Usc Arcadia Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility failed to ensure translation services were utilized based on the patients’ preferred language when presented and asked to sign the “Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient’s responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)” form for two of 30 sampled patients (Patient 13 and Patient 20) in accordance with the facility’s policy and procedure regarding patient rights. This deficient practice had the potential to result in Patient 13 and Patient 20 to not fully understand what they were agreeing to, nor what their patient rights were upon signing the COA form. (Refer to A-0117) 2. The facility failed to ensure one of 30 sampled patients’ (Patient 26) “Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient’s responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)” form not in Patient 26’s preferred language was signed by the patient or patient’s representative in accordance with the facility’s policy and procedure regarding admitting procedures. This deficient practice had the potential for Patient 26 to not fully understand their patient rights, treatment, billing process, payments, and services rendered by the facility. (Refer to A-0117) 3. The facility failed to ensure its nursing staff obtained a physician order for restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 30 sampled patients (Patient 24) in accordance with the facility’s policy and procedure on restraints use when Patient 24 was placed in soft restraints (padded, fabric-based devices designed to temporarily restrict a patient’s movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes) without a physician order for three hours and 3 minutes. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 24 which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). (Refer to A-0168) 4. The facility failed to ensure two of 30 sampled patients (Patient 17 and Patient 24), who were placed on soft restraints (padded, fabric-based devices designed to temporarily restrict a patient’s movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes), were monitored by nursing staff every two hours in accordance with the facility’s policy and procedure regarding restraints. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 17 and Patient 24, which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 45774 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure an individualized nursing care plan (a document that helps a patient’s care team communicate and organize patient care) was initiated for seven of 30 sampled patients (Patient 3, Patient 16, Patient 18, Patient 22, Patient 23, Patient 25 and Patient 27) in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying patients’ needs and risks and could lead to patients not receiving safe and effective care. (Refer to A-0396) 2. The facility failed to ensure five of 30 sampled patients (Patient 8, Patient 11, Patient 16, Patient 23, and Patient 26) had intravenous (IV, a tube going directly into the vein) sites labeled with the insertion (placement) date and the nurse’s initials in accordance with the facility’s policy and procedure regarding IV therapy management. This deficient practice had the potential to place patients at risk for a skin infection (infection, a growth of germs that can cause illness), a blood infection, blood clots (a gel-like clump of blood), and tissue (a body part that performs a specific function, such as skin) damage at the IV insertion site. (Refer to A-0398) 3. The facility failed to ensure one of 30 sampled patients (Patient 16) wore a fall risk armband in accordance with the facility’s policy and procedure regarding falls prevention. This deficient practice had the potential for Patient 16 falling and becoming injured due to not being provided extra fall risk monitoring and precautions. (Refer to A-0398) 4. The facility failed to ensure antibiotic medications (medications for infection) were given as ordered for two of 30 sampled patients (Patient 11 and Patient 12) in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential for Patient 11 and Patient 12 experiencing drug complications due to not maintaining a constant therapeutic level of a drug in their bodies. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to: 1. Ensure translation services were utilized based on the patients’ preferred language when presented and asked to sign the “Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient’s responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)” form for two of 30 sampled patients (Patient 13 and Patient 20) in accordance with the facility’s policy and procedure regarding patient rights. This deficient practice had the potential to result in Patient 13 and Patient 20 to not fully understand what they were agreeing to, nor what their patient rights were upon signing the COA form. 2. Ensure one of 30 sampled patients’ (Patient 26) “Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient’s responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)” form not in Patient 26’s preferred language was signed by the patient or patient’s representative in accordance with the facility’s policy and procedure regarding admitting procedures. This deficient practice had the potential for Patient 26 to not fully understand their patient rights, treatment, billing process, payments, and services rendered by the facility. Findings: 1. a. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/1/2025, the H&P indicated Patient 13 was admitted to the facility on 9/1/2025 for epigastric pain for eight months related to acute cholecystitis (sudden inflammation of the gallbladder). During a review of Patient 13’s “Discharge Plan/Social Worker Evaluation,” dated 9/2/2025, the evaluation indicated Patient 13’s preferred language was Mandarin. The note also indicated Patient 13 required language assistance. During a concurrent interview and record review on 9/3/2025 at 3:10 PM with Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 13’s “Condition of Admission/Service (COA),” dated 9/2/2025, was reviewed. The COA, printed in English, indicated Patient 13 signed the form without the indication of a translation service being used to interpret and explain the form to her in Mandarin. The CSQ 1 stated no translation service for Mandarin was indicated on the signed form. The CSQ 1 also stated the risk of not using a translation service was that the patient would not be fully aware of their rights as a patient. During an interview on 9/4/2025 at 2:08 PM with the Associative Administrator of Patient Access (APA), the APA stated an interpreter identification number should be indicated on the COA itself if the patient did not receive a COA in their preferred language. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights/Responsibilities,” dated 2/2022, the P&P indicated, “Patients have the right to care in a private, confidential, and safe environment where they can communicate their needs . . . Patients have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, beliefs and preferences . . . Receive information . . . in terms they can understand”. 1. b. During a review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/29/2025, the H&P indicated Patient 20 was admitted to the facility on 8/29/2025 for high creatine kinase (CPK - creatine phosphokinase provides energy for muscle contraction; normal level of 55 to 170 in males and 30 to 135 in females) level of 689. Patient 20 had a past medical history of schizophrenia (a mental illness that is characterized by disturbances in thought), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). The H&P also indicated Patient 20 was placed on seizure precautions (safety measures taken to prevent or minimize injuries during a seizure) due to his history of seizure disorder. During a review of Patient 20’s “Discharge Plan/Social Worker Evaluation,” dated 8/29/2025, the evaluation indicated Patient 20’s preferred language was primarily Cantonese and was limited English speaking. During a concurrent interview and record review on 8/29/2025 at 10:50 AM with Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 20’s “Condition of Admission/Service (COA),” dated 8/29/2025, was reviewed. The COA, printed in English, indicated Patient 20 verbally consented to the form without the indication of a translation service being used to interpret and explain the form to him. The CSQ 1 stated no translation service for Cantonese was indicated on the sign form. The CSQ 1 also stated the risk of not using a translation service was that patient would not be fully aware of their rights as a patient. During an interview on 9/4/2025, at 2:08 PM, with the Associative Administrator of Patient Access (APA), the APA stated an interpreter identification number should be indicated on the COA itself if the patient did not receive a COA in their preferred language. During a review of the facility’s policy and procedure (P&P), titled, “Patients’ Rights/Responsibilities,” dated 2/2022, indicated, “Patients have the right to care in a private, confidential, and safe environment where they can communicate their needs . . . Patients have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, beliefs and preferences . . . Receive information . . . in terms they can understand”. 2. During a review of Patient 26’s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 8/31/2025, the H&P indicated Patient 26 was admitted to the facility on 8/31/2025 for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) from a boarding care facility. During a review of Patient 26’s COA form, dated 8/31/2025 at 8:35 p.m., the COA indicated that Patient 26 was unable to sign “due to medical condition” and was witnessed by two staff with their signatures. During a review of Patient 26’s “Discharge Plan/Social Worker Evaluation”, dated 9/1/2025, the Evaluation indicated Patient 26 was Spanish speaking, self-responsible, independent, and able to engage in conversation with the social worker. The Evaluation further indicated Patient 26 was able to provide information about their medical history and answer questions independently. During an interview on 9/4/2025 at 2:10 p.m. with Admitting Manager (AM), AM stated that the purpose of the COA was to inform patients about their rights, billing information, expected behavior, and consent for photograph. All patients or patient’s representatives (PR) should be informed of the conditions of admission (COA) and obtain signature from patient or PR. If patients were not able to sign the COA during the first attempt, the admitting staff should make another attempt to follow the patients on the floor for completion of COA signature. During an interview on 9/4/2025 at 2:10 p.m. with Associative Administrator of Patient Access (AAPA), AAPA stated that per their department’s internal record, the admitting staff did not make another attempt to go to the floor to follow up the COA with Patient 26. AAPA further stated there was a gap in that process that the staff did not follow the policy and procedure. During a review of the facility’s policy and procedure (P&P) titled, “Conditions of Admission – Admitting Consent Forms,” last revised on 1/2022, the P&P indicated, “USC Arcadia Hospital will maintain a registration process that complies with federal, state and laws and payer requirements. The forms must be signed by the patient and/or the patient’s legal representative: e.g. parent, conservator or legal guardian on admission.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure its nursing staff obtained a physician order for restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 30 sampled patients (Patient 24) in accordance with the facility’s policy and procedure on restraints when Patient 24 was placed in soft restraints (padded, fabric-based devices designed to temporarily restrict a patient’s movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes) without a physician order for three hours and 3 minutes. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 24 which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). Finding: During a review of Patient 24’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/30/2025, the H&P indicated Patient 24 was admitted to the facility for advanced dementia (conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), uncontrolled atrial fibrillation (condition where the heart’s upper chambers [atria] beat irregularly and rapidly, without adequate medical management), and recurrent (having two or more episodes within a six-month period, or three or more episodes within one year) urinary tract infection (UTI, an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra). During a concurrent interview and record review on 9/3/2025 at 3:40 p.m. with Stroke Program Coordinator (SPC), Patient 24’s “Restraint” flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/30/2025, was reviewed. The flowsheet indicated Patient 24 was placed on restraints on 8/30/25 at 11:00 p.m., then Patient 24’s restraints were assessed on 8/31/2025 at 2:32 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m. Concurrently, Patient 24’s physician order for restraints was reviewed. The order indicated that the first order for soft wrist restraints for Patient 24 was ordered on 8/31/25 at 2:04 a.m. There was no physician order when nursing staff initiated the restraints on 8/30/2025 at 11:00 p.m. Patient 24 was placed in restraints without a physician order from 8/30/2025 at 11:00 p.m. to 8/31/2025 at 2:03 a.m. for a total of three hours and three minutes. SPC stated that the nurse should obtain a physician order for any type of physical restraint. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 7/2025, the P&P indicated, “All patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff ... Use of restraints must be in accordance with the order by a physician or licensed practitioner who is primarily responsible for the care of the patient and authorized to write restraint orders. Orders for restraint use are episode specific. Removal of physical restraints prior to order expiration requires a new order if new need is identified. Orders for the use of restraints must never be written as a standing order, ’ as needed’ or on a PRN basis. A trial release constitutes a PRN order; therefore, a new order will be required to re-apply physical restraints.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure two of 30 sampled patients (Patient 17 and Patient 24), who were placed on soft restraints (padded, fabric-based devices designed to temporarily restrict a patient’s movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes), were monitored by nursing staff every two hours in accordance with the facility’s policy and procedure regarding restraints. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 17 and Patient 24, which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). Findings: 1. During a review of Patient 17’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/26/2025, the H&P indicated Patient 17 was admitted to the facility for worsening altered mental status related to septic shock (a life-threatening condition that occurs due to infection) and bacteremia (bacteria present in the blood). Patient 17 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities) and recent hip repair. During a review of Patient 17’s physician order, dated 8/26/2025, the order indicated Patient 17 was ordered to be placed on bilateral (both) soft wrist restraints. During a concurrent interview and record review on 9/4/2025 at 10:17 AM with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 17’s “Restraint” flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/26/2025, was reviewed. The flowsheet indicated Patient 17 was monitored and checked on 8/26/2025 at: 7:30 AM, 9:30 AM, 11:30 AM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM. The CSQ 1 stated Patient 17 was not monitored and checked every two hours on 8/26/2025 during restraint use at 1:30 PM and 3:30 PM. The CSQ 1 also stated restraints were to be checked every two hours for patient safety to ensure patient’s wellbeing, check circulation, and assess the necessity of restraint itself. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 7/2025, indicated, “Ongoing monitoring content and restraints flowsheet documentation - At a minimum every 2 hours”. 2. During a review of Patient 24’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/30/2025, the H&P indicated Patient 24 was admitted to the facility for advanced dementia (conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), uncontrolled atrial fibrillation (condition where the heart’s upper chambers [atria] beat irregularly and rapidly, without adequate medical management), and recurrent urinary tract infection (UTI, is defined as having two or more episodes of a UTI within a six-month period, or three or more episodes within a one-year). During a concurrent interview and record review, on 9/3/2025 at 3:40 p.m., with Stroke Program Coordinator (SPC), Patient 24’s “Restraint” flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/30/2025, was reviewed. The flowsheet indicated Patient 24 was placed on restraints on 8/30/2025 at 11:00 p.m. Patient 24 was checked and monitored on 8/31/2025 at 2:32 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m. while on restraints. The SPC stated Patient 26 was not checked and monitored every two hours between 8/30/2025 at 11:00 p.m. to 8/31/2025 at 2:32 a.m. for a total of three hours and 32 minutes. SPC stated that restraints were to be checked every two hours for patient safety to ensure patient’s wellbeing, check circulation, and assess the necessity of restraint itself. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 7/2025, indicated, “Ongoing monitoring content and restraints flowsheet documentation - At a minimum every 2 hours”.”

“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: 45774 Based on interview and record review, the facility failed to ensure an individualized nursing care plan (a document that helps a patient’s care team communicate and organize patient care) was initiated for seven of 30 sampled patients (Patient 3, Patient 16, Patient 18, Patient 22, Patient 23, Patient 25 and Patient 27) in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying patients’ needs and risks and can lead to patients not receiving safe and effective care. Findings: 1. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/31/2025, the H&P indicated Patient 3 was admitted to the facility for acute hypoxic respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the body’s tissues leading to low oxygen levels). During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with Clinical Quality Specialist (CQS) 2, Patient 3’s “Adult Patient Profile”, dated 8/31/2025, was reviewed. The Adult Patient Profile indicated Patient 3’s preferred language was Chinese. During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with CQS 2, Patient’s 3’s “Personalized Care Flowsheet,” dated 9/02/2025, was reviewed. The Personalized Care Flowsheet indicated Patient 3 was Mandarin speaking and very hard of hearing (HOH, a condition where a person has reduced hearing ability). During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with CQS 2, Patient 3’s “Plan of Care” was reviewed. CQS 2 verified Patient 3’s Plan of Care, Assessment and Interventions did not include care plans for language preference (Mandarin) or the hearing impairment. During an interview on 9/03/2025 at 2:30 p.m. with CQS 2, CQS 2 stated it was “definitely important to address interventions so they’re individualized for him (Patient 3).” During a review of the facility’s P&P titled, “Interdisciplinary Plan of Care,” dated 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient’s primary problem and co-morbidity.” 2. During a review of Patient 16’s “H&P,” dated 8/29/2025, the H&P indicated Patient 16 admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 had a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Patient 16’s “Adult Assessment Interventions,” dated 8/28/2025, the “Interventions” indicated Patient 16’s Morse Fall Scale (a clinical assessment tool used by healthcare professionals to determine a patient’s risk of falling with low fall risk score being 0 to 24 points, moderate fall risk score being 25 to 45 points and high fall risk score being 45 points and greater) score on 8/28/2025 at 5:30 PM was 95 (high fall risk). The “Interventions” further indicated the only safety intervention placed was an activated bed alarm. During a concurrent interview and record review on 9/3/2025 at 4:00 PM, with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 16’s “Adult Plan of Care,” dated 8/28/2025 was reviewed. The “Plan of Care” indicated Patient 16 did not have a fall risk care plan initiated. The CSQ 1 stated Patient 16’s plan of care for fall risk was not initiated. The CSQ 1 also stated the importance of initiating the fall risk care plan was to ensure the staff are aware of the patient’s goals of care and maintain patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Falls Prevention,” dated 5/2024, the P&P indicated, “Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls.” The P&P also indicated, “Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . “Initiate Fall Risk Care Plan - a plan of care is developed with appropriate interventions individualized to patient needs.” During a review of the facility’s P&P titled, “Interdisciplinary Plan of Care,” dated 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient’s primary problem and co-morbidity.” 3. During a review of Patient 18’s “H&P,” dated 8/31/2025, the H&P indicated Patient 18 was admitted to the facility on 8/31/2025 for worsening peripheral edema (swelling in the extremities, typically the feet, ankles, legs, and arms). Patient 18 had a past medical history of chronic kidney disease stage III (moderate damage to organ that filters waste products from the blood), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Patient 18’s “Adult Assessment Interventions,” dated 8/31/2025, the “Interventions” indicated Patient 18’s Morse Fall Scale score on 8/31/2025 at 7:45 PM was 35. The record indicated the only safety intervention placed was an activated bed alarm. During a concurrent interview and record review on 9/4/2025 at 10:33 AM with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 18’s “Adult Plan of Care,” dated 8/31/2025, was reviewed. The record indicated Patient 18 did not have a fall risk care plan initiated. The CSQ 1 stated Patient 18’s plan of care for fall risk was not initiated. The CSQ 1 also stated the importance of initiating the fall risk care plan was to ensure staff were aware of the patient’s goals of care and maintain patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Falls Prevention,” dated 5/2024, the P&P indicated, “Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls.” The P&P also indicated, “Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . “Initiate Fall Risk Care Plan - a plan of care is developed with appropriate interventions individualized to patient needs.” During a review of the facility’s P&P titled, “Interdisciplinary Plan of Care,” dated 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient’s primary problem and co-morbidity.” 4. During a review of Patient 22’s “H&P,” dated 9/1/2025, the H&P indicated Patient 22 was admitted to the facility on 9/1/2025 for pericardial effusion (an abnormal accumulation of fluid in the pericardial sac, the thin membrane that surrounds the heart) and small bowel obstruction (SBO, a condition that occurs when the flow of food, fluid, and gas through the small intestine is blocked). During a concurrent interview and record review on 9/3/2025 at 3:00 p.m. with the Stroke Program Coordinator (SPC), Patient 22’s care plan was reviewed. The care plan indicated no plan of care was developed for Patient 22’s diagnoses of small bowel obstruction for this admission. The APC stated the nurse should develop an individualized plan of care for Patient 22 regarding SBO and develop a care for all actual or potential patient’s needs to plan patient care such as relieving symptoms, maintaining fluid and electrolyte balance (the body’s essential process of regulating the correct amount of water and electrically charged minerals [electrolytes like sodium and potassium] to maintain stable, healthy internal conditions), and interventions toward meeting those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” reviewed 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation” and “14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list.” 5. During a review of Patient 23’s “H&P,” dated 8/31/2025, the H&P indicated Patient 23 was admitted to the facility for sepsis (a body’s overwhelming and life-threatening response to infection), hypertension (high blood pressure), and right obstructive uropathy (condition where the flow of urine from the right kidney to the bladder is blocked). During a concurrent interview and record review on 9/3/2025 at 3:20 p.m. with the Stroke Program Coordinator (SPC), Patient 23’s care plan was reviewed. The care plan indicated no plan of care was developed for Patient 23’s diagnoses of right obstructive uropathy for this admission. The APC stated the nurse should develop a plan of care for Patient 23 regarding right obstructive uropathy and develop a care plan for all actual or potential patients’ needs to plan patient care, such as monitoring fluid balance, intake, and output (measuring and recording how much fluid goes in and out of a patient’s body), promoting bladder emptying and complete voiding (urinating), and interventions toward meeting those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” reviewed 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation” and “14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list.” 6. During a review of Patient 25’s “H&P,” dated 8/30/2025, the H&P indicated Patient 25 was admitted to the facility for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) and urinary tract infection (UTI, an infection in any part of the urinary system). During a concurrent interview and record review on 9/3/2025 at 3:20 p.m. with the Stroke Program Coordinator (SPC), Patient 25’s care plan was reviewed. The care plan indicated no plan of care was developed for Patient 25’s diagnoses of UTI for this admission. The APC stated the nurse should develop a plan of care for Patient 25’s UTI and develop a care plan for all actual or potential patients’ needs to plan patient care such as monitoring dysuria (pain while urinating), urgency (intense desire to urinate), frequency (having to urinate too often in a small time interval), fever, chills, flank (the sides of the lower back between the ribs and hips) pain, and malaise (general feeling of discomfort), and interventions toward meeting those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” reviewed 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation” and “14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list.” 7. During a review of Patient 27’s “H&P,” dated 8/29/2025, the H&P indicated Patient 27 was admitted to the facility on 8/30/2025 for possible subacute cerebrovascular accident (stroke, when a blood vessel in the brain becomes blocked or ruptures, cutting off blood flow to the brain) and hypertension (high blood pressure). During a review of Patient 27’s “Face Sheet” (concise summary of a patient’s essential demographic, financial, and clinical information), the “Face Sheet” indicated Patient 27’s preferred language was Spanish. During a concurrent interview and record review on 9/4/2025 at 10:10 a.m. with the Stroke Program Coordinator (SPC), Patient 27’s care plan was reviewed. The care plan indicated no plan of care was developed for Patient 27’s language barrier that the patient’s preferred language was Spanish. The SPC stated the nurse should develop a plan of care for Patient 27’s language barrier, such as interventions using qualified professional medical interpreters and translated materials that meet those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” reviewed 5/2025, the P&P indicated, “Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation” and “14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list.””

“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: 45774 Based on observation, interview, and record review, the facility failed to: 1. Ensure five of 30 sampled patients (Patient 8, Patient 11, Patient 16, Patient 23, and Patient 26) had intravenous (IV, a tube going directly into the vein) sites labeled with the insertion (placement) date and the nurse’s initials in accordance with the facility’s policy and procedure regarding IV therapy management. This deficient practice had the potential to place patients at risk for a skin infection (infection, a growth of germs that can cause illness), a blood infection, blood clots (a gel-like clump of blood), and tissue (a body part that performs a specific function, such as skin) damage at the IV insertion site. 2. Ensure one of 30 sampled patients (Patient 16) wore a fall risk armband in accordance with the facility’s policy and procedure regarding falls prevention. This deficient practice had the potential for Patient 16 falling and becoming injured due to not being provided extra fall risk monitoring and precautions. Findings: 1. a. During a review of Patient 8’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/29/2025, the H&P indicated Patient 8 was admitted to the facility for a right ankle wound and sepsis (a life-threatening blood infection). During a concurrent observation and interview on 9/02/2025 at 2:45 p.m. with Nurse Manager (NM) 2 at Patient 8’s bedside, Patient 8 had an IV insertion site in his right posterior (back part) hand without an insertion date or initials of nurse who inserted the IV. NM 2 stated she did not observe an insertion date or initials of nurse who inserted the IV written on Patient 8’s right hand IV site. NM 2 stated it was important to have an insertion date, time, and initials of nurse because “the possibilities of issues are we didn’t insert it (the IV), we don’t know when it was inserted.” During a concurrent observation and interview on 9/02/2025 at 2:45 p.m. with Pediatric Emergency Care Coordinator (PECC) at Patient 8’s bedside, Patient 8 had an IV insertion site in his right posterior (back part) hand without an insertion date or initials of nurse who inserted the IV. PECC stated she did not observe an insertion date or initials of nurse who inserted the IV on Patient 8’s right posterior hand IV site. During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Management Guidelines,” dated 4/2023, the P&P indicated, “All IV sites will be labeled with the insertion date and the nurse’s initials.” 1. b. During a review of Patient 11’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/1/2025, the H&P indicated Patient 11 was admitted to the facility on 9/1/2025 for infection related to a cat bite on their thumb. Patient 11 had a past medical history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). During a concurrent observation and interview on 9/2/2025 at 2:02 PM with the Director of the Emergency Department (DED), in Patient 11’s room, Patient 11’s left forearm IV site was observed to be missing a label with a date, time and initials of the staff member who placed the IV. The DED stated she did not observe the IV site to be labeled. The DED also stated all IV sites should be labeled at the time of insertion. During an interview on 9/1/2025 at 2:13 PM with Registered Nurse 2 (RN 2), RN 2 stated, “Whoever inserts the IV should label, date, time and initial the site and document this in the chart as well. All IVs are to be changed every 4 days and as needed.” During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Management Guidelines,” dated 4/2023, the P&P indicated, “All IV sites will be labeled with the insertion date and the nurse’s initials.” 1. c. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/29/2025, the H&P indicated, Patient 16 was admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 had a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a concurrent observation and interview on 9/2/2025 at 2:36 PM with the DED, in Patient 16’s room, Patient 16’s left upper forearm IV site was observed to be missing a label with a date, time and initials of the staff member who placed the IV. The DED stated she did not observe the IV site to be labeled. The DED also stated all IV sites should be labeled at the time of insertion. During an interview on 9/1/2025 at 2:13 PM with Registered Nurse 2 (RN 2), RN 2 stated, “Whoever inserts the IV should label, date, time and initial the site and document this in the chart as well. All IVs are to be changed every 4 days and as needed.” During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Management Guidelines,” dated 4/2023, the P&P indicated, “All IV sites will be labeled with the insertion date and the nurse’s initials.” 1. d. During a review of Patient 23’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/31/2025, the H&P indicated Patient 23 was admitted to the facility for sepsis (a body’s overwhelming and life-threatening response to infection), hypertension (high blood pressure), and right obstructive uropathy (condition where the flow of urine from the right kidney to the bladder is blocked). During a concurrent observation and interview on 9/02/2025 at 2:05 p.m. with Clinical Quality Specialist (CQS2) in Patient 23’s room, Patient 23 had two IV insertion sites on left antecubital (inner front area of the elbow) and right antecubital. Both IV insertion sites were observed without an insertion date or initials of the nurse who inserted the IV. CQS2 confirmed that both insertion sites had no date or initials of nurse. CQS2 stated it was important to have an insertion date, time, and initials of the nurse because without labeling the date, it could compromise the IV site for risk of infection. During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Management Guidelines,” dated 4/2023, the P&P indicated, “All IV sites will be labeled with the insertion date and the nurse’s initials.” 1. e. During a review of Patient 26’s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 8/31/2025, the H&P indicated Patient 26 was admitted to the facility on 8/31/2025 for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) from a boarding care facility. During a concurrent observation and interview on 9/02/2025 at 2:25 p.m. with Clinical Quality Specialist (CQS2) in Patient 26’s room, Patient 26 had two IV insertion sites on the left mid-forearm and right mid-forearm. Both IV insertion sites were observed without an insertion date or initials of the nurse who inserted the IV. CQS2 confirmed that both insertion site had no date or initials of nurse. CQS2 stated it was important to have an insertion date, time, and initials of nurse because without labeling the date, it could compromise the IV site for risk of infection. During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Management Guidelines,” reviewed 4/2023, the P&P indicated, “IV sites will be rotated at an interval not longer than 96 hours unless there are no other peripheral (located in the arms or legs) sites available,” and “All IV sites will be labeled with the insertion date and the nurse’s initials.” 2. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/29/2025, the H&P indicated Patient 16 was admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 has a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Patient 16’s “Adult Assessment Interventions,” dated 8/28/2025, the “ Interventions” indicated Patient 16’s Morse Fall Scale (a clinical assessment tool used by healthcare professionals to determine a patient’s risk of falling with low fall risk score being 0 to 24 points, moderate fall risk score being 25 to 45 points and high fall risk score being 45 points and greater) score on 8/28/2025 at 5:30 PM was 95 (high fall risk). The “ Interventions” indicated the only safety intervention placed was an activated bed alarm. During a concurrent observation and interview on 9/2/2025 at 2:40 PM with the Nurse Manager 3 (NM 3) in Patient 16’s room, Patient 16 was observed to not have a yellow fall risk identification armband on, despite being identified as a fall risk with the use of fall risk precaution signage on the door entry way. The NM 3 stated Patient 16 should have a yellow fall risk armband on to indicate to staff that Patient 16 was a fall risk and to take proper fall risk precautions. During a review of the facility’s P&P titled, “Falls Prevention,” dated 5/2024, the P&P indicated, “Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls.” The P&P also indicated the following “interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . “Initiate Fall Risk Care Plan – a plan of care is developed with appropriate interventions individualized to patient needs” . . . “Provide yellow fall risk armband.””

“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: 45774 Based on interview and record review, the facility failed to ensure antibiotic medications (medications for infection) were given as ordered for two of 30 sampled patients (Patient 11 and Patient 12) in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential for Patient 11 and Patient 12 experiencing drug complications due to not maintaining a constant therapeutic level of a drug in their bodies. Findings: 1. During a review of Patient 11’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/1/2025, the H&P indicated Patient 11 was admitted to the facility on 9/1/2025 for infection related to a cat bite on the thumb. Patient 11 had a past medical history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). During a concurrent interview and record review on 9/3/2025 at 2:00 PM with the Clinical Quality Specialist Registered Nurse 1 (CSQ 1), Patient 11’s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 9/2/2025, was reviewed. The MAR indicated Patient 11 was ordered on 9/2/2025 to receive Ampicillin-Sulbactam (a type of antibiotic medication) 3 grams (a metric unit of measurement used for medication amount) via intravenous piggyback (IVPB, a method of medication administration where a small volume of fluid is given intravenously [into the vein] through a primary fluid infusion) every 8 hours with the first administration on 9/2/2025 at 4:26 AM. The next doses given were on: a. 9/2/2025 at 10:49 AM (administered one hour and 37 minutes early) b. 9/2/2025 at 6:57 PM c. 9/3/2025 at 5:10 AM (administered two hours and 13 minutes late) d. 9/3/2025 at 11:36 AM (administered one hour and 34 minutes early) The CSQ 1 stated the medications were not given timely. The CSQ 1 also stated the importance of administering medications timely was to not overload the patient and maintain a therapeutic level of the drug in the blood. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 4/2024, the P&P indicated, “Prior to administering a medication, the licensed independent practitioner or appropriate healthcare professional shall: Verify the five “rights’ of medication administration: Right patient, Right medication, Right time, Right dose, Right route.” During a review of the facility’s P&P titled, “Medication Administration Time Schedule,” dated 11/2024, the P&P indicated, “Non-time critical medications that are prescribed more frequently than daily but no more frequently than every 4 hours are to be given within 1 hour before or after the scheduled time.” 2. During a review of Patient 12’s “Progress Note,” dated 8/20/2025, the note indicated Patient 12 was admitted to the facility on 9/2/2025 for left total knee arthroplasty (replacement). Patient 12 had a past medical history of hypertension (high blood pressure), gastric bypass (a type of weight loss surgery) and hernia (a condition where an organ or tissue protrudes through a weak spot in a muscle or connective tissue) repair and lumbar (part of spine) laminectomy (removal of part of spine). During a concurrent interview and record review on 9/3/2025 at 2:50 PM with the CSQ 1, Patient 12’s MAR, dated 9/2/2025, was reviewed. The MAR indicated Patient 12 was ordered on 9/2/2025 to receive Vancomycin (a type of antibiotic medication) 1,000 milligram (mg, a metric unit of measurement used for medication dosage or amount) via IVPB every 12 hours with the first administration on 9/2/2025 at 8:32 PM. The next dose was given on 9/3/2025 at 11:06 AM (administered two hours and 34 minutes late). The CSQ 1 stated the medication was not given timely. During an interview on 9/2/2025 at 2:28 PM with the CSQ 1, the CSQ 1 stated the importance of administering medications timely was to not overload the patient and maintain a therapeutic level of the drug in the blood. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 4/2024, the P&P indicated, “Prior to administering a medication, the licensed independent practitioner or appropriate healthcare professional shall: Verify the five “rights’ of medication administration: Right patient, Right medication, Right time, Right dose, Right route.” During a review of the facility’s P&P titled, “Medication Administration Time Schedule,” dated 11/2024, the P&P indicated, “Non-time critical medications that are prescribed more frequently than daily but no more frequently than every 4 hours are to be given within 1 hour before or after the scheduled time.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to ensure six of 30 sampled patients’ (Patients 1, Patient 7, Patient 8, Patient 10, Patient 14, and Patient 17) Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were either signed by the patient or the patient’s representative or appropriately witnessed by facility staff per policy & procedure. This deficient practice resulted in violating the patients ’ right of not knowing options of patient rights, treatment, billing process, payment and service rendered by facility. (Refer to A-0117) 2. The facility failed to provide consent for surgery (document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) to one of 30 patients (Patient 25) in Patient 25 ’ s preferred language. This deficient practice may lead to a decision which is not in the patient ’ s best interest. (Refer to A-0131) 3. The facility failed to follow and implement (carry out) the facility’s falls prevention policy for one of 30 sampled patients (Patient 14). This deficient practice placed patients at risk for falls and injury. (Refer to A-0144) 4. The facility failed to ensure one of 30 sampled patients (Patients 1), was free from abuse (the improper treatment of a person), when Patient 1 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff. This deficient practice resulted in Emergency Room Technician inappropriately responding by physically assaulting Patient 1 after getting provoked by the patient. (Refer to A-0145). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure six of 30 sampled patients’ (Patients 1, Patient 7, Patient 8, Patient 10, Patient 14, and Patient 17) Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were either signed by the patient or the patient’s representative or appropriately witnessed by facility staff per policy & procedure. This deficient practice resulted in violating patients ’ right of not knowing options of patient rights, treatment, billing process, payment and service rendered by facility. Findings: 1. A review of Patient 1 ’ s Emergency Department (ED) Provider note dated 3/26/2025 indicated Patient 1 was brought into the ED by Emergency Medical Service (EMS) for alcohol intoxication (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream). During a concurrent interview and record review on 5/16/2025, at 10:35 a.m., with Nurse Manager (NM 1), Patient 1 ’ s condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) was not found on Patient 1 ’ s medical records. NM1 stated that she had been checking all the areas of Patient 1 ’ s medical records and was unable to find Patient 1 ’ s COA. During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:45 a.m., the AM confirmed that all patients require to sign the COA even when patient is seeking medical examination in ED or patient is admitted to the facility. During a review of the facility’s Police and Procedure (P&P) titled “Conditions of Admission (COA) - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, “the hospital will maintain a registration process that complies with federal, state and laws and payer requirements. The forms must be signed by the patient and/or the patient ’ s legal representative: e.g. parent, conservator or legal guardian on admission. The original document (COA) will be scanned or uploaded into the patients ’ electronic medical record (EMR). 2. During a review of Patient 7 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 5/13/2025 at 8:24 p.m., the H&P indicated Patient 7 was admitted to the facility on 5/13/2025 for complicated urinary tract infection (UTI, an infection in any part of the urinary system), acute kidney injury (AKI- sudden and often temporary loss of kidney function), and cerebral palsy (a congenital disorder of movement, muscle tone, or posture). During a review of Patient 7 ’ s , “The Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc” dated 5/15/2025 at 2:31 p.m. , indicated the patient ’ s signature part is blank and stated Patient 7 was unable to sign due to medical condition (cerebral palsy) which was witnessed by Admitting Representative (AR 3). During review of Patient 7 ’ s “The Conditions of Admission/Service (COA)- indicated no second staff signature to witness as required per facility policy. During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility’s Condition of Admission/ Service (COA) policy & procedure (P&P) indicated if verbal consent was given to sign the COA, then there should be two witnesses. During a review of the facility’s P&P titled “Conditions of Admission - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, “If the patient is physically unable to sign, but can express his/her agreement to the terms of the form, by nodding yes or stating yes then this shall be witnessed by two people. 3. During a review of Patient 8 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 5/6/2025 at 10:16 a.m., the H&P indicated Patient 8 was admitted to the facility on 5/6/2025 for acute hypoxia (deficiency in the amount of oxygen reaching the tissues which can cause confusion) and hypercapnic respiratory failure (body inability to remove carbon dioxide from the blood and result in high levels of carbon dioxide in the blood). During a review of Patient 8 ’ s “Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)”, dated 5/7/2025 at 9:30 a.m., indicated the signature part is empty and Patient 8 was unable to sign due to medical condition which was witnessed by Admitting Representative (AR 4). There were no second staff to witness as required per facility policy. During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility’s policy & procedure (P&P) states if verbal consent is given to sign the COA, then there should be two witnesses. During a review of the facility’s P&P titled “Conditions of Admission - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, If the patient is physically unable to sign, but can express his/her agreement to the terms of the form, by nodding yes or stating yes then this shall be witnessed by two people. 4. During a review of Patient 10’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/27/2025 at 1:01 a.m., the H&P indicated Patient 10 was admitted to the facility on 4/27/25 for complicated urinary tract infection (UTI, an infection in any part of the urinary system), Metabolic toxic encephalopathy (condition where brain function is impaired due to an accumulation of toxins or metabolic disturbances in the body), and anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness). During a review of Patient 10’s Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA indicated the patient ’ s signature part was blank and indicated Patient 10 verbally acknowledged/agreed which was witnessed by Admitting Representative (AR 5). There were no second staff to witness verbal acknowledgement from Patient 10 per facility policy. During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility’s policy & procedure (P&P) indicated if patient gave a verbal consent for the COA, then there should be two witnesses who would sign the COA. During a review of the facility’s P&P titled “Conditions of Admission - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, “If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient’s agreement to the terms of the form.” 5. During a review of Patient 14’s Face Sheet (a document that summarizes a patient ’ s medical history and personal information, including patient ’ s name, address, and date of birth, insurance information, and emergency contact information), dated 5/13/2025, the Face Sheet indicated Patient 14 was admitted to the hospital for a fracture of the left femur (thigh bone). During a review of Patient 14’s Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA did not have Patient 14’s signature. Instead, the COA indicated written on the COA, that Patient 14 gave “verbal understanding,” which was witnessed by Admitting Representative (AR) 1. and there was no other staff present to witness the verbal understanding Patient 14 expressed. During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility’s policy & procedure (P&P) indicated if verbal consent was given/expressed to sign the COA, then there should be two witnesses who would sign the COA. During a review of the facility’s P&P titled “Conditions of Admission - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, “If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient’s agreement to the terms of the form.” 6. During a review of Patient 17’s Face Sheet, dated 5/13/2025, the Face Sheet indicated Patient 17 was admitted to the facility for seizures (abnormal involuntary movement of the body). During a review of Patient 17’s Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA did not have Patient 17’s signature. Instead, the COA indicated Patient 17’s next of kin (a person’s closest living relative) “gave verbal consent via telephone,” which only AR 2 witnessed. Aside from the AR 2, there was no other staff who witnessed the verbal consent for Patient 17 ’ s COA. During an interview with the AM, on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility’s policy & procedure (P&P) indicated if a verbal consent was given to acknowledge the COA, there should be two witnesses required per facility policy. During a review of the facility’s P&P titled “Conditions of Admission - Admitting Consent Forms,” last reviewed 2/2022, the P&P indicated, “If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient’s agreement to the terms of the form.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to provide consent for surgery (document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) in patient’s preferred language for one of 30 sampled patients (Patient 25). This deficient practice may lead to Patient 25 decision which was not based on the complete knowledge of the procedure ’ s risk, benefits and alternatives and not in the patient ’ s best interest. Findings: During an interview on 5/16/2025 at 11:30 AM, the RMD (Risk Management Director) stated she did not know if Patient 25 ’ s consent for ORIF (Open Reduction Internal Fixation, surgery used to repair fractures, where the broken bone is repositioned, open reduction, and then held in place with surgical hardware, internal fixation, like screws or plates) of the right femur (thigh bone) needs to be in Patient 25 ’ s preferred language; only that a responsible party translated the details of consent for this surgery to Patient 25. During a review of the ’ History and Physical ’ (H&P, a formal and complete assessment of the patient and the problem) for Patient 25, dated 5/12/2025, indicted last night Patient 25 slipped and fell onto his right leg; an x-ray showed a comminuted fracture (bone broken into several pieces) of Patient 25 ’ s right femur. During a review of the ’ Consultation ’ dated 5/12/2025, the Consultation confirmed that there was a comminuted fracture (bone broken into several pieces) of Patient 25 ’ s right femur, and the plan was for an ORIF of the right femur on 5/13/2025. During a review of the ’ Adult Patient Profile ’ , this document indicated the following regarding Patient 25: language assistance is required, Chinese is the preferred spoken language, Chinese is the preferred language read, there is an alternative decision maker for this hospitalization, there is a designated caregiver (Patient 25 ’ s daughter). During a review of the ’ Consent for Surgery or Special Procedures ’ dated 5/12/2025 and signed by Patient 25 ’ s daughter, indicated a right distal femur open reduction internal fixation was performed on 5/12/2025. This consent form was written in English. During a review of the ’ Consent for Surgery or Special Procedures ’ dated 5/15/2025 and signed by Patient 25 ’ s daughter, another consent document indicated a right foot soft tissue and bone debridement (procedure where dead, damaged, or infected tissue is removed from a wound to facilitate healing) was performed on 5/15/2025. This consent form was written in English. During a review of the policy ’ Patients ’ Rights/Responsibilities ’ #MA700, revised date 2/2022, indicated the Consent to Surgery or Special Procedures form must have signature by patient or patient ’ s legal representative. Name and method of interpretation (explanation), if needed. If a patient or his legal representative cannot communicate with the physician because of a language or communication barrier, will arrange for interpretation. The name and method of interpretation will be documented on the consent form.”

“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: 45774 Based on observation, interview, and record review, the facility failed to follow and implement the facility’s falls prevention policy for one of 30 sampled patients (Patient 14). This deficient practice placed patients at risk for falls and injury. Findings: During a review of Patient 14’s History & Physical (H&P - a formal and complete assessment of the patient and the problem), dated 5/13/2025, at 11:00 a.m., the H&P indicated Patient 14 was admitted to the facility after falling in the bathroom at home. During a review of Patient 14’s “Adult Assessment Intervention” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 5/15/2025, at 8:00 a.m., the flowsheet indicated Patient 14 scored a 70 on the Morse Fall Scale (a tool used to assess a patient’s risk of falling in a healthcare setting-0-26-low fall risk, no interventions (planned actions), 25-45-moderate (common) fall risk and 45 and above-high fall risk implement (start) high risk fall preventions). During a concurrent observation and interview, on 5/15/2025, at 10:22 a.m., with Registered Nurse (RN) 2, Patient 14 was observed laying in bed. RN 2 stated Patient 14 was admitted to the facility due to falling at home, which placed them at a high risk for falls. On Patient 14’s right wrist was a hospital identification wristband with name, date of birth, and medical record number, but there was no other band present on either wrist. RN 2 stated Patient 14 was supposed to have a yellow-colored wristband indicating their high fall risk and confirmed that it was not present. RN 2 further stated it was important for patients to have that wristband because it served as a visual warning indicator to the nursing staff to pay attention to the patients’ safety. During a review of the facility’s policy and procedure (P&P), titled “Falls Prevention,” last reviewed 5/2024, the P&P indicated, “Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale: ... Provide yellow fall risk armband.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45774 Based on observation, interview and record review, the facility failed to: Ensure one of thirty sampled patients (Patient 1) were free from all forms of abuse care while he was in Emergency Department (ED) on 3/26/25 for Alcohol detoxification (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream). Ensure the facility staffs follow facility policy and procedure in dealing with the aggressive patient or physical assault situation. Ensure the facility staffs follow their policy and procedure for reporting any abuse allegation to supervisor and risk management immediately. Ensure the alleged perpetrator was removed immediately from the patient care area for further potential harm to other patients. This deficient practice resulted in Emergency Room Technician (ERT) inappropriately responding by physically assaulting Patient 1 after getting provoked by Patient 1. On 5/15/2025, at 11:30 a.m., the survey team called an Immediate Jeopardy (IJ - a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) situation in the presence of the Chief Quality Officer (CQO), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Risk Management Director (RMD), Director Quality and Chief Medical Officer (CMO). On 3/26/25 at 9:47 p.m., Emergency Room Technician (ERT) hit Patient 1 four times on his face and head area after provoked (to anger a person) by Patient 1. The Emergency Department charge nurse (EDCN1) did not report this incident to higher management immediately per facility policy. ERT was not removed from patient care area immediately that may cause potential harm to other patients. The facility failed to Ensure one of thirty sampled patients (Patient 1) were free from all forms of abuse while Patient 1 was in Emergency Department (ED) on 3/26/25 for Alcohol detoxification (a person consumes enough alcohol to impair their cognitive (reasonable) function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream). Ensure the facility staffs follow their policy and procedure in dealing with the physical assault (violent use against another person) which happened. Ensure the facility staffs follow their policy and procedure for reporting any abuse allegation to supervisor and risk management (process use to identify risks that can harm the organization). Ensure the alleged perpetrator (a person who carry out a harmful act) was removed from the patient care area for further potential harm to other patients. The IJ Removal Plan indicated: On 3/27/2025 at 9:30a.m., the organization placed the employee on administrative suspension. The employee ’ s suspension continues pending the completion of the termination process. On 3/27/2025 (five employees total) - 03/31/2025 (two employees total), the Director of Risk Management reinforced the escalation ( a rapid increase) expectations with the staff during the preliminary investigative interviews. On 3/28/2025, the Emergency Department Director provided coaching to the Register Nurse (RN) Lead to review the appropriate steps to follow for escalation. On 5/15/2025, the Emergency Department Director & Medical Director conducted immediate staff huddles on the topics of “De-escalation (process of reducing a violent situation) & Chain of Command.” No Emergency Department (ED) Staff member will be engaged in patient care until such training is received. This education included review of policy MA710 and will continue each shift until the online training module has been deployed on 5/16/2025 (see attached outline). On 5/15/2025 at 1630, Administration conducted a leadership huddle with organizational leaders that included a review of MA710 and organizational expectations of escalation of information in the event of an abuse allegation (see transcript for attendance). The organization will create an online learning module reviewing the expectations related to workplace violence events where actual or potential physical assaultive behavior from a patient towards the staff occurs. This online module will emphasize the process for de-escalation, which includes but is not limited to, removing oneself from the immediate vicinity of the patient for safety. The module will be deployed on 5/16/2025; with completion by ED staff by 5/31/2025. All patient-facing staff will complete the training module by 7/31/2025. Continue the “Healing Environment” (see signage below) campaign. The Executive Team, in conjunction with Risk Management team will make face-to-face contact with staff throughout the organization during the month of June promoting a healing environment concluding on 6/30/2025. The hospital Director of Threat Assessment and Management has initiated targeted de-escalation training with the Emergency Department beginning on 5/16/2025 and will continue until 100% of active staff have received the education. Posters created as a visual cue (provide information) to direct staff to activate Code Gray (security code for aggressive behavior) to be posted in workstations in the emergency department, and the nursing stations Finding: A review of Patient 1 ’ s Emergency Department (ED) Provider note dated 3/26/2025 indicated Patient 1 was brought into the ED by Emergency Medical Service (EMS) for alcohol intoxication (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream). During a review of the facility ’ s security camera video with the Risk Management Director (RMD) and Clinical Supervisor (CS), the video showed a staff to patient abuse allegation occurred on 3/26/2025 at 9:45 p.m., Patient 1 was sleeping and lying on a gurney (bed with wheels) in the hallway of the ambulance bay; Emergency Room Technician (ERT) was trying to wake Patient 1 by shaking Patient 1 ’ s chest and shoulder. At 9:47 PM Patient 1 swung his left arm toward ERT once and ERT stepped back then punched Patient 1 four times on Patient 1 ’ s head and face area. During an interview with Clinical Supervisor (CS) on 5/14/25 at 1:29 pm, stated that facility does not have a policy indicating that staff was allowed to hit the patient even in an aggressive violence situation. Concurrently, CS stated that ERT was removed from main ED area and placed at fast-track area to work until the end of the shift. During an interview with Risk Management Director (RMD) on 5/14/25 at 5:10 pm, stated the facility did not have a de-escalation (process of reduce violent situation) policy. Facility was using Work Plan Violence (WPV) Plan which indicated that security officers were responsible for responding to a violent incident without placing themselves in danger and were responsible for correcting any workplace violent hazard in the incident - including verbal de-escalation techniques. Concurrently, RMD stated that staff should have let security handle the aggressive situation. During an interview with Clinical Supervisor (CS) on 5/14/25 at 2:05 pm, stated the charge nurse (CN1) did not report this staff to patient abuse allegation to house supervisor. Concurrently, CN1 reported this patient abuse allegation around 7:00 am on 3/27/25 when CS arrived at work. Abuse incident occurred on 3/26/2025. ERT was reassigned to a new patient care area until the end of the shift at 7:00am on 3/27/25. During an interview with Emergency Department Registered Nurse (RN) 1 on 5/14/25 at 3:09 p.m. who stated that ERT, who was assigned to the main ED, and the other tech who was previously working in the fast-track area switched assignments after the incident occurred. ERT went to the fast-track area to resume patient care duties. During an interview with Risk Mangement Director (RMD) on 5/14/25 at 2:05 p.m. who stated that she and CS notified Human Resources (HR) the morning after ERT ’ s night shift, HR placed him on administrative leave. ERT was placed on administrative leave pending investigation. A review of Patient 1 ’ s ED provider note dated 3/26/25, indicated that Patient 1 had laceration on left superior periorbital (around the eye) region, appears 1.25 cm in length and is linear (straight) and superficial (outside) in appearance. Also, Patient 1 had laceration (deep tear in the skin) on left superior scalp (skin on top of the head) that appeared to be two separate opens since one wound size was measured 0.5cm and one wound size was measured 2.5 cm in length for a total of 3 cm of length. Computed Tomography (CT) Brain (detail x-ray) without contrast was done and the report indicated no acute intracranial abnormality. A review of the facility ’ s policy & procedure titled “Patient Allegations of Abuse During Hospital Visit”, last reviewed 4/2022, indicated that Hospital staff will immediately contact the risk manager or nursing supervisor when a patient or family member alleges abuse of any patient by hospital staff, whether or not the staff feels the allegation is credible. A review of the facility ’ s policy & procedure titled “Patient Rights/Responsibilities,” last reviewed 2/2022, indicated, “Patients have a right to: ... Receive care in a safe setting, free from mental, physical, sexual or verbal abuse or neglect, exploitation or harassment.””