Chino Valley Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure safe and effective quality of care for a universe of 32 sampled patients who were admitted on January 20, 2026, when the GB did not ensure an effective quality improvement program and provide effective oversight of patient safety and quality care related to telemetry alarm response, discharge process, intravenous (IV - given through the veins) medication administration, pain reassessment, crash cart verification, handoff communication process, and restraints monitoring. (Refer to A-0049). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51099 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for five of 32 sampled patients (Patient 1, 2, 9, 17, and 21), as evidenced by: 1. The facility did not ensure an ongoing program to monitor, collect data and analyze the process of telemetry (system that lets healthcare staff monitor a patient’s heart rate and rhythm) alarm responses, notifications, nor handoff communication/documentation. (Refer to A-0273). 2. The facility did not maintain an effective and ongoing hospital wide, data driven QAPI program to identify opportunities from the collected data of the issues addressing nursing surveillance processes related to critical cardiac alarm responses, and handoff communication fo r improvement to patient outcomes. (Refer to A-0283). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem-prone areas, implement effective performance improvement activities, and ensure the provision of quality health care services in nursing services and patient assessments, which could place patients at risk for harm.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 51269 Based on interview and record review the facility failed to maintain effective and organized nursing services for four of 34 sampled patients (Patient 2, 9, 17, and 21), as evidenced by: 1. For one patient (Patient 17), the nursing staff did not respond promptly to the bedside after notification of sustained bradycardia (ongoing slow heart rate) from telemetry (continuous monitoring of the patient’s heart rhythm) monitor technician. (Refer to A-395) 2. For one patient (Patient 17), the nursing staff did not verify patient’s identity when responding to a telemetry alarm resulting in the assessment of the incorrect patient. (Refer to A-398) 3.Nursing staff did not escalate care for one telemetry patient (Patient 17), experiencing sustained bradycardia prior to progression to cardiac arrest. (Refer to A-395) 4. For one patient (Patient 21), the nursing staff did not document handoff communication during the transfer of care before Patient 21 underwent a procedure. (Refer to A-398) 5. For one patient (Patient 2), the nursing staff did not document the assessment and need for restraints (used to prevent patient from pulling IV lines or tubes) every 2 hours as required and indicated in the policy. (Refer to A-398) 6. Four of eight crash carts (a wheeled container carrying medicine and equipment for use in emergency resuscitations) were missing entry dates for December 2025 and January 2026 on the checklist. (Refer to A-398) 7. For one patient (Patient 9), intravenous (IV- given through a tube directly into the blood stream) Morphine (medication to treat pain) was administered for a pain score (A tool to assess the severity of pain , typically 0-10 scale, 0-is no pain, 10 is the worst pain) that did not meet the parameters specified in the physician’s order. (Refer to A-405) 8. For one patient (Patient 9), the nursing staff did not assess Patient 9’s pain score after the administration of Morphine. (Refer to A-405) The cumulative effects of these systemic problems resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, evaluation, and treatment which jeopardized the health and safety of the patients.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to identify and ensure patient safety and provide quality care for five of 32 sampled patients (Patients 1, 9, 17, 21, and 2) when the GB did not have an effective oversight on nursing surveillance related to telemetry (continuous monitoring of the patient’s heart rhythm via wireless monitors) alarm responses and notification processes to prevent delay in care and escalation of care for patients in deteriorating conditions, handoff communication were completed and documented per the facility policy and procedure (P&P). These failures resulted in the facility’s failure to identify the problem prone areas and deliver care with the GB oversight, and to provide safe patient care environment with adequate supervision, which could jeopardize the health and safety of the patients. Findings: During a review of the facility documents titled, “Governing Board Meeting Minutes,” dated September 9, 2025, through December 9, 2025, the documents indicated quality care outcomes and identified safety concerns discussed at monthly meetings per department reporting to the Qualities Department and following up to the Medical Executive Committee (MEC) and GB. The meeting minutes included updates related to pain re-assessment, restraints, and resuscitation codes, but there was no documented data of nursing surveillance related to telemetry response and notification processes. During an interview on January 23, 2026, at 12:00 PM, in the conference room, with the members of the GB: Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and the Medical Director for Emergency Services (MS ED), the survey team’s following findings were discussed: - For Patient 17, the “Telemetry Monitoring Standardized Procedure” policy and procedure (P&P) was not followed when nursing staff did not properly identify and respond to a critical cardiac notification for a deteriorating patient in a timely manner, resulting in delayed care and intervention. The “Nursing Notes” dated July 4, 2025, indicated nursing staff was notified by the telemetry monitor technician at 10:29 PM, but Patient 17 was not assessed until 10:39 PM, when Patient 17’s EKG (electrocardiogram - snapshot of the heart’s rhythm and beats) indicated asystole (flatline on the heart monitor, indicating heart has stopped beating and there’s no electrical activity). - For Patient 21, handoff communication was not completed nor documented when Patient 21 was transferred from the Medical-Surgical/Telemetry (MST) unit to the OR (operating room) for a procedure. - For Patient 9, Morphine (medication to treat pain) was administered for a pain score (a tool to assess the severity of pain, typically 0-10 scale, 0-is no pain, 10 is the worst pain) that did not meet the parameters (moderate pain 4-6), specified in the physician’s order. The nursing staff did not re-assess pain score after administration of Morphine. - For Patient 2, nursing staff did not document the assessment and need of restraints (used to prevent patient from pulling IV lines or tubes) every two hours as required and indicated in the policy. - For Patient 1, appropriate shelter/housing was not referred on January 6, 2026, to appropriately after discharge. The Chief Executive Officer (CEO) stated, the GB was not aware of any telemetry alarm monitoring or response issues prior to the incident involving Patient 17, or the discharge concerns related to Patient 1 being discharged to an inappropriate shelter/housing. The CEO further stated, the facility keeps track and audits pain assessment and re-assessment timeframes as well as appropriate restraint use with continuous monitoring. The CEO stated the GB relied on reports from leadership but acknowledged that telemetry alarm monitoring and handoff communication had not been incorporated into governing oversight or tracking mechanisms. The CEO stated, GB has overall responsibility for the facility and for overall patient care and safety. The CEO further stated, when opportunities are identified, it was the responsibility of the GB to provide oversight of corrective actions and ensure trends are moving in the right direction. During a review of the facility’s document titled, “Performance Improvement Plan 2025” revised January 2025, the document indicated, “ ...The Governing Board of [Name of Hospital] has the authority and responsibility for: ...1. Determining priorities regarding which processes to monitor (indicators and frequency) with data collection and the subsequent development of planned improvement efforts ...2. Assuring patient safety and quality of patient care and services ...3. Systematic evaluation of the effectiveness of the organization-wise performance improvement function ...4. Appropriate delegation of adequate resources for measuring, assessing, improving, and sustaining [Name of Hospital] performance and the reduction of risk to patients ...5. Delegation of responsibility for performance improvement functions to MEC and the Performance Improvement (PI)/Risk Management Committee ...” During a review of the facility’s document titled, “Amended and Restated Governing Board Bylaws,” reviewed May 6, 2025, the document indicated, “ ...3.8 Duties: The Board of Directors shall determine the duties and authority of the Governing Board from time to time. The current duties of the Governing Board are as follows: ...(c). To ensure that the Medical Staff properly establishes and revises standards for the quality of services to be made available at the Hospital and Hospital policies implementing, such standards which standards shall be applied uniformly to all patents ...(f). Review and advise the CEO regarding the Hospital’s plan for improving the organization’s performance, describing an overall approach; assuring that the necessary processes and structures are in place; and that the planning and improvement process is collaborative ...(o). Assure that the hospital-wide Performance Improvement and Training Programs address problems identified the individual(s) responsible for infection prevention and control and that corrective action plans are successfully implemented ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51099 Based on interview and record review, the facility did not ensure an effective and ongoing Quality Assessment and Performance Improvement (QAPI) program for five of 32 sampled patients (Patient 1, 2, 9, 17, and 21), when the facility failed to monitor, collect data and analyze the process of telemetry ( system that lets healthcare staff monitor a patient’s heart rate and rhythm) alarm responses, notifications, nor handoff communication/documentation. This failure had resulted in the missed opportunities to identify patient safety issues and created changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: During an interview on January 23, 2026, at 11:19 AM, with six members of the QAPI: Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Performance Improvement Coordinator (PIC), Performance Improvement Manager (PIM), Performance Improvement Director (QD), and Medical Director for Emergency Services (MS ED), the facility’s QAPI program was discussed. The QD stated the facility collects unit-based data every month, the collected data would be brought to the quality department for analysis. The Quality Department would conduct an analysis and will then escalate to the Medical Executive Committee (MEC), and then the Governing Board (GB) for final approval. During a concurrent interview and record review on January 23, 2026, at 11:30 AM, with the QD, the facility documents titled “Performance Improvement/Patient Safety Committee Meeting Minutes” dated August 29, 2025, through November 14, 2025, were reviewed. The document indicated audits and data tracking related to medication administration for pain assessments and timeframes for pain re-assessment. There were also data collected for discharge communication, but there was none related to disposition and verifying placements (post discharge location). There was also no data collection or analysis related to telemetry alarm escalation and accuracy of patient identification during alarms. During a follow-up interview on January 23, 2026, at 11:51 AM, the survey team brought up some of the issues identified during survey as follows: nursing staff did not identify or verify the correct patient (Pateint 17), after a critical telemetry alarm alert from the telemetry monitor technician, and there were was no documented evidence indicated a handoff being completed during a transfer of care for Patiet 21. The CNO and QD stated, the facility was not aware of these issues, but should have been collecting data. The QD further stated, the facility does random checks of the charting, but there were no specific indicators for handoff, telemetry read backs (practice of verifying patient identity and information by reading back what was notified), nor documentation of discharge placement verification. A record review of the facility’s policy and procedure (P&P) , “Performance Improvement Plan 2025,” revised January 2025, indicated, the QAPI program is designed to,” track and trend on critical patient safety indicators” and leadership is responsible for “organizing and integrating performance improvement activities into a comprehensive, interdisciplinary program that focuses on a process of ongoing monitoring and evaluation to facilitate the delivery of the highest quality of patient care and services ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 51099 Based on interview and record review, the facility did not ensure the Quality Assessment and Performance Improvement (QAPI) maintained an effective and ongoing hospital wide, data driven program to identify opportunities from the collected data for five of 32 sampled patients (Patient 1, 2, 9, 17, and 21), when the QAPI program did not identify the issues regarding nursing telemetry surveillance and utilize the collected data for pain medication administration, pre and post assessments for improvement to patient outcomes. This failure resulted in the hospital’s inability to focus on problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment, leading to serious patient safety events across telemetry units, placing patients at risk for harm. Findings: During an interview on January 23, 2026, at 11:19 AM, with six members of the QAPI: Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Performance Improvement Coordinator (PIC), Performance Improvement Manager (PIM), Performance Improvement Director (QD), and Medical Director for Emergency Services (MS ED), the facility’s QAPI program was discussed. The QD stated the facility collects unit-based data every month, and the collected data would be brought to the quality department for analysis. The Quality Department would conduct an analysis then escalate to the Medical Executive Committee (MEC), and then the Governing Board (GB) for final approval. During a concurrent interview and record review on January 23, 2026, at 11:30 AM, with the QD, the facility documents titled “Performance Improvement/Patient Safety Committee Meeting Minutes” dated August 29, 2025, through November 14, 2025, were reviewed. The documents indicated, there was evidence of tracked audits for pain medication administration, pre and post assessments, restraint monitoring, but there was no evidence of data collection, tracking, or trending related to telemetry alarm notifications, response times, or telemonitor logs. The QD confirmed that audits for pain medication administration, pre and post assessment, and restraints showed improvement, but is still something the facility continues to monitor. QD further stated, there were no routine audits were conducted related to telemetry alarm response times, telemonitor notification accuracy, read-back compliance, telemonitor log completeness. During a subsequent interview and record review on January 23, 2026, at 11:39 AM, with the QD, facility’s document titled “Performance Improvement/Patient Safety Committee Meeting Minutes” dated August 29, 2025, through November 14, 2025, were reviewed. The document indicated there were no indicators, audits, or data collection related to handoff communication nor discharge disposition tracking. QD confirmed handoff communication was not routinely audited, tracked, or reported through QAPI program. A record review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Plan 2025,” revised January 2025, indicated, “The purpose of the Performance Improvement Plan is to establish the organizational duties and responsibilities, procedures, and processes by which the Governing Board, Medical Staff, and [Name of Hospital] staff may achieve and maintain high-quality patient care at [Name of Hospital] ...A. Performance Improvement activities will track and trend on critical patient safety indicators ...””

“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: 51099 Based on interview and record review, the facility failed to ensure nursing staff provided ongoing nursing surveillance and timely response to a change in patient condition for one of 32 sampled patients (Patient 17), when: Nursing staff did not respond promptly to the bedside and identify the correct patient after notification of a sustained bradycardia (ongoing slow heart rate) from telemetry (continuous monitoring of the patient’s heart rhythm via wireless monitors) monitor technician and escalate care for Patient 17 experiencing sustained bradycardia prior to progression to cardiac arrest. This failure resulted in delayed recognition and response to Patient 17’s deteriorating cardiac (heart) condition and which may have contributed to Patient 17’s fall and subsequent death. Findings: A review of Patient 17’s face sheet (contains medical and demographic information) indicated, Patient 17 was admitted to the facility on July 1, 2025, with a diagnosis of a Non-ST elevation myocardial infarction (NSTEMI- a type of heart attack with partial blockage). During a concurrent interview and record review on January 20, 2026, at 2:08 PM, with the Chief Nursing Officer (CNO), Patient 17’s “H&P (History & Physical)” dated July 1, 2025, was reviewed. The H&P indicated, Patient 17 came to the facility for chest pain and blurry vision, and was placed on continuous telemetry monitoring. A review of Patient 17’s “Cardiology Consultation” dated July 2, 2025, indicated, “ ...Assessment: chest pain, mild troponin (protein found in heart muscle) elevation (high troponin indicated heart trouble) ... Plan : follow up transthoracic echocardiogram (TTE - non-invasive ultrasound of the heart), obtain [Brand NAME of Medication] SPECT (nuclear stress test that uses obtain [Brand NAME of Medication] instead of a treadmill to stress the heart, and takes pictures of blood flow using a single photon emission computed tomography [SPECT] scan ...” A further concurrent interview and record review on January 20, 2026, at 3:02 PM, with the CNO, Patient 17’s telemetry strips (printout or screenshot of a patient’s heart rhythm from continuous monitoring used to track for any arrhythmias [problem with heart rhythm], heart rate, or changes) indicated the following on July 4, 2025: - At 22:27 PM: HR 97 bpm [beats per minute- heart rate per minute] - 22:29 PM: HR 38 bpm - 22:30 PM: HR 60 bpm - 22:31 PM: HR 45 bpm - 22:32 PM: HR 38 bpm - 22:33 PM: HR 38 bpm - 22:34 PM: HR 35 bpm - 22:35 PM: HR 35 bpm - 22:36 PM: HR 30 bpm - 22:37 PM: HR 28 bpm - 22:38 PM: HR 30 bpm - 22:39 PM: HR 33 bpm - 22:40 PM and onwards: artifact/uninterpretable The CNO confirmed the trend of bradycardia (low heart rate, usually defined as below 60 beats per minute [bpm]). A review of the telemetry monitor log dated July 4 , 2025, indicated the telemetry monitor technician (TMT) notified Registered Nurse 3 (RN 3), who was Patient 17’s primary nurse, at 10:29 PM of bradycardia with a heart rate of 38 bpm. However, the log did not reflect documentation of a read-back or confirmation of patient identification. A second notification to nursing staff was not documented in the telemetry monitor log. A review of Patient 17’s “Nursing Note,” dated July 4, 2025, at 10:39 PM, indicated, “Received call from tele (telemetry) room r/t (related to) pt’s (patient’s) low HR (heart rate) at 2229 [10: 29 PM]and CN (charge nurse) notified of pt asystole at 2234 [10:34 PM], at this time pt was checked and not in bed, bathroom door locked and when unlocked found lying face side down and unresponsive on bathroom floor; at this time, pt was moved from bathroom and CPR [Cardio Pulmonary Resuscitation-emergency life saving measures when someone’s heart or breathing stops] efforts started. After several rounds of CPR, MD called time of death at 2309 [11:09 PM] ...” A review of Patient 17’s “Record of Death/Authorization for Release of Remains” dated July 4, 2025, at 11:09 PM, indicated Patient 17 died of cardiac arrest. Applicable parties were notified. During a concurrent interview and record review on January 21, 2026, at 1:45 PM, with Registered Nurse 3, Patient 17’s telemetry strips dated July 4, 2025, was reviewed. RN 3 stated that upon receiving the initial notification from the TMT, she misheard the patient’s room number and assessed the wrong patient. RN 3 further stated that she did not verify the patient’s name on the telemetry monitor screen and did not immediately assess Patient 17 at the bedside following notification of the abnormal rhythm. RN 3 confirmed the telemetry strips on July 4, 2025, and verified Patient 17 was experiencing bradycardia and the TMT first notified her on 10:29 PM. During an interview with Charge Nurse 3 (CN 3), on January 22, 2026, at 11:48 AM, CN 3 stated she was later notified by the TMT that Patient 17 was in asystole (flatline on the heart monitor indicated the heart has stopped beating and there’s no electrical activity). Upon arrival at the patient’s room, Patient 17 was found unresponsive on the bathroom floor, and a Code Blue (hospital emergency call for a patient who’s not breathing or doesn’t have a heartbeat) was initiated. CN 3 further stated, RN 3 was not in the room until after the Code Blue was initiated. During a continued interview with the CN 3 on January 22, 2026, at 11:50 AM, stated, telemetry monitor technicians only notify nurses using a patient’s room number and bed, not necessarily the patient’s name. CN 3 stated, this practice can be an issue because sometimes the room number is misheard or the patient may be moved to a different room. CN 3 further stated, it was important to do a read-back to verify the patient and ensure timely response to the correct patient. During a concurrent interview and record review on January 22, 2026, at 12:13 PM, with the Interim Director of Medical Surgical/Telemetry (MST) unit (IDMSTI), the policy and procedure (P&P) titled, “Telemetry Monitoring Standardized Procedure,” revised August 2025, was reviewed. The P&P indicated, “ ...The purpose of this policy is to outline the criteria for admission, transfer and discharge to/from telemetry monitoring to ensure monitored beds are available and used appropriately to meet patient care needs ...b. Monitor Technician Responsibilities: ...2. Perform continuous monitoring and communicate with RN or PCT to maintain quality signal; alert if any mechanical or persistent artifact ....4. Notify RN if any change in rate and or rhythm that is outside of parameters: ...b. Bradycardia of less than 50 beats/minute ...Roles and Responsibilities - RN: ...4. Respond promptly to patient bedside, if notified by Central Monitor Technician, for any change in rhythm, rate of arrhythmia. 5. Assess the patient and notify physician as appropriate or call the Rapid Response Team (RRT), if indicated ...” The IDMSTI stated, the expectation is that if a telemetry monitor technician notifies nursing staff of any abnormalities in a patient’s heart rhythm, the nurse should promptly respond to the correct patient in a timely manner. IDMSTI further stated, it is best practice to repeat back what you hear when you get updates from the telemetry monitor technician. IDMSTI further stated, the facility did not follow P&P. A review of the facility’s Job Description (JD), titled “Registered Nurse,” revised July 2021, the JD indicated, “ ...The registered nurse is directly responsible and accountable for the care given to their assigned patients. They communicate with the physician about changes in the patient’s clinical condition including cardiac monitoring, results of diagnostic studies and symptomatology. Is able to respond quickly and accurately to changes in condition and/or response to treatment ...5. Demonstrates knowledge of the National Patient Safety Goals ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 51269 Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to hospital policies and procedures (P&P), to provide adequate supervision and evaluation for three of 34 sampled patients (Patient 2, Patient 17, and 21) when: 1. For one patient (Patient 2), the nursing staff did not document the assessment and need for restraints (an item used to stop a patient from removing medical equipment or hurting themselves) every two hours as required as per the policy “Restraints: Non- Violent Behavior” . 2. Four of eight crash carts (a wheeled container carrying medicine and equipment for use in emergency resuscitations) were incomplete as per the P&P “Code Blue & Cart Checks- Adult” . 3.For one patient (Patient 21), the nursing staff did not document handoff communication during the transfer of care before Patient 21 underwent a procedure as per the P&P “Communication: Handoff/SBAR,” . These failures resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed evaluation, monitoring, supervision , deterioration of patient conditions, and unsafe patient care. 4. For one patient (Patient 17), the nursing staff did not verify patient identity when responding to a telemetry (continuous monitoring of the patient’s heart rhythm) alarm resulting in the assessment of an incorrect patient as per the P&P “Telemetry Monitoring Standardized Procedure” . This failure resulted in delayed recognition and response to Patient 17’s deteriorating cardiac (heart) condition and which may have contributed to Patient 17’s fall and subsequent death. Findings: 1. During a review of Patient 2’s “History and Physical” (H&P- a document containing demographic information), dated January 10, 2026, at 11:53 PM, the H&P indicated, Patient 2 was admitted on January 10, 2026, for a diagnosis of Urinary Tract Infection (UTI-infection in the urinary system (the body system that makes, stores, and gets rid of urine)). Patient 2 had a medical history of diabetes (high blood sugar), urinary incontinence (leaking urine or not being able to control when you pee), hypertension (high blood pressure) and stroke (blood flow to a part of the brain is blocked or when a blood vessel in the brain bursts causing weakness or numbness to one side of the body, trouble speaking, and severe headache). A review of Patient 2’s physician’s orders dated January 11, 2026, through January 13, 2026, indicated, “Soft restraints ...fabric restraints; restraint location: bilateral [both] wrists; restraint ... continuous ...” During a facility tour on January 20, 2026, at 11:50 AM in room 1 of the Intensive Care Unit (ICU- area of the hospital with critically sick patients) Patient 2 was observed to have bilateral soft wrist restraints. During an interview on January 22, 2026, at 2:19 PM with Registered Nurse (RN 1), RN 1 stated, the nursing staff are required to document and monitor patients during the shift assessment and every two hours while the patients remain on restraints. RN 1 stated it is important to assess and document every two hours while the patients are on restraints because it helps the nursing staff respond to the patient’s basic needs such as food, water, bathroom breaks and check that the skin integrity is intact. During a concurrent interview and record review on January 22, 2026, at 2:48 PM, with the Interim Director of Medical Surgical/ Telemetry/ Intensive Care Unit (IDMSTI) Patient 2’s “flowsheet history” [part of the electronic health record to show the interventions performed by the staff] for restraints dated January 11, 2026, though January 13, 2026, was reviewed. The “flowsheet history” for restraint documentation was not completed every two hours as follows: January 12, 2026, 2:22 PM: “ ...in place ...” January 12, 2026, 8:30 PM: “ ...in place ...” (6 hours and 8 minutes without documentation) January 13, 2026, at 12:38 AM: “ ...in place ...” (4 hours and 8 minutes without documentation) The IDMSTI verified and confirmed that the nursing staff did not document every two hours and should have. The IDMSTI stated that it was important for the nursing staff to assess and document every two hours while the patients are on restraints because it helps the nursing staff respond to the patient’s basic needs and monitor patient safety. During a concurrent interview and record review on January 23, 2026, at 10:08 AM with the IDMSTI and the Chief Nursing Officer (CNO) the facility’s P&P titled “Restraints: Non- Violent Behavior” dated October 2024 was reviewed. The P&P indicated, “ ...Monitoring and care ....1. A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient. 2.Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff ...” The CNO and IDMSTI verified the policy was not followed according to the nursing documentation. The CNO stated it is important to follow the policy because “it is in compliance with the law”, and if the nursing staff does not document it then there is no proof it was done. 2a. During a concurrent observation, interview, and record review on January 20, 2026, at 10:20 AM, with the Med surg/Tele Charge Nurse (CN 1), in the south side of the Medical Surgical (Med surg- area in the hospital for patients after surgery or general medical problems that are not critical)/ Telemetry (Tele- area of the hospital for patients who need continuous heart monitoring) unit, the “Adult crash cart daily checklist” (CC Checklist- a checklist ensuing emergency medications and equipment are readily available and in working order) for December 2025 and January 2026 was incomplete for two shifts as follows: On December 21, 2025: PM Shift (7:00 PM to 7:30 AM) On January 10, 2026: PM Shift CN 1 verified and confirmed the CC checklists on On December 21, 2025, and On January 10, 2026,were incomplete for the PM shift. CN 1 stated licensed staff are assigned to the task at the start of each shift. CN 1 stated the charge nurse is responsible for verifying it has been completed. CN 1 stated it is important to check the crash cart in case of an emergency. During an interview on January 20, 2026, at 10:25 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated either an RN or LVN is responsible to complete the CC checklist, so they can be prepared in case of an emergency. During a concurrent interview and record review on January 22, 2026, at 2:41 PM, with the IDMSTI, the P&P titled “Code Blue & Cart Checks- Adult” dated June 2025 was reviewed. The P&P Indicated “ ...Code Cart Check. 6. Each and every crash cart shall be checked EVERY Shift in accordance with the following schedule and AFTER EACH USE. a. The Clinical Supervisor/ Relief Charge Nurse on duty on all patient care areas are accountable for performing the crash cart check at the beginning of their shift and when crash cart is replaced ...” The IDMSTI stated that the policy was not followed. The IDMSTI added, it is important to check the crash cart to ensure that it is in a working condition and supplies are available in case of an emergency. 2b. During an observation on January 20, 2026, at 11:05 AM, in the emergency department (ED), the CC checklist for crash cart “T2b” was incomplete” missing signatures indicating that the crash cart was not checked for the following shifts: January 2, 2026: AM shift (7:00 AM to 7:30 PM) January 6, 2026: PM shift January 9, 2026: AM shift and PM shift January 12, 2026: PM shift During a concurrent interview and record review on January 20, 2026, at 11:06 AM, with RN 2, in the emergency department (ED), the CC checklist for crash cart “T2b” was reviewed. RN 2 verified and confirmed CC checklist missing signatures indicating that the crash cart was not checked for the following shifts: January 2, 2026: AM shift January 6, 2026: PM shift January 9, 2026: AM shift and PM shift January 12, 2026: PM shift . 2c. During an observation in the ED on January 20, 2026, at 11:19 AM, the CC checklist for crash cart in “Radiology” dated January 2026 was incomplete. During a concurrent interview and record review on January 20, 2026, at 11:20 AM, with RN 2, in the ED, the CC checklist for crash cart in “Radiology” dated January 2026 was reviewed. RN 2 verified and confirmed the missing the CC checklist was missing signatures indicating that the crash cart was not checked on January 8, 2026 AM Shift. 2d. During an observation, interview,and record review on January 20, 2026, at 11:21 AM, with RN 2, in the ED, the “Pediatric Crash Cart Checklist ED TRAUMA 2” dated January 2026 was incomplete, missing signatures indicating that the crash cart was not checked for two (2) shifts as follows: January 2, 2026: AM January 9, 2026: AM RN 2 concurrently reviewed verified “Pediatric Crash Cart Checklist ED TRAUMA 2” for January 2026,and confirmed the missing signatures on January 2, 2026 and January 9, 2026. During an interview on January 20, 2026, at 11:24 AM with RN 2, RN2 stated, it is the responsibility of the nurse and staff to complete the crash cart checklist in the ED, in order to be prepared for any emergency. During a concurrent interview and record review on January 20, 2026, at 11:28 AM with the Emergency Department Charge Nurse (CN 2), the CC checklist for “T2b”, “Radiology”, and “Pediatric Crash Cart Checklist ED Trauma 2” were reviewed. CN 2 confirmed the incomplete CC checklist on “T2b”, “Radiology”, and “Pediatric Crash Cart Checklist ED Trauma 2”. CN 2 stated that there should not be any missing entries. CN 2 stated that “ultimately the charge nurse is responsible to verify that crash cart checks are complete”. CN 2 further stated it is important to check the crash carts to be ready for any emergency. During a concurrent interview and record review on January 22, 2026, at 3:40 PM with the CNO, the facility’s P&P Titled “Code Blue & Cart Checks- Adult” dated June 2025 and “Code Blue & Cart Checks-Peds” dated June 2025 were reviewed. The “Code Blue & Cart Checks- Adult” indicated “ ...Code Cart Check. 6. Each and every crash cart shall be checked EVERY Shift in accordance with the following schedule and AFTER EACH USE. a. The Clinical Supervisor/ Relief Charge Nurse on duty on all patient care areas are accountable for performing the crash cart check at the beginning of their shift and when crash cart is replaced ...” The “Code Blue & Cart Checks-Peds” indicated, “ ...7. Crash Cart Checks. 8. 7.1 Pediatric Crash Cart and or Broselow Flying Carpet bag (a specialized,, lightweight, and foldable mat used in pediatric emergency care to provide a clean, organized, and color-coded surface for patient assessment, treatment, and resuscitation) will be checked Every Shift in accordance with the following schedule and after each use. A. The Clinical Supervisor/ Relief Charge Nurse on duty on all patient care areas are accountable for performing the crash cart check at the beginning of their shift and when crash cart is replaced ...” The CNO stated that the policies were not followed and should have been. The CNO added, staff should be prepared for emergency situations. 51099 3. During a review of Patient 21’s face sheet (contains demographic and medical information), Patient 21 was admitted to the facility on January 19, 2026, with diagnoses including gastrostomy tube (g-tube - tube that goes straight into the stomach for feeding) replacement (swapping out an old or dislodged g-tube with a new one), dementia (brain condition that slowly makes it harder for someone to think, make decisions, or take care of themselves), and hypertension (high blood pressure). During a concurrent interview and record review on January 21, 2026, at 10:21 AM, with the Performance Improvement Manager (PIM), Patient 21’s “Esophagogastroduodenoscopy (EGD - test where a doctor uses a thin camera tube to look inside the esophagus [swallowing tube], stomach, and the duodenum [first part of the small intestine] Procedure Note” dated January 20, 2026, indicated, Patient 21 was transferred from the Medical-Surgical/Telemetry (MST) unit to the Gastrointestinal (GI) unit for an EGD with a new g-tube placement. During a subsequent interview and record review, with the PIM on January 21, 2026, at 11:00 AM, Patient 21’s medical record “Handoff” (when one healthcare provider passes important patient information to another during a shift change, transfer, or break) section was reviewed. The “Handoff” section indicated documentation of routine bedside nurse-to-nurse shift handoff reports on January 20, 2026, at 7:12 AM and 7:00 PM. However, there was no documented nursing handoff report between the MST Registered Nurse (RN 4) and the receiving procedural/operating room (OR) nurse (RN 5) at the time of transfer for the EGD procedure. The PIM reviewed and confirmed there was no documented evidence to indicate a handoff communication to indicate RN 4 completed a handoff to the OR nurse before Patient 21 underwent procedures. During a concurrent interview and record review with RN 5 on January 21, 2026, at 11:42 AM, Patient 21’s “Pre-procedure checklist” was reviewed. RN 5 confirmed there was no documentation of handoff given to him by Patient 21’s primary nurse in the chart. RN 5 stated, he was given handoff verbally by RN 4 at bedside, however, he could not find documented evidence of it. RN 5 further stated, it was important to give report when transferring care to another department, so they are aware of changes or significant risks to watch out for, and this report should have been documented on the chart. During a concurrent interview and record review on January 21, 2026, at 3:30 PM, with the CNO the facility’s policy and procedure (P&P), titled, “Communication: Handoff/SBAR,” revised February 2023, was reviewed. The P&P indicated, “To provide accurate information about a patient’s care, treatment, or service, and their current conditions with any recent or anticipated changes when responsibilities are “handed off” from one care provider to the next, in permanent and/or temporary situations ...Hand-offs: The patient hand-off is a process when the passing of patient specific information occurs from one caregiver to another or from one department to another. A hand-off also includes transferring the responsibility of care from one caregiver to another ...” CNO stated the facility did not follow policy, and handoff should have been documented in the chart or else it did not happen. 4. A review of Patient 17’s face sheet (contains medical and demographic information) indicated, Patient 17 was admitted to the facility on July 1, 2025, with a diagnosis of a non-ST elevation myocardial infarction (NSTEMI- a type of heart attack with partial blockage). During a record review on January 20, 2026, at 2:08 PM, with the Chief Nursing Officer (CNO), Patient 17’s “History and Physical (H&P)” dated July 1, 2026, was reviewed. The H&P indicated, Patient 17 came to the facility for chest pain and blurry vision and was placed on continuous telemetry monitoring (a way to constantly watch a patient’s heart rate and rhythm using wireless monitors). A review of Patient 17’s “Cardiology Consultation” dated July 2, 2025, indicated, “ ...Assessment: chest pain, mild troponin (protein found in heart muscle) elevation (high troponin indicated heart trouble) ... Plan: follow up transthoracic echocardiogram (TTE - non-invasive ultrasound of the heart), obtain [Brand NAME of the medication]. SPECT (nuclear stress test that uses [Brand NAME of the medication]. instead of a treadmill to stress the heart, and takes pictures of blood flow using a single photon emission computed tomography [SPECT] scan ...” A further concurrent interview and record review on January 20, 2026, at 3:02 PM, with the CNO, Patient 17’s telemetry strips dated July 4, 2025, indicated the following: o at 22:27 PM: HR 97 bpm [beats per minute-number of heart rate in aminute] o 22:29 PM: HR 38 bpm o 22:30 PM: HR 60 bpm o 22:31 PM: HR 45 bpm o 22:32 PM: HR 38 bpm o 22:33 PM: HR 38 bpm o 22:34 PM: HR 35 bpm o 22:35 PM: HR 35 bpm o 22:36 PM: HR 30 bpm o 22:37 PM: HR 28 bpm o 22:38 PM: HR 30 bpm o 22:39 PM: HR 33 bpm o 22:40 PM and onwards: artifact/uninterpretable The CNO confirmed the trend of bradycardia (low heart rate, usually defined as below 60 beats per minute [bpm]). A review of the telemetry monitor log dated July 4, 2025, indicated the telemetry monitor technician (TMT) notified Registered Nurse 3 (RN 3), who was Patient 17’s primary nurse, at 10:29 PM of bradycardia with a heart rate of 38 bpm. However, the log did not reflect documentation of a read-back or confirmation of patient identification. A second notification to nursing staff was not documented in the telemetry monitor log. A review of Patient 17’s “Nursing Note,” dated July 4, 2025, at 10:39 PM, indicated, “Received call from tele (telemetry) room r/t (related to) pt’s (patient’s) low HR (heart rate) at 2229 [10:29 PM] and CN (charge nurse) notified of pt asystole at 2234 [10: 34 PM], at this time pt was checked and not in bed, bathroom door locked and when unlocked found lying face side down and unresponsive on bathroom floor; at this time, pt was moved from bathroom and CPR efforts started. After several rounds of CPR (cardiopulmonary resuscitation - a way to keep someone alive when their heart stops beating or they stop breathing), MD called time of death at 2309 [11:09 PM] ...” During a concurrent interview and record review on January 21, 2026, at 1:45 PM, with Registered Nurse 3,Patient 17’s telemetry strips dated July 4, 2025, was reviewed. RN 3 stated that upon receiving the initial notification from the TMT, she misheard the patient’s room number and assessed the wrong patient. RN 3 further stated that she did not verify the patient’s name on the telemetry monitor screen and did not immediately assess Patient 17 at the bedside following notification of the abnormal rhythm. RN 3 confirmed the telemetry strips on July 4, 2025, and verified Patient 17 was experiencing bradycardia and the TMT first notified her on 10:29 PM. During an interview on January 22, 2026, at 11:48 AM, with Charge Nurse 3 (CN 3), CN 3 stated, she was the one that found Patient 17 on the bathroom floor and initiated a Code Blue (hospital emergency call for a patient who’s not breathing or doesn’t have a heartbeat). CN 3 further stated, TMTs only notify nurses using a patient’s room number and bed, not the patient’s name. CN 3 stated, this practice can be an issue because it allows the room number to be misheard or the patient may be moved into a different room. It was important to do a read-back (practice verifying an order or information back out loud to confirm it’s correct) to verify the patient and ensure timely response to the correct patient. During a concurrent interview and record review on January 22, 2026, at 12:13 PM, with the Interim Director of Medical Surgical/Telemetry (MST) unit (IDMSTI), the policy and procedure (P&P) titled, “Telemetry Monitoring Standardized Procedure,” revised August 2025, was reviewed. The P&P indicated, “ ...The purpose of this policy is to outline the criteria for admission, transfer and discharge to/from telemetry monitoring to ensure monitored beds are available and used appropriately to meet patient care needs ...b. Monitor Technician Responsibilities: ...2. Perform continuous monitoring and communicate with RN or PCT to maintain quality signal; alert if any mechanical or persistent artifact ....4. Notify RN if any change in rate and or rhythm that is outside of parameters: ...b. Bradycardia of less than 50 beats/minute ...Roles and Responsibilities - RN: ...4. Respond promptly to patient bedside, if notified by Central Monitor Technician, for any change in rhythm, rate of arrhythmia. 5. Assess the patient and notify physician as appropriate or call the Rapid Response Team (RRT), if indicated ...” The IDMSTI stated, the expectation is that if a telemetry monitor technician notifies nursing staff of any abnormalities in a patient’s heart rhythm, the nurse should promptly respond to the correct patient in a timely manner. IDMSTI further stated, it is best practice to repeat back what you hear when you get updates from the telemetry monitor technician. The IDMSTI further stated, the facility did not follow the P&P. During a concurrent interview and record review on January 22, 2026, at 3:40 PM, with the CNO, the facility’s Job Description (JD) titled “Registered Nurse,” revised July 2021, was reviewed. The JD indicated, “ ...The registered nurse is directly responsible and accountable for the care given to their assigned patients. They communicate with the physician about changes in the patient’s clinical condition including cardiac monitoring, results of diagnostic studies and symptomatology. Is able to respond quickly and accurately to changes in condition and/or response to treatment ...5. Demonstrates knowledge of the National Patient Safety Goals ...” The CNO stated, the practice of read-back is part of the National Patient Safety Goals (NPSG), and it is best practice to read-back any verbal information communicated in order to ensure accuracy and safety.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 51269 Based on interview and record review, the facility failed to ensure that medications were administered in accordance with the physician’s orders and facility policy and procedure for one of 34 sampled patients (Patient 9) when: 1. For one patient (Patient 9), intravenous (IV- given through a tube directly into the blood stream) Morphine (medication to treat pain) was administered for a pain score (A tool to assess the severity of pain , typically 0-10 scale, 0-is no pain, 10 is the worst pain) that did not meet the parameters specified in the physician’s order and the nursing staff did not reassess Patient 9’s pain score after administration of Morphine. . This failure placed patient 9 at risk for ineffective pain management, preventable medication errors with discrepancy and undetected adverse reactions and had the potential which could negatively affect patient’s health, safety, prolonged hospitalization, and lead to actual harm or death. Findings: 1a. During a review of Patient 9’s “History and Physical” (H&P- a document containing demographic information), dated January 16, 2026, at 10:22 PM, the H&P indicated, Patient 9 was admitted to the facility for acute (sudden) cholecystitis (inflammation of the gallbladder (a small organ under the liver that stores bile) most commonly caused by a gallstone (harden pieces of bile that form in the gallbladder). Patient 9 had a history of diabetes (high blood sugar), Hypertension (high blood pressure), and coronary artery disease (a condition where the blood vessels that supply the heart become narrow or blocked because of fatty buildup). A review of Patient 9’s “Medication” orders with the start date January 16, 2026, through January 25, 2026, indicated “Morphine injection 2mg [milligram-unit of measurement] ...intravenous ...every 4 hours as needed for moderate pain (4-6) ...” During an interview on January 22, 2026, at 2:14 PM with Registered Nurse (RN 1), RN1 stated that the nursing staff are required to follow the parameters of the medication orders. RN 1 added that it was important to follow the physician’s order because that is within the nursing scope and if a nurse disagrees with the order or needs clarification, then the nursing staff should communicate with the physician. During a concurrent interview and record review on January 22, 2026, at 2:27 PM, with the Interim Director of Medical Surgical/ Telemetry/ Intensive Care Unit (IDMSTI), Patient 9’s “Flowsheet History” of pain dated January 20, 2026, and “All Administration of morphine injection 2 mg” dated January 16, 2026, through January 20, 2026, was reviewed. The “flowsheet History” indicated on January 20, 2026, at 4:42 PM pain score of 10. The “All administration of morphine injection 2mg” indicated “given: 2 mg ... intravenous ... recorded time 1/20/2026 4:43 PM ...” The IDMSTI stated that according to the documentation the physician’s order was not followed as the pain score was out of the 4-6 pain score range, and the nurse should have notified the physician. The IDMSTI stated nursing staff are expected to follow the physician’s order. During a concurrent interview and record review on January 22, 2026, at 4:09 PM, with the Chief Nursing Officer (CNO) the facility’s policy and procedure (P&P) titled “Medication Administration” dated January 2025 was reviewed. The P&P indicated, “Administration of Medications ...4. Prior to administration, the 6 R’s must be verified: a. Right drug- Verify that the medication selected for administration is the correct one based on the medication order and product label ...” The CNO stated that according to the documentation, the policy was not followed by the nursing staff. The CNO added it is important to follow the order to keep the patients comfortable and address the patients’ pain. 1b.During an interview on January 22, 2026, at 2:17 PM with RN 1, RN 1 stated the nursing staff are expected to do pain reassessments after the administration of pain medications. RN 1 stated, for oral (by mouth) medications, the nursing staff have to reassess within one hour of administration and within 30 minutes for IV medications. RN 1 further stated it is important to do the reassessment for patient comfort and safety. A review of Patient 9’s physician’s orders with the start date January 16, 2026, through January 25, 2026, indicated “Morphine injection 2mg ...intravenous ...every 4 hours as needed for moderate pain (4-6) ...” During a concurrent interview and record review with the IDMSTI on January 22, 2026, at 2:20 PM, Patient 9’s “Flowsheet History” pain assessments dated January 20, 2026, and “All administration of morphine injection 2mg” dated January 16, 2026, through January 20, 2026, were reviewed. The “Flowsheet History” pain assessments are as follows: January 20, 2026, 4:42 PM: Pain score 10 (Prior to Morphine administration) January 20, 2026, 9:34 PM: Pain Score 6 (5 hours after Morphine was given) The “All administration of Morphine injection 2mg” indicated “given: 2 mg ... intravenous ... recorded time 1/20/2026 4:43 PM ...” The IDMSTI verified and confirmed the nursing staff did not document a reassessment of pain after the administration of IV morphine and should have. The IDMSTI stated, it is important for the nursing staff to do a reassessment to verify the efficacy of medication and if the medication did not control the pain so they can notify the physician if needed. During a concurrent interview and record review on January 22, 2026, at 4:12 PM, with the CNO, the facility’s policy titled “Pain Management” dated October 2025 was reviewed. The P&P indicated, “ ...After pain medication is administered to evaluate the effectiveness of intervention within 30 minutes after an intramuscular [into the muscles]and or intravenous pain medication is administered. 60 minutes after an oral pain medication is administered ...” The CNO stated that the nursing staff did not follow the policy and should have. The CNO further stated it is important to do a reassessment to ensure that the nursing staff keep the patient comfortable and address any pain the patient is experiencing.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 51269 Based on interview and record review, the facility failed to ensure an appropriate and safe discharge planning evaluation was made for one of 34 sampled patients (Patient 1) when the facility was unable to provide any documented evidence to show Patient 1 was discharged to a homeless shelter without verifying the shelter’s ability to accept the patient, honoring the patient’s expressed request for placement, and follow up appointment with a primary care physician. This failure resulted in poor communication between Patient 1 and the healthcare team, and had the potential to result in unsafe discharge, lack of continuity of care, and unmet post (after)-discharge needs. Findings: During a review of Patient 1’s “History and Physical” (H&P- a document containing demographic information), dated January 4, 2026, the H&P indicated, Patient 1 was admitted on January 3, 2026, with the diagnoses of congestive heart failure (CHF- a condition where the heart muscle is unable to pump blood effectively enough to meet the body’s needs) with cardiomyopathy (a condition where the heart muscle becomes weak, thick or stiff making it difficult for the heart to pump blood effectively) Patient 1 had a medical history of diabetes (high blood sugar), hypertension (high blood pressure), Atrial fibrillation (A-fib- irregular heart rhythm), and methamphetamines (drug) abuse. A review of the “Discharge Summary Notes” dated January 6, 2026, indicated patient 1 was discharged on “ ... January 6, 2026, at 3:58 PM .... discharge follow-up instructions: Follow up with PCP [Primary care physician] within 1 week ...” During an interview on January 21, 2026, at 2:21 PM with the Social Worker (SW 1), in regard to determining placement for homeless, SW 1 stated, the SW will identify patient preference, if there is no preference, the facility will try in the area that the patient resides in, and if no availability, then they go to the first available shelter. During a concurrent follow-up interview and record review on January 21, 2026, at 2:40 PM, with SW 1, Patient 1’s “social worker” notes dated from January 5, 2026, to January 6, 2026, were reviewed as follows: Patient 1’s “Social Worker” notes dated January 5, 2026 indicated, “ ....Pt [patient] was A&OX4 [Alert and oriented to person place, time, situation], and SW [social worker- trained profession who helps with housing placement, mental health, substance use, benefits, discharge planning, resources] identified no delays or disabilities ....pt is agreeable to go back into treatment, but wanted to go to [homeless shelter in City 1] campus. SW called and left a message on the [homeless shelter in City 2] Intake phone ...” Patient 1’s “Social Worker” notes dated January 6, 2026, indicated “SW called [homeless shelter in [name of City 2] ... and intake stated pt would make excuses to go to the hospital and was transported every day for two weeks to the hospital and was caught using methamphetamines (drugs) several times. Pt will not be accepted back. SW will transport Pt to [homeless shelter in City 3] @ [at] [address that is different to the homeless shelter mentioned].” SW 1 verified and confirmed that the address put on the “Social Worker” notes dated January 6, 2026, was not the address for the homeless shelter [in City 3]. SW 1 stated, “the facilities are a couple miles away” and to his understanding that address on the notes is the intake center for the homeless shelter the SW 1 intended to send Patient 1 to. SW 1 verified that the address/facility where Patient 1 was sent to was never contacted. SW 1 stated, he was unsure if there were any notes in the medical record regarding attempts made to place Patient 1 in the preferred location. During an interview on January 22, 2026, at 4:06 PM with the Chief Nursing Officer (CNO), the CNO stated that the expectation is that the social workers document attempts made to place the patient in the medical record. CNO stated that if Patient 1 wanted to go to a homeless shelter in [name of City 1] and that homeless shelter did not accept Patient 1, that should be documented in the patient’s medical record. During a joined telephone interview on January 22, 2026, at 4:32 PM with the Physician (MD-physician who works at the address that Patient 1 was sent to) and the CNO, MD stated that the address Patient 1 was sent to is not affiliated with the shelter Patient 1 was intended to go to. During a concurrent interview and record review on January 23, 2026, at 8:41 AM with SW 1 and the CNO, the facility’s Policy and Procedure (P&P) titled “Homeless Patient Discharge Management Of” dated September 2025 was reviewed. The P&P indicated, “ ...Requirements for Shelter/ Community Based Housing Placement. 1. Social worker/Nurse. 1.1 The Shelter should be within the geographic area that the patient is currently residing in, unless the patient makes a specific request, if applicable ...” The CNO and SW 1 stated that the policy was not followed and should have been. SW 1 stated it is important to follow the policy to show evidence that an attempt was made to place the patients within the area requested or the area the patient resides in.”

“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: 46696 Based on observation, interview and record review, the facility failed to ensure sharp objects were properly disposed off for one of 64 patients (Patient 1). This failure had the potential to result an injury or infection of blood borne pathogens to patient,visitor, and staff . Findings: During an observation on January 22, 2024, at 10:00 AM, in patient room 214B, a sharp uncapped needle with syringe attached was observed to be resting on the windowsill next to the patient’s bed. During an interview on January 22,2024, at 10:01 AM, with Patient 1, Patient 1 stated, “The nurse last night was using that to fix my JP Drain (Jackson-Pratt (JP) drain a surgical suction drain that gently draws fluid from a wound to help you recover after surgery), she must have left it there.” During concurrent observation and interview on January 22, 2024, at 10:10 AM, with the Chief Nursing Officer (CNO), in room 214B, an uncapped needle with syringe attached was observed to be resting on the windowsill next to the patient’s bed. The CNO stated, “an open needle should not ever be left at a patient’s bedside, it could injure a patient or anybody else who touches it, it is also an infection control risk.” The CNO further stated, “This is not standard nursing practice and does not follow our facility policy on sharp disposal.” During a review of the facility’s policy and procedure (P&P) titled, (Standard Precautions: Infection prevention and control Manual), Dated August 2021, indicated, “III Contaminated Sharps (Needles, scalpel Blades, Lancets, etc. ...Needles/Sharps are discarded in a biohazard labeled, impervious, puncture resistant container. A needle/sharp container is located in each patient room, medication rooms and in patient therapeutic departments. All used sharps must be disposed of immediately after use to minimize risk of injury to patients and healthcare workers.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47682 Based on interview and record review, the facility failed to ensure an adequate number of licensed registered nurses (RN) were available to meet patient needs when RN 1 was assigned to care for a total of 5 patients, along with three (3) high-acuity telemetry (heart monitoring). This failure resulted in delays in medication administration for one of 30 sampled patients (Patient 15), which had the potential to result in further delay of care and decreased therapeutic outcomes. Findings: During a review of Patient 15’s “History and Physical” (H&P) dated January 22, 2024, the “H&P” indicated, Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 had a past medical history of Hypertension (high blood pressure), Myelofibrosis (an uncommon type of bone marrow cancer that disrupts the body’s normal production of blood cells and Thrombocytopenia (a condition causing a low blood platelet count. Platelets are colorless blood cells that help blood clot). During an interview on January 23, 2024, at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, “I have not yet given the morning medications. I did not give the medications earlier because I was trying to prioritize my patients based on acuity. Based on my resources available, I was focusing on other patients.” RNR1 further stated, the normal timeframe for medication administration is plus or minus one hour. To deviate from the order, the best practice is to clarify with the physician first. “I haven’t had time to call the doctor yet.” During an interview on January 23, 2024, at 2:00 PM, with the MS/T Clinical Supervisor (MSTCS), the MSTCS stated, “we have to call and let the physician know if we want to hold medications. It is a physician order so it should be given as ordered or else confirmed with the physician. Holding or delaying administration of a medication like Protonix because it is ‘not critical’ is still not an excuse not to call the doctor for permission.” During a concurrent interview and record review on January 23, 2024, at 3:30 PM, with the MS/T Director, (MSTD), the policy and procedure (P&P) titled, “Medication Administration” dated April 2023, was reviewed. The P&P indicated, “Prior to administration, the 6 R’s must be verified: ...C. Right Time: 30-60 minutes before or after the scheduled medication time.” The MSTD stated, “These medications were given out of the administration window. This is not standard of practice.” During a concurrent interview and record review on January 24, 2024, at 4:00 PM, with the Chief Nursing Officer (CNO), the document “MS/T Patient Care Assignment Sheet” dated January 23, 2024, was reviewed. The “MS/T Patient Care Assignment Sheet” indicated that 5 patients were assigned to Registry Nurse 1 (RNR1) during the day shift (7:00 AM - 7:30 PM) of January 23, 2024. The CNO stated “RNR1 is out of ratio with 3 Telemetry patients and 2 Medical-Surgical (general hospital unit) patients .” During an interview on January 25, 2024, at 9:00 AM, with the CNO, the CNO stated, the House Supervisor got 4 call-offs during the night and realized at 7:15 AM, on January 23, 2024, that they would be over ratio on the Medical-Surgical / Telemetry (MS/T) unit. One nurse was asked to stay over to assist but did not take an assigned patient load. This did not count towards the nursing ratio because she did not take an assignment and was only assisting until and she left at 11:00 AM. The CNO stated, the hospital attempted to bring in an additional RN but was unsuccessful. The CNO further stated, they remained out of ratio for the duration of the shift. During a concurrent interview and record review on January 25, 2024 at 10:00 AM, with the CNO, Patient 15’s “Medication Administration Record” (MAR) dated January 23, 2024, was reviewed. The “MAR” indicated medications Colace (a stool softener) and Protonix (to reduce stomach acid) were scheduled to be administered at 9:00 AM and were not given until 10:48 AM, on January 23, 2024. The CNO further stated, the nurse who was over ratio (RNR1) was delayed in administering morning medications (protonix and colace) by an hour and 45 minutes. During a review of the facility’s policy and procedure (P&P) titled “Organizational Plan for Providing Patient Care” dated August, 2022, the “P&P” indicated, “Mandated staffing ratio (on MS/T) is 4:1 patient-to-nurse ratio, with the ability to staff 5:1 for a patient case load that encompasses only the ‘Medical-Surgical’ patient status, with no telemetry monitoring.” During a review of the facility’s policy and procedure (P&P) titled “Medication Administration Times” dated April, 2021, the “P&P” indicated, “Medications are to be scheduled and administered according to the hospital-wide routine schedule. Any exceptions to the schedule must be communicated to the pharmacy either via a written physician order or the nursing Medication Administration Record.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46696 Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the facility’s policy and procedure (P&P) appropriately when staff did not label IV tubing (tubes used to administer medications into the veins) and peripheral IV sites (a small tube inserted into a vein used to deliver medications and fluids) for nine of 64 patients (Patient 1, Patient 2, Patient 3, Patient 7, Patient 8, Patient 9, Patient 10, Patient, 41 and Patient 42). This failure had the potential to result in longer than the intended use of peripheral IV’s and IV tubing placing vulnerable patients at risk for infection and prolonged hospitalization. Findings: 1a. During a review of patient 1’s “History and physical” (H&P -a formal and complete assessment of the patient and their medical problem), the H&P indicated, Patient 1, presented to the hospital for cough, difficult breathing, and weakness post COVID 19 (viral infection with difficulty breathing) infections. During an observation on January 22, 2024, at 10:00 AM, in room 214B, IV tubing was observed to be hanging at patient 1’s bedside without a date or label. 1b. During a review of patient 2’s H&P, the H&P indicated patient 2, had a history of renal failure (failure of the kidneys), hypertension (high blood pressure) and worsening shortness of breath. During an observation on January 22, 2024, at 10:15 AM, in room 218B, IV tubing was observed to be hanging at Patient 2’s bedside without a date or label. 1c. During a review of Patient 3’s H&P, the H&P indicated, Patient 3 was an 85-year-old male with past medical history of recent CVA (bleeding in the brain), hypertension, and diabetes mellitus (a condition causing high blood sugar). During an observation on January 22, 2024, at 10:20 AM, in room 217B, IV tubing was observed to be hanging at Patient 3’s bedside without a date or label. During an interview on January 22,2024, at 10:25 am, with Registered Nurse (RN 8), RN8 stated, tubing should be changed every 96 hours if not, possiblity for the nurse to not change the tubing and it was an infection risk for the patient. 1d. During an observation on January 22, 2024, at 10:55 am, in room 223B, Patient 41’s Peripheral IV located on their left arm was observed to have unlabeled with a date of insertion on the site. 1e. During a review of Patient 7’s “H&P”, the H&P indicated, Patient 7,had a past medical history of significant coronary artery disease (a narrowing of arteries in the heart, limiting blood flow to the heart), and hypertension. During an observation on January 22, 2024, at 11:05am, in room 212, IV tubing was observed to be hanging at Patient 7’s bedside with a label indicating “Change Wednesday” on the tubing but without a date. 1f. During a review of Patient 8’s H&P, the H&P indicated, patient 8 is a 57-year-old Male with Past medical history of Hypertension and complaints of dry cough post COVID 19 infection. During an observation on January 22, 2024, at 11:10 am, in room 207B, IV tubing was observed to be hanging at Patient 8’s bedside with a label on the tubing indicating “Change Wednesday” but without a date. 1g. During a review of Patient 9’s H&P, the H&P indicated, Patient 9 was a 56-year-old female with past medical history of diabetes mellitus. During an observation on January 22, 2024, at 11:15 am, in room 208A, IV tubing was observed to be hanging at Patient 9’s bedside with a label on the tubing indicating “Change Thursday” but without a date. 1h. During a review of Patient 10’s “H&P”, the H&P indicated, Patient 10 was presented to the facility with complaints of sudden onset of rash and coughing. During an observation on January 22, 2024, at 11:25 am, in room 203B, IV tubing was observed to be hanging at Patient 10’s bedside with a label on the tubing but without a date. 1i. During an observation on January 22, 2024, at 11:35 am, in room 204A, Patient 42’s Peripheral IV located on their left arm was observed to not have a date of insertion labeled on the site. During an interview on January 22,2024, at 10:10 am with the Chief Nursing Officer (CNO), the CNO stated, “All IV tubing should be labeled, the policy is it should be labeled for disposal every 96 hours if main line tubing and 24 hours if secondary tubing.” The CNO further stated “Patients would be at risk of the tubing not being changed for more than 96 hours which is an infection control risk. During a review of the facility policy and procedure (P&P) titled, “Intravenous Infusion: Peripheral Lines” dated March 2023, the P&P indicated,” IV sites are Changed every 4 days. Any exceptions must have a written Physician order. IV sites are labeled with the start date, time, and nurses initials .... Primary, secondary and extension set tubing’s are changed every 4 days.””

“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: 47682 Based on interview and record review, the facility failed to ensure medications were administered according to accepted standards of practice when one of 30 sampled patients (Patient 15) did not receive medications as ordered by the physician, when, 1a. Protonix (to reduce stomach acid) and Colace (a stool softener) administration were delayed by 1 hour and 48 minutes. 1b. Heparin (a medication to slow blood clotting) was held without a physician’s prior approval. These failures had the potential to result in harm to the patient when prescribed medications were not administered as ordered which may contribute to negative outcomes and can jeopardize the health and safety of the patient. Findings: 1a. During a review of Patient 15’s “History and Physical” (H&P) dated January 22, 2024, the “H&P” indicated Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 has a past medical history of Hypertension (high blood pressure), Myelofibrosis (an uncommon type of bone marrow cancer that disrupts the body’s normal production of blood cells and Thrombocytopenia (a condition causing a low blood platelet count. Platelets are colorless blood cells that help blood clot). During a concurrent interview and record review on January 23, 2024 at 10:30 AM, with the Director of Emergency Department, (EDD), Patient 15’s active “Medication Administration Record” (MAR) dated January 23, 2024, was reviewed. The EDD stated, from looking at his chart, this patient should already have had his 9: 00 AM, medications. The EDD stated, these medications (Protonix, Heparin and Colace) are already an hour and a half late. The EDD further stated, Registered Nurse (RN) should have clarified with the physician first, if he wanted to hold or delay administration of any medications. During an interview on January 23, 2024 at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, “I did not give the medications earlier because I was trying to prioritize my patients based on acuity. Based on my resources available, I was focusing on other patients.” RNR1 stated, the normal timeframe for medication administration is plus or minus one hour. RNR1 further stated, to deviate from the order, the best practice was to clarify with the physician first. “I haven’t had time to call the doctor yet.” During a review of Patient 15’s “Medication Administration Record” (MAR) dated January 23, 2024, the “MAR” indicated, medications Colace and Protonix were scheduled to be administered at 9:00 AM and were not given until 10:48 AM, on January 23, 2024. During an interview on January 23, 2024 at 2:00 PM, with the Medical-Surgical / Telemetry unit (MS/T) Clinical Supervisor (MSTCS), the MSTCS stated, nurses are expected to call and let the physician know if we are holding medications. The MSTCS stated, it was a physician order so it should be given as ordered or else confirmed with the physician. The MSTCS further stated, holding, or delaying administration of a med icine like Protonix because it was ‘not critical’ and it was still not an excuse to call the doctor for permission. During a concurrent interview and record review on January 23, 2024 at 3:30 PM, with the MS/T Director, (MSTD), the policy and procedure (P&P) titled, “Medication Administration” dated April 2023, was reviewed. The P&P indicated, “Prior to administration, the 6 R’s must be verified: ...C. Right Time: 30-60 minutes before or after the scheduled medication time.” The MSTD stated, “these medications were given out of the administration window. This is not standard of practice.” 1b. During a review of Patient 15’s “H&P” dated January 22, 2024, the “H&P” indicated Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 has a past medical history of Hypertension, Myelofibrosis and Thrombocytopenia. During a concurrent interview and record review on January 23,2024, at 10:30 AM, with the Director of Emergency Department, (EDD), Patient 15’s active “MAR” dated January 23,2024, was reviewed. The EDD stated, “from looking at his chart, this patient should already have had his 9 AM medications. He should have clarified with the physician first, if he wanted to hold or delay administration of any medications. During an interview on January 23, 2024, at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, he/she held the heparin because Patient 15 was going for a procedure. RNR 1 stated, he did not have time to call the doctor yet and was focusing on other patients. RNR1 further stated, to deviate from the order, best practice was to clarify with the physician first. During a review of Patient 15’s “Nurse Notes” dated January 23, 2024, at 1: 52 PM, the “Nurse Notes” indicated RNR1 documented “confirmed with the Surgeon and Anesthesia it was Okay to hold Heparin and Colace”. During an interview on January 23, 2024, at 2:00 PM, with the MS/T Clinical Supervisor (MSTCS), the MSTCS stated, licensed nurses are expected to call and let the physician know if we want to hold medications. The MSTCS stated, it was a physician order so it should be given as ordered or else confirmed with the physician. The MSTCS further stated, holding a medication without prior physician approval was not our standard practice and we must notify a physician for every medicine that is held. During an interview on January 23, 2024, at 2:05 PM, with the Chief Nursing Officer (CNO), the CNO stated, “nurses have to use their nursing judgement on holding medications. However, best practice is that he should have communicated that with the physician prior.” During an interview on January 23, 2024 at 3:30 PM with the MS/T Director, (MSTD), the MTSD stated, “you should definitely call the physician to confirm holding or not giving a medication. That is the standard of practice as long as I have been a nurse. Most likely the physician would have said to hold, but he still needed to call to confirm.” During a review of the facility’s policy and procedure (P&P) titled “Medication Administration Times” dated April 2021, the “P&P” indicated, “Medications are to be scheduled and administered according to the hospital-wide routine schedule. Any exceptions to the schedule must be communicated to the pharmacy either via a written physician order or the nursing Medication Administration Record.””