain level on admission, during the shift assessment ...””

“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: 38534 Based on record review and interview, the facility failed to ensure the nursing staff developed and implemented an individualized care plan for one of 30 sample selected patients (Patient 24), when Patient 24 was using Patient-Controlled Analgesia (PCA) and staff did not care plan the PCA. This failure had the potential to result in patient 24’s risk of inadequate pain relief, overdose, unmanaged side effects, prolonged hospital stays, and increased anxiety, all of which can negatively impact recovery and overall health. Findings: A review of Patient 24’s History and Physical (H&P) dated 4/14/25, indicated Patient 24 was hospitalized for scheduled hysterectomy (a surgical operation to remove all or part of the uterus). A review of Patient 24’s medication order on 4/14/25, indicated, “ ... Hydromorphone (a medication used to relieve pain severe enough to require opioid treatment) ... via PCA ...” A review of Patient 24’s Care Plan, dated 4/16/25, indicated staff did not develop any care plan for pain nor PCA. During an interview on 4/17/25, at 11:15 a.m., with the Medical Surgical Intensive Care Unit Manager (MSICUM), MSICUM stated staff should initiate a care plan for PCA and assess and re-assess the pain frequently. MSICUM stated a care plan for pain control for Patient 24 could help Patient 24 be comfortable and make the recovery from surgery faster. A review of the facility’s policy and procedure (P&P) titled, “Patient Assessment and Reassessment,” dated 8/2024, indicated, “ ... All members of the care team document the treatment strategies and/or education provided to the patient to meet the plan of care goals, using the appropriate navigator in the EHR. The appropriate care provider will: 1. Select/add the appropriate care plan template(s) based on the patient’s diagnosis and assessment findings. Documentation will address the goals of the care plan, interventions will facilitate resolution of problems, and individualized expected end dates by the time of discharge. 2. Add additional goals and interventions as needed throughout the hospitalization. 3. Edit the care plan goal(s) and intervention(s) and individualize them to the patient. Care plan goals and interventions can also be customized using free text. 4. Evaluate the patient and document the goal(s) and intervention(s) implemented ... b. All stable, acute patients will be reassessed as appropriate for their condition during/post treatments and prior to discharge or transfer c. Patients who have continued pain will be reassessed as appropriate ...””

“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: 38534 Based on observation and interview and record review, the facility failed to prevent contamination and implement infection prevention plan when: 1. Two of 13 Operation Room (OR) doors were not functioning correctly and were open during the operation. 2. Medication room refrigerator for IV (intravenous) medications was not clean and had unknown white residue. 3. Staff did not maintain aseptic technique during the foley catheter (a type of indwelling urinary catheter (IUC) used to drain urine from the bladder when a person cannot do so naturally) insertion for one of 30 sample selected patients (Patient 24). These failures had the potential to result in: 1. Increase of risk of infection in OR, Disruption of Airflow Control, Higher Noise Levels, and Temperature and Humidity Changes. 2. Contamination of refrigerator and risk of infection for patients. 3. Urinary tract infections, catheter-associated infections, sepsis, tissue damage, and hospital protocol violations, all which compromise patient safety and increase medical risks. Findings: During a review of post operation progress note, “gynecologic oncology progress note” indicated Patient 27 (who had surgery in OR 11) on 4/16/25, at 11:43 a.m., had a total abdominal hysterectomy (surgery to remove the uterus). During a review of post operation progress note, “HBO (Hepato-Pancreato-Biliary) surgical oncology progress note” indicated Patient 28 (who had surgery in OR 12) on 4/16/25, at 10:27 a.m., had a pancreatectomy (a surgical procedure involving the removal of all or part of the pancreas). During a concurrent interview and observation of OR on 4/14/25, at 11:10 a.m., with Operation Room Supervisor (ORS), OR room doors numbered 11 and 12 were open during active operation. ORS confirmed the doors were not closed and not functioning correctly and stated the OR staff were aware of the issue. During an interview on 4/14/25, at 11:20 a.m., with the Clinical Educator (CE), CE observed the OR doors (11 and 12) and stated the OR doors should be closed all the time during the surgery, with minimum traffic because open doors can cause contamination. During an interview with the Accreditation and Regulatory Supervisor (ARS) on 4/17/25, at 11:50 a.m., ARS stated that facility doesn’t have any policy and procedure to keep the OR doors closed during the operation. During a concurrent observation and interview on 4/15/25, at 9:45 a.m., in medication room at unit 5A (Tele/Oncology) with the Registered Nurse (RN)1, there was unidentified white residue inside the refrigerator, and RN 1 stated staff use that refrigerator for storing patient’s IV medication. During an interview on 4/16/25, at 2:30 p.m., with the Pharmacist Manager (PM), PM stated part of pharmacy scope is to keep the medication refrigerators clean. When the pharmacist or technician checks the medication rooms, they should check the medication refrigerators and clean them. PM stated the nurses can report to the pharmacy if the refrigerators need to be cleaned. Furthermore, PM stated the facility does not have a specific policy and procedure for cleaning the refrigerator and that it is their practice to keep them clean. During a concurrent observation and interview on 4/14/25, at 1:30 p.m., in the OR with the Operation Room Supervisor (ORS), Registered Nurse (RN)2 prepared the tray for inserting foley catheter for Patient 24: RN 2 took sponges from the sterile tray with right hand and opened the vagina area with left hand and cleaned the contaminated vaginal area with sponges, did not change the gloves, and then held the sterile foley catheter with right hand and inserted it into the bladder with the same contaminated gloves. ORS confirmed the observation and stated that is not the facility’s standard of practice for nurses to touch the sterile foley catheter with contaminated gloves. ORS stated RN2 should have changed her gloves in order to touch the sterile foley catheter. During an interview on 4/16/25, at 9:39 a.m., with the Infection Preventionist (IP), IP stated the OR doors should be kept closed during the operation to minimize the risk of surgical site infection. IP stated the medication refrigerators should be kept clean to prevent infection, and furthermore stated nurses should change their gloves between contaminated and sterile areas of care. A review of the facility’s policy and procedure (Mosby) titled, “Urinary catheter: Indwelling insertion (female)” undated, indicated, “ ...6. Wash the perinea! area with soap and water, locate the urinary meatus, and dry the area. Have an assistant hold an alternative light source to illuminate the perineum as needed. Rationale: Washing minimizes contamination in the area before catheter insertion. An alternative light source is helpful because seeing the urinary meatus of a female patient may be difficult because of the patient’s distinct anatomy.7. Discard used supplies, remove gloves, and clean hands ... The dominant gloved hand remains sterile. Cleaning follows the principles of medical asepsis and reduces the number of microorganisms at the urethral meatus, decreasing the likelihood that flora on the skin is introduced into the urethra or bladder. If the labia are allowed to close during cleaning, the cleaning procedure must be repeated because the area is contaminated. 15. With the sterile dominant hand, pick up the catheter. Hold the distal end of the catheter loosely coiled in the palm of the dominant hand ...””