Menifee Global Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR 489.20 and 489.24, when it failed to transfer a patient having an emergency medical condition [severe health issues with acute symptoms requiring immediate medical attention] that required higher level of care [specialized 24/7 care for severe life threatening conditions], administer medications as ordered, and reassess pain after medication administration, for one of 20 sample patients (Patient 2). (Refer to A2407) These failures had the potential to contribute to Patient 2’s death.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to transfer a patient having an emergency medical condition [severe health issues with acute symptoms requiring immediate medical attention] that required higher level of care [specialized 24/7 care for severe life threatening conditions], administer medications as ordered, and reassess pain after medication administration, for one of 20 sample patients (Patient 2). These failures had the potential to contribute to Patient 2’s death. Findings: On March 24, 2026, at 9:53 a.m., an interview was conducted with EDMD 1 in the ED. EDMD 1 stated when patients present to the ED, they find out the reason for the visit and determine if there is an emergent (a critical, unexpected condition requiring immediate, life-saving intervention within minutes) condition that exists. EDMD 1 stated the facility does not have a “Cath lab” (cardiac catheterization laboratory, a special room where doctors use special imaging [process that makes pictures of areas inside the body] to diagnose and treat heart and blood vessel conditions). EDMD 1 stated, “for STEMI [ST Elevation Myocardial Infarction, heart attack where there is complete blockage of a main coronary (heart) artery] or “highly probable MI,” they transfer the patients to the nearest “open cardiac [heart] facility [a specialized hospital focused entirely on diagnosing, treating, and managing heart-related conditions]. EDMD 1 stated, “you want to get them out immediately, 15 minutes if possible.” On March 24, 2026, at 2:01 p.m., a review of Patient 2’s medical record was conducted with the ED/ICU (Intensive Care Unit, a unit that takes care of critically ill patients) Director (EID). An untitled and undated document was reviewed. The document indicated, “ ...[Name of Patient 2] ...Reason for Visit: Chest pain ...Occurrence Date: 05/20/2025 [May 20, 2025] 21:00 [9 p.m.] ...” A facility document titled “Emergency Department Record,” dated May 20, 2025, was reviewed. The document indicated, “ ...[Name of Patient 2] ...Attending [Name of EDMD 2] ...presenting to the ER via POV [Privately Owned Vehicle, car] due to complaints of right back pain and nausea...Past medical history: NSTEMI [Non ST Elevation Myocardial Infarction, a heart attack where there is a partial blockage in the main coronary artery ] (04/2025 [April, 2025]) ...Cardiac stent [a tiny wire-mesh tube] placement [a procedure used to open narrowed or blocked coronary arteries] x 5 [five stents used] (12/2024 [December, 2024], 04/2025 [April, 2025] [Name of Facility B] ...Physical Examination ...Lithargic [sic] [Lethargic, reduced mental alertness or excessive drowsiness] ...tachycardic [fast heart rate] at 120bpm [beats per minute] ...EKG [electrocardiogram (ECG), test that records the electrical signals of the heart to detect irregularities] Interpreted by me: Heart rate: 115 H [high] beats per minute ...Interpretation: ...significant ST [ST segment, a line on an EKG that represents the pause when the heart contracts and relaxes] depression [below the baseline which means reduced blood flow to the heart] ...” An untitled facility document, dated May 20, 2025, was reviewed. The document indicated, “ ...20-May-2025 [May 20, 2025] 20:27 [8:27 p.m.] ...Sinus tachycardia [fast heart rate] ...Marked ST abnormality ...subendocardial injury [damage to the innermost layer of the heart muscle] ...Abnormal ECG ...” During the record review with the EID there was no documented evidence of a previous EKG prior to Patient 2’s visit on May 20, 2026. A facility document titled, “Daily Focus Assessment Report,” dated May 20, 2027, through May 22, 2025, was reviewed. The document indicated, “ ...ED Initial Assessment [a process where a nurse gathers, sorts and analyzes a patient’s health information] ...Entered by: [Name of Registered Nurse [RN] 1 ...05/20/2025 22:00 [10 p.m.] ...Pt [Patient] Brought [sic] in By spouse due to right flank [area between the back rib and the waist] pain with weakness, diaphoresis [cold sweats] and lethargy. Pt has an extensive cardiac hx [history]. Cardiac stents placed at [Name of facility C] in december [sic] that eventually occluded and in April had stents redone at [Name of facility B] ...” A facility document titled, “Vital Signs Report,” dated May 20, 2025, Through May 22, 2025, was reviewed. The document indicated, “ ...[Name of Patient 2] ...05/20/2025 21:40 [9:40 p.m.] ...HR [Heart Rate] 115 ...Mean BP ...67 ...Pain Score 8 ...05/20/2025 22:54 [10:54 p.m.] ...103/53 ...NIBP [non-invasive blood pressure, the standard, automatic method of measuring a patient’s blood pressure using an inflatable cuff placed around the arm] ...Mean BP ...69 ...104/59 ...05/20/2025 23:04 [11:04 p.m.] ...Mean BP ...74 ...” A facility document titled, “Medication Administration History Report,” dated May 20, 2025, through May 21, 2025, was reviewed. The document indicated, “ ...Medication: ASPIRIN [a medicine used to relieve mild-to-moderate pain] ...Order Dose: 324 MG [Milligrams, a unit of measurement] ...Frequency: ONCE ...Admin [Administration] Dt/Tm [Date/Time] 05/20/2025 21:53 [9:53 p.m.] ...Adm [Administered] ar54 [RN 1] ...” A facility document titled, “Medication Administration History Report,” dated May 20, 2025, through May 21, 2025, was reviewed. The document indicated, “ ...Medication: FENTANYL CITRATE ...Route: INTRAVENOUS [within the vein] ... Admin Dt/Tm 05/21/2025 [May 21, 2025] 01:07 [1:07 a.m.] ...Adm Dose 25 MCG [micrograms, a unit of measurement] Adm [RN1] ...” During the record review with the EID there was no documented evidence Patient 2’s pain was reassessed and addressed from May 20, 2025, 10 p.m., through May 21, 2025, 1 a.m. A facility document titled, “CPOE Orders Report,” dated May 20, 2025, was reviewed. The document indicated, “ ...ADD ...Verbal ...Route ...IV [Intravenous] ...Rare/Frequency ...2MCG [microgram, a unit of measurement] TITRATE [to gradually adjust the dose of a medication upward or downward to find the lowest effective dose] PER PROTOCOL ...(Levophed) ...Instructions: ...Goal: MAP > [greater than] 65, OR SBP [Systolic Blood Pressure, the top number in a blood pressure reading,] >100 ...Initial: 2 mcg/min [minute] ...Titrate: 2 mcg/min Q 5 min ...NOREPINEPHRINE (Levophed) ...Submitted by: ...[Name of RN 1] ...Verbal electronically signed by ...[Name of EDMD 2] ...” A facility document titled, “ IV Site and Fluid Report,” dated May 20, 2026, through May 22, 2026, was reviewed. The document indicated, “ ...Norepinephrine ...Titrate ...Fluid started by: [Name of RN 1] on 05/20/2025 2254 [10:54 p.m.] ...” There was no documented evidence Patient 2’s blood pressure was low prior to the administration of norepinephrine. A facility document titled, “Attempts to Transfer Call Log,” dated May 21, 2025, was reviewed. The document indicated, “ ...[Name of outside hospital] ...5/21/25 @ [at] 130 [1:30 a.m.] ...S/W [Spoke with] ...gave Pt [Patient 2] info [information] for transfer ...fax face sheet & [and] clinicals [paperwork, documentation] ...” There was no documented evidence cardiology was consulted by EDMD 2. There was no documented evidence attempts to transfer Patient 2 was initiated immediately after Medical Screening Exam [an exam to quickly determine if an emergency exists] by EDMD 2 from May 20, 2026, 10 p.m. to May 21, 2026, 1:30 a.m. A facility document titled, “Daily Focus Assessment Report,” dated May 21, 2025, was reviewed. The document indicated, “ ...05/21/2025 03:15 [3:15 a.m.] ...Pt [Patient 2] Became increasingly agitated, anxious and SOB [short of breath] ...” A facility document titled, “ CODE BLUE RECORD,” dated May 21, 2025, was reviewed. The document indicated, “ ...REASON CODE INITIATED ...asystole [a cardiac arrest where all electrical and mechanical activity in the heart stops] ...0334 [3:34 a.m.] ongoing CPR [Cardiopulmonary Resuscitation, an emergency treatment done when someone’s breathing or heartbeat has stopped] ...0346 [3:46 a.m.] ...asystole ...0440 [4:40 a.m.] Pronounced by [Name of EDMD 2] ...” On March 24, 2026, at 1:30 p.m., an interview was conducted with the EID. The EID stated there was no call for transfer to Facility D or other facilities prior to 1:30 a.m. The EID stated there was no cardiology consult on the call log. The EID stated Patient 2’s pains was not reassessed after Aspirin and Fentanyl administration. The EID stated the nurse should have reassessed Patient 2’s pain. The EID stated Patient 2’s vital signs prior to Levophed administration was not referred to the doctor. The EID stated Levophed should not have been given to Patient 2 for a blood pressure of103/53. The EID stated it will make the patient more tachycardic. The EID stated the nurse should have advocated for the patient and referred it to the doctor or the charge nurse. On March 25, 2026, at 8:18 a.m., an interview with RN 1 was conducted. RN 1 stated she did not reassess Patient 2’s pain after giving Aspirin. RN 1 stated she should have reassessed Patient 2’s pain after giving Aspirin. RN 1 stated she did not give any medication for Patient 2’s severe pain aside from Aspirin from 10 p.m. May 20, 2025, until she administered Fentanyl at 1:07 a.m. on May 21, 2025. RN 1 stated Levophed is given for “hypotensive [low blood pressure] patients, usually parameters (limit) are about 90 to 95 and the MAP of 65.” RN 1 stated she should not have started Levophed when Patient 2’s blood pressure was 103/53 and MAP was 65 on May 20, 2025, at 10:54 p.m. On March 25, 2025, at 11:51 a.m., an interview was conducted with the Emergency Department Medical Director (EMD). The EMD stated for patients that come to the ED with complaints of mid or upper back pain, he is concerned with stent occlusion, MI, triple A (abdominal aortic aneurysm, it is the ballooning or weakening of the main artery [aorta] in the abdomen) or pyelonephritis (bacterial infection of one or both kidneys). The EMD stated the facility does not have the capability to treat an MI, a blocked stent or a triple A. The EMD stated they do not have CT (cardio thoracic surgery, a specialty focused on surgical treatments for diseases affecting organs inside the chest, primarily the heart, lungs, and esophagus) surgery for a triple A, or a cardiac cath lab for blocked stent or MI. The EMD stated if a patient comes in with these conditions, they transfer them. The EMD stated Patient 2’s EKG showed ST elevation on lead II (limb lead, electrical sensors placed on the arms and legs (typically wrists/ankles) that measure the heart’s electrical activity ) possibly lead I and st depression on leads II and III. The EMD stated he would have sent Patient 2 as a transfer for higher level of care right away to Facility D. The EMD stated they re-evaluate patients for severe pain. The EMD stated there was no re-evaluation done for Patient 2’s pain. The EMD stated he would have re-evaluated Patient 2’s severe pain in 30 minutes. The EMD stated with Patient 2’s BP and MAP at 10:54 p.m., he would not have given Levophed. The EMD stated the two biggest things he would have done were ordering a CT scan (Computed Tomography Scan, an imaging test that combines X-rays with computer processing to create detailed pictures of the inside of the body) and transferring Patient 2 right away. The EMD stated if things were done differently, “Maybe there would have been a change in outcome.” On March 30, 2026, at 1:35 p.m., an interview was conducted with the Chief of Staff (COS). The COS stated the expectation for ED doctors are to do their duties and responsibilities as a physician and give the best possible patient care available in the hospital. The EOS stated they do not have a cardiac cath lab. The EOS stated any abnormal findings in the EKG should be evaluated in a timely manner and evaluate for appropriate care and “if it is not available, we have to provide the care by transferring the patient as needed. A facility rules and regulations titled, “Rules and Regulations Professional Medical staff,” dated May 23, 1989, was reviewed. The Document indicated, “ ...a physician member of the professional staff shall be responsible for the medical care and treatment of each patient in the hospital ...” A facility policy and procedure titled, “EMTALA [Emergency Medical Treatment and Labor Act, is a federal law ensuring public access to emergency services regardless of ability to pay] -MEDICAL SCREEENING EXAMINATION AND STABILIZATION POLICY,” Dated April 2023, was reviewed. The document indicated, “ ...PURPOSE ... To establish guidelines for Providing appropriate medical screening examinations(“MSE”) and any the necessary stabilizing treatment or an appropriate transfer for the individual as required ... If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and the capability of the facility, or an appropriate transfer as defined by and required by EMTALA ...Stabilizing Treatment Within Hospital Capability ...The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital ...” A facility policy and procedure titled, “PAIN MANAGEMENT,” dated November 2024, was reviewed. The document indicated, “ ...PURPOSE ... To assure that patients receive an assessment and management of their pain consistent with the scope of care, treatment and service provided ...An Appropriate assessment and/or reassessment of a patient’s pain should be conducted that is consistent with the scope of care, treatment and service provided ...If A treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15-60 minutes following treatment (depending on the type of intervention) ...Pain Scales ...Pain score 7-10 Would be considered severe pain ...” A review of the facility policy and procedure titled, “TITRATABLE DRIP MEDICATIONS,” dated February 2024, was reviewed. The document indicated, “ ...it is the policy of [Name of facility A] ...to standardize all titratable drip medications to ensure safe, appropriate and effective use of these medications ...Norepinephrine (Levophed) ...titrate up/down by 1 mcg/min q5min to keep MAP>65 mmHG (millimeter mercury, standard unit for measuring blood pressure) or SBP > 90 ...””

“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: 50433 Based on interview and record review, the facility failed to ensure risks, benefits, or alternative therapies were discussed before antibiotic therapy (the use of antibiotics [a medication used to inhibit growth of or destroy harmful microorganisms] to treat infection) was discontinued prior to completion, for one patient of 24 sampled patients (Patient 14). This failure had the potential for Patient 14 to have an undertreated infection which could lead to severe illness or death. Findings: On November 24, 2025, at 3:05 p.m., a review of Patient 14’s medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, “History and Physical,” dated August 14, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on August 13, 2025, with a diagnosis of heart failure (when the heart cannot pump enough blood to meet the body’s needs). A facility document titled, “Bacteriology, [the study of bacteria]” dated August 16, 2025, was reviewed. The document indicated Patient 14 had a bacterial infection, Entercoccus Faecalis (specific type of bacteria) in his blood. A facility document titled, “Order Inquiry,” dated August 14, 2025, was reviewed. The document indicated Patient 14 was ordered to have Zosyn (an antibiotic) 3.375 mg (milligrams, a unit of measurement) every six hours. A facility document titled, “Progress Notes Report,” dated August 17, 2025, was reviewed. The document indicated Patient 14 refused a dose of Zosyn, the physician was notified, and the medication was discontinued. A facility document titled, “Medication Administration Record,” dated August 14, 2025, through August 22, 2025, was reviewed. The document indicated the order for Zosyn was prescribed from August 14, 2025, at 8 a.m., through August 17, 2025, at 8:14 p.m. The document indicated Patient 14 had refused multiple doses of the medication. A review of facility documents titled, “Progress Note,” dated August 18, 2025, through August 21, 2025, was conducted. The documents indicated, “...Entercoccus Facalis bacteremia [bacteria in the blood] - keep on Zosyn to complete 5 days therapy...” on each day. There was no documented evidence acknowledging the discontinuation of the antibiotic. There was no documented evidence risks, benefits, or alternative therapies for treatment were discussed with Patient 14. On November 25, 2025, at 10:50 a.m., an interview and concurrent record review was conducted with the SC. The SC stated Patient 14 did not complete five days of antibiotic therapy. On November 25, 2025, at 1:15 p.m., an interview was conducted with Medical Doctor (MD) 1. MD 1 stated Zosyn can be an effective antibiotic for treatment of Entercoccus Facalis and the range of treatment days can vary from 5 to 7 days or 10 to 14 days depending on how well the patient is responding to the medication. MD 1 stated if a patient was to refuse the antibiotic therapy, an alternative antibiotic therapy, including oral (pill form) antibiotics could be offered. MD 1 stated, “An attempt should be made to offer an alternative.” MD 1 stated if a patient directly told him he didn’t want a medication or therapy he would document it in the patient’s medical record. A facility policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated November 2022, was reviewed. The P&P indicated, “...All patients at [name of facility] have the right to...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as they may need in order to give informed consent or to refuse a course of treatment...this information shall include a description of the procedure or treatment, the medical significant risks involved, alternative courses of treatment or non-treatment and the risks involved in each...” A facility document titled, “Rules and Regulations Professional Medical Staff,” dated October 2025, was reviewed. The document indicated, “...Informed Decision Making...There is evidence in the medical record that the patient has been given information necessary to enable him/her to make treatment decision that reflect his/her wishes...The documentation will included the proposed treatment(s) or procedure(s)...This includes any significant alternatives to the course of treatment proposed...””

“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: 47071 Based on interview and record review, the facility failed to ensure the facility’s policy and procedures (P&P) were implemented by not ensuring a safe environment when one of 24 sampled patients (Patient 10) was unattended on multiple days. These failures had the potential to impact the health and safety and cause a delay in treatment for Patient 10. Findings: On November 25, 2025, at 12:15 p.m., a review of Patient 10’s medical record was conducted with the Emergency Department/Intensive Care Unit Director (ED/ICUD). A facility document titled, “History and Physical,” dated September 22, 2025, was reviewed. The document indicated Patient 10 was admitted for detoxification (the process of removing toxic substances) of Fentanyl (a powerful synthetic drug) and Methamphetamine (a powerful and highly addictive drug). An undated facility document titled, “Ordering,” was reviewed with the ED/ICUD. The document indicated Patient 10 was ordered a sitter (person to watch the patient one on one) on September 24, 2025, at 12:07 a.m., for high risk behavior (actions that increase likelihood of injury), extreme agitation (restlessness) and acute detoxification. A facility document titled, “SITTER OBSERVATION DOCUMENTATION,” dated September 24, 2025, was reviewed. The document indicated, “...observation codes every thirty (30) minutes for Confused/Safety...” The first document dated September 24, 2025, indicated the sitter did not document monitoring the patient at 6:30 a.m. A second facility document titled, “SITTER OBSERVATION DOCUMENTATION,” dated September 24, 2025, was reviewed. The second document dated September 24, 2025, indicated the sitter did not document monitoring the patient at 6:30 a.m. There was no documented evidence of observation on September 25, 2025. A facility document titled, “SITTER OBSERVATION DOCUMENTATION,” dated September 26, 2025, was reviewed. The document indicated the sitter did not document monitoring the patient at 6:30 a.m. On November 25, 2025, at 12:35 p.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated, the nurses assigned to be a sitter should have been with the patient (Patient 10) and documented every 30 minutes. The ED/ICUD stated the sitters did not follow the facility policy and left the patient unattended. The ED/ICUD further stated the sitters did not document at 6:30 a.m. on September 24, and 26, 2025. The ED/ICUD the second Sitter Observation Documentation dated September 24, 2025, was mislabeled and should have been dated September 25, 2025. On November 25, 2025, at 12:40 p.m., an interview with the Registered Nurse House Supervisor (RNHS) was conducted. The RNHS stated there was a Sitter Observation Documentation missing at 6:30 a.m. each day. The RNHS stated there is a gap in the shift between the Certified Nursing Assistant (CNA, a person which provides basic patient care under the supervision of a registered nurse) and the sitters. A facility Policy and Procedure (P&P) titled “Sitters,” dated May 2024, was reviewed. The document indicated, “...Patients who are identified as a risk for harm to self or others shall have increased observation based upon the assessment of observed patient behaviors...Patient confusion, high risk for falls or self-harm other than suicide...the charge nurse will notify the nurse manager or house supervisor for the need of a sitter...””

“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: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 24 sampled patients (Patients 2, 3, 15, 16, and 21) when: 1. For Patients 2, 15, and 16, oral (mouth) care was not provided every two hours per facility policy; 2. For Patients 2 and 21, Intravenous (IV, small plastic tube inserted into the vein for medication) medication was not labeled according to the facility policy; and 3. For Patient 3, a critical laboratory value was not reported to the physician. These failures had the potential to compromise patient safety, expose patients to disease causing pathogens (germs), and may cause a delay in the treatment of the patients. Findings: 1a. On November 25, 2025, at 8:15 a.m., a review of Patient 15’s medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, “History and Physical,” dated November 17, 2025, was reviewed. The document indicated Patient 15 was admitted to the facility on November 15, 2025, with a diagnosis of sepsis (a life-threatening medical emergency where the body ‘s extreme response to an infections damages its own tissues and organs) and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body). The document further indicated Patient 15 was intubated (a medical procedure of inserting a plastic tube through the mouth and into the airway to keep it open). A facility document titled, “Daily, Activities of Daily Living,” dated November 15, 2025, through November 22, 2025, was reviewed. The document indicated Patient 15 was dependent on oral care. The document further indicated oral care was not performed for Patient 15 on: -November 17, 2025, from 8 a.m. to 6 p.m. (10 hours); -November 18, 2025, from 8 a.m. to 6 p.m. (10 hours); and -November 19, 2025, from 8 a.m. to 6 p.m. (10 hours). 1b. On November 25, 2025, at 9 a.m., a review of Patient 16’s medical record was conducted with the SC. A facility document titled, “History and Physical,” dated July 17, 2025, was reviewed. The document indicated Patient 16 was admitted to the facility on July 17, 2025, with a diagnosis of respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). The document further indicated Patient 16 was intubated. A facility document titled, “Daily, Activities of Daily Living,” dated July 17, 2025, through July 22, 2025, was reviewed. The document indicated Patient 16 was dependent on oral care. The document further indicated oral care was not performed for Patient 16 on: -July 18, 2025, from 8 a.m. to 8 p.m. (12 hours); -July 19, 2025, from 8 a.m. to 12 p.m. (4 hours); -July 20, 2025, from 12 p.m. to 6 p.m. (6 hours); and -July 21, 2025, from 10 a.m. to 4 p.m. (6 hours) and from 4 p.m. to 8 p.m. (4 hours). On November 25, 2025, at 10:20 a.m., an interview was conducted with the SC. The SC stated the facility expectation is for oral care to be provided every two hours to intubated patients. 1c. On November 24, 2025, at 1:59 p.m., Patient 2’s medical record was reviewed with the Emergency Department/Intensive Care Unit Director (ED/ICUD). A facility document titled, “History and Physical,” dated October 26, 2025, at 12:53 p.m., was reviewed. The document indicated Patient 2 was admitted to the hospital on October 25, 2025, for respiratory failure and was intubated with bilateral lobe pneumonia (serious infection that can inflame and scar the lungs). The document further indicated Patient 2 was intubated. An facility document titled, “Activities of Daily Living,” dated November 16, 2025, through November 23, 2025, was reviewed. The document indicated oral care was not performed for Patient 2 on: -November 16, 2025, from 10 a.m. to 2 p.m. (4 hours), from 4 p.m. to 6 p.m. (4 hours) and from 8 p.m. to 12 a.m. (4 hours); -November 17, 2025, from 12 p.m. to 4 p.m. (4 hours); and -November 23, 2025, from 6 a.m. to 2 p.m. (8 hours). On November 24, 2025, at 2:17 p.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated Patient 2 was not given oral care according to the facility policy. The ED/ICUD further stated oral care for the intubated patient is to be provided every two hours. The facility P&P titled, “Ventilator [a medical machine which assists or takes over breathing for a patient who cannot do it adequately on their own] Associated Pneumonia [an infection of the lungs],” dated December 23, 2023, was reviewed. The document indicated, “...Ventilator-associated pneumonia is a lung infection that develops in a person who is on the ventilator...The care of ventilated patients will follow standards of nursing care...for the prevention of ventilator associated pneumonia...Routine Oral Care...Swab, suction, and rinse oral cavity [mouth] every 2 hours with an alcohol free antiseptic solution...” 2a. A tour of the Intensive Care Unit (ICU) was conducted on November 24, 2025, at 9:35 a.m., with the Quality Administrative Director (QAD). During the tour on Unit I, in Patient 2’s room, an IV Meropenem (type of antibiotics) for injection and Sodium Chloride (salt water) injection 1gm/50 ml (gram/milliliter, units of measurement) was observed infusing with no date or time labeled on the medication. An interview was conducted on November 24, 2025, at 9:38 a.m., with the QAD. The QAD stated the two infusing IV bags were not dated, timed, or labeled. The QAD further stated the nurse assigned to the patient should have dated, timed and labeled according to the facility P&P. An interview was conducted on November 24, 2025, at 9:40 a.m., with the Registered Nurse (RN) 1. The RN 1 stated the IV medications being administered were not labeled properly based on the facility policy. RN 1 further stated the medication should have been labeled with the patient’s name, date, and time the medication was started. A facility document titled, “History and Physical,” dated October 26, 2025, at 12:53 p.m., was reviewed. The document indicated Patient 2 was admitted to the hospital on October 25, 2025, for respiratory failure and was intubated, with bilateral lobe pneumonia. An untitled and undated facility document was reviewed. The document indicated, “...11/16/2025...[November 16, 2025]...07:39 [7:39 a.m.]...MEROPENEM-0.9% SODIUM CHLORIDE 1 GRAM. 50 ML 1 GRAM/50 ML BAG IV...EVERY 8 HOURS...Order Date/Time... 11/16/2025...[November 16, 2025]...07:39 [7:39 a.m.]... Start... 11/16/2025...[November 16, 2025]...Stop...11/27/2025...[November 27, 2025]...” An undated facility document titled, “Medical Adminstration Record (MAR),” was reviewed. The document indicated, “...Merophenem 0.9% Sodium Chloride [1 GRAM/50 ML]...Piggy Back...INTRAVENOUS EVERY 8 HOURS...Start...11/16/2025...[November 16, 2025]...08:00 [8 a.m.]...08:00/08:04 [8 a.m./8:04 a.m.]...” 2b. A tour of the Intensive Care Unit (ICU) was conducted on November 24, 2025, at 9:25 a.m., with the QAD. During the tour on Unit I, in Patient 21’s room there were two IV medications Propofol (short-acting medication used to induce and maintain sleep) and Heparin (blood thinner) observed infusing. The medications were infusing without a label, date, and time on the IV medications accroding to the P&P. An interview was conducted on November 24, 2025, at 9:30 a.m., with the QAD. The QAD stated the two infusing IV medications were not dated, timed, or labeled. The QAD further stated the nurse assigned to the patient should have dated, timed and labeled according to the facilities P&P. An interview was conducted on November 24, 2025, at 9:50 a.m., with RN 2. RN 2 stated the IV medication should have been labeled with name, time, and date the medication was started according to the facility P&P. A facility document titled, “History and Physical,” dated November 25, 2025, at 1:30 p.m., was reviewed. The document indicated Patient 21 was admitted on November 23, 2025, for acute metabolic encephalophy and respiratory failure. An interview was conducted on November 25, 2025, at 1:35 p.m., with the ED/ICUD. The ED/ICUD stated the nurse that administered the medication should have put Patient 21’s name, date, and time the medication was started, name of drug and strength of the medicaiton. The ED/ICUD further stated the nurse did not follow the policy. An undated, facility document, titled, “Ordering” was reviewed. The document indicated, “...November 23, 2025, at 23:14 [11:14 p.m.]...PROPOFOL 10 mg/mL [unit of measurement] 100 ML Intravenous [IV]...on mechanical ventilator...TITRATE [continuously measure and adjust] PER PROTOCOL...” 3. On November 25, 2025, at 8:49 a.m., a review of Patient 3’s record was conducted with the ED/ICUD. A facility documented titled, “History and Physical (H&P),” was reviewed. The document indicated Patient 3 was admitted to the facility on November 24, 2025, for altered level of consciousness (mental state that differs significantly from a waking state), extreme weakness, hypernatremia (abnormally high concentration of sodium in the blood), dehydration (body loses more fluid than it takes in) and a stage 4 decubitus ulcer (a severe, wound that involves damage to muscle, bone, or tendons) on the right hip. An undated facility document titled, “Order Inquiry,” was reviewed. The document indicated on November 24, 2025, Basic Metabolic Panel Calcium (common blood test), total was ordered. An undated facility document titled, “FLOWSHEETS,” was reviewed with the ED/ICUD. The document indicated, “..Glucose [amount of sugar in a persons blood]...Nov. 24, 2025 [November 24, 2025]...11:25 [11:25 a.m.]...523 [normal range of 70 mg/dL (milligrams/decileters unit of measurement)-140 mg/dL]...C [critical]...” There was no documented evidence the critical lab result for the high glucose was reported to the physician. On November 25, 2025, at 9:02 a.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated the nurse did not document the critical lab. The ED/ICUD stated the nurse did not document the critical lab was reported to the physician. The ED/ICUD further stated the nurse should have documented the critical lab and reported to the physician right away. A facility Policy and Procedure (P&P) titled, “Critical lab values and diagnostic test results; notification,” dated May 2025, was reviewed. The P&P indicated, “the responsible physician...will be notified as soon as possible, but no later than 60 min...””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to maintain a complete medical record for one of 24 sampled patients (Patient 14) when a physician progress note (a medical record created by healthcare providers to document a patient’s condition, treatment, and progress on a given day) was not entered into the electronic medical record (EMR). This failure had the potential to result in medical errors and affect continuity of care (ongoing, consistent, and coordinated care). Findings: On November 24, 2025, at 3:05 p.m., a review of Patient 14’s medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, “History and Physical,” dated August 14, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on August 13, 2025, with a diagnosis of heart failure (a condition when the heart cannot pump enough blood to meet the body’s needs). A review of Patient 14’s daily physician progress notes from August 14, 2025, through August 21, 2025, was conducted with the SC. There was no documented evidence of a progress note on August 17, 2025. On November 24, 2025, at 3:53 p.m., and interview was conducted with the SC. The SC stated physicians are expected to see their patients daily and document it in the EMR. A facility document titled, “Rules and Regulations Professional Medical Staff,” dated October 2025, was reviewed. The document indicated, “...Progress notes shall be written daily for each patient...””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50433 Based on observation, record review, and interview, the facility failed to maintain accessibility to the emergency department (ED) when the automatic door failed and would not open. This failure had the potential to delay patient care for patients requiring emergency services at the facility. Findings: On November 25, 2025, at 3:15 a.m., the automatic ED access door was observed to not open when approached. There was no signage observed to indicate how patients and visitors could gain access to the ED. There was no observed staff member present at the desk inside the entry way. On November 25, 2025, at 3:35 a.m., an interview and observation were conducted with the Nursing Supervisor (NS). The NS stated the ED entry door was broken. A facility document titled, “Work Order,” dated November 20, 2025, was reviewed. The document indicated, “...Problems with ER [emergency room] lobby automatic door...needs new controller will order...” On November 25, 2025, at 5:42 a.m., an interview was conducted with the NS. The NS stated the facility was aware the ED entry door was broken. The NS stated a patient with a disability would probably not have been able to gain access to the facility if they had presented for services. On November 25, 2025, at 5:53 a.m., an interview was conducted with Patient 24. Patient 24 stated he had to knock on the door and wait for someone to come let him into the facility. On November 25, 2025, at 5:55 a.m., an interview was conducted with RN 5. RN 5 stated the ED entry door had been broken “off and on.” RN 5 stated patients and visitors knock on the door and when registration staff hears them knocking, they go to assist them into the ED. On November 25, 2025, at 6 a.m., an interview was conducted with Visitor 1. Visitor 1 stated she did not know how to gain entry to the facility when she arrived. Visitor 1 stated she knocked on the window to the waiting room and a patient inside alerted staff to let her in. On November 25, 2025, at 7:10 a.m., an interview was conducted with the Director of Facilities Management (DFM). The DFM stated a work order had been received on November 20, 2025. The DFM stated the door had been looked at by an electrician the same day. The DFM stated it was determined a replacement part was required; however, it had not been ordered. The Americans with Disabilities Act (ADA, a civil rights law requiring reasonable accommodations and accessibility in public places) Title III [three] Regulations, dated March 8, 2012, were reviewed. The regulations indicated, “...A public accommodation shall maintain in operable working condition those features of facilities and equipment that are required to be readily accessible to and usable by persons with disabilities...” The facility policy and procedure (P&P) titled, “Utilities Systems Management Plan,” dated January 2025, was reviewed. The P&P indicated, “...The Utility Systems Program provides a process for...maintenance of...equipment to support a safe patient care and treatment environment...The Engineering Department will respond to assess the situation and contact additional assistance if needed...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to comply with provisions in 42CFR 489.20 and 489.24, when it failed to, within its licensed capacity, follow their pain management policy for three patients (Patients 1, 11, and 15), who arrived in the emergency department with complainants of pain. (Refer to A2406). These failures resulted in patient’s pain not be addressed or treated in a timely manner.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to implement their “Pain Management” policy for three of 30 sampled patients (Patient 1, 11, and 15), when: 1. For Patients 1 and 11, pain medications were not provided timely after arriving at the Emergency Department (ED), complaining of pain. 2. For Patient 15, no pain medications were provided when the patient stated they had pain. These failures resulted in patient’s pain not to be addressed or treated in a timely manner. Findings: On April 1, 2025, an unannounced visit was conducted at the facility for an EMTALA (Emergency Medical Treatment and Labor Act) survey. 1a. On April 2, 2025, at 11 a.m., Patient 1’s medical record was reviewed with the Interim Emergency Room/Intensive Care Unit Director (I-ED/ICU Director). Patient 1 was seen in the ED after a fall at home. The facility document titled, “[Name of facility] Triage Report,” dated March 17, 2025, at 8:36 p.m., was reviewed. The document indicated Patient 1 was triaged (sorting of patients (as in an emergency room) according to the urgency of their need for care) at 8:29 p.m., and had pain of 10/10 (pain scale from 0-10 with 0 being no pain and 10 being worst pain ever). The document further indicated Patient 1 had a blood pressure of 205/98 (normal blood pressure 120/80). There was no documented evidence Patient 1 received any medication for the high blood pressure. The facility document titled, “ED Provider Notes”, dated March 17, 2025, at 9:05 p.m., was reviewed. It indicated Patient 1 was seen by the provider at 9:05 p.m. The document further indicated Patient 1 presented to the ED on March 17, 2025, with a chief complaint of left-sided headache, left neck pain, left chest pain, left hip pain, low back pain, left knee pain, and left shoulder pain after a fall at home. The facility document titled, “Vitals Inquiry,” dated March 17, 2025, at 8:20 p.m., indicated, “...03/17/2025 [March 17, 2025] 20:29 [8:29 p.m.]...Pain Score 10 Numeric hip, left...” The document further indicated the facility staff did not reassess Patient 1’s pain after the initial assessment. The facility document titled, “Medication Administration Record,” dated March 17, 2025, was reviewed. The document indicated, “...Ketorolac - STAT - injectable...[30 MG/ML - unit of measurement]...Dose...15 mg...Start 03/17/2025 [March 17, 2025]...22:52 [10:52 p.m.] admin...23:02 [11:02 p.m.]...” Two hours and 33 minutes after Patient 1 reported having 10/10 pain. On April 2, 2025, at 11:14 a.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 1 should not have waited 2 hours and 33 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 33 min would not be timely. 1b. On April 3, 2025, at 12:30 p.m., Patient 11’s medical record was reviewed with the I-ED/ICU Director. Patient 11 was seen in the ED for complaint of bilateral (both) knee pain for three weeks. The facility document titled, “[Name of facility] Triage Report,” dated April 1, 2025, at 10:23 a.m. was reviewed. The document indicated Patient 11 was triaged at 10:23 a.m., and had pain of 10/10. The facility document titled, “CPOE Orders Report,” dated April 1, 2025, was reviewed. The document indicated, “...Drug... HYDROCODONE-ACETAMINOPHEN [pain medication]...5-325 MG...Start...04/01/2025 [April 1, 2025] 12:22 [12:22 p.m.]...” Order was placed one hour and 59 minutes after Patient 11 indicated she had 10/10 pain. The facility document titled, “ED Summary Report”, dated April 1, 2025, was reviewed. The document indicated, “...Chief Complaint...Hip Pain...Vital Signs...04/01/2025 [April 1, 2025]...10:45 [10:45 a.m.] pain 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain 10...Medication Orders...HYDROCODONE-ACETAMINOPHEN...Route...ORAL...Last Given...04/01/2025 [April 1, 2025] 12:38 [12:38 p.m.]...” This was two hours and 15 minutes after Patient 11 indicated she had 10/10 pain. The document further indicated, “...LIDOCAINE PATCH 5%...1 PATCH...Last given 12:39 [12:39 p.m.]. This was two hours and 16 minutes after Patient 11 indicated she had 10/10 pain. The facility document titled, “Vitals Inquiry,” dated April 1, 2025, at 10:23 a.m., indicated, “...04/01/2025 [April 1, 2025] 10:45 [10:45 a.m.]...Pain Score 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain Score 10...” On April 3, 2025, at 12:55 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 11 should not have waited 2 hours and 15 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 15 min would not be timely. 2. On April 3, 2025, at 10 a.m., Patient 15’s medical record was reviewed with the Director Inpatient Services (DIS). It indicated Patient 15 was seen in the ED for evaluation of parasite infection, and soft stool. The facility document titled, “Emergency Department Record,” dated March 25, 2025, at 3:50 a.m., was reviewed. The document indicated Patient 15 was triaged and had a pain of 7/10 [7 being moderate pain]. The facility document titled, “Vital Sign Report,” dated March 25, 2025, at 3:06 a.m., was reviewed. The document indicated Patient 15 had a pain score of 7. There was no documented evidence Patient 15’s pain was addressed. The facility document titled, “CPOE Orders Report”, dated March 25, 2025, was reviewed. There was no documented evidence pain medications were ordered for Patient 15’s pain scale of 7/10. On April 3, 2025, at 10:15 a.m., an interview with the DIS was conducted. The DIS stated, there was no pain medications given or documented pain interventions for 7/10 pain when there should have been. further indicated Patient 16’s pain was assessed at 5 p.m., and had a pain score of 9. There was no documented evidence Patient 16’s pain was addressed. The facility document titled, “Medication Administration History Report”, dated March 30, 2025, was reviewed. There was no documented evidence pain medications were ordered for Patient 16. On April 3, 2025, at 10:15 a.m., an interview with the DIS was conducted. The DIS stated, there was no pain medication given or documented interventions for Patient 16’s 10/10 pain when there should have been. A review of the policy and procedure (P&P) titled, “PAIN MANAGEMENT,” dated October 2024, was conducted. The P&P indicated, “...To assure...patients receive an assessment and management of their pain...Patients have the right to pain management. It is the policy of [name of facility], to provide individualized pain management for all patients...patient’s stated level of pain is unique to the patient and it is the best indicator of the amount of pain he/she is experiencing...appropriate assessment and reassessment of a patient’s pain should be conducted...treatment and service provided in the specific care setting in which the patient is being managed...Achieving optimum pain management is a joint effort between the patient...the physician and interdisciplinary team...patient will be reassessed for the presence of pain no less frequently than the minimum requirements for the taking of vital signs in the care setting...In the ED...should also be reassessed at the time of discharge...in general...shall receive treatment for any active pain issue...when intensity exceeds their acceptable level...Reassessment Following Treatment for Pain...if a treatment intervention for pain is provided, the response to that intervention should be reassessed...Reassessment is recommended to occur within 15-60 minutes following treatment...Numeric Scale: 0-10: The numerical rating scale is designed to be used by those over age 9, 0 would mean the patient is experiencing no pain...Pain scored 7-10 would be considered severe pain...””

“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: 47071 Based on interview and record review, the facility failed to ensure a consent for surgery or special procedure for Hemodialysis, was signed by the provider, prior to the procedure for one of 30 sampled patients (Patient 27). This failure had the potential for Patient 27 to not be informed of the risks, benefits, and side effects of hemodialysis and delay patient care. Findings: On April 1, 2025, at 12:32 p.m., a record review and concurrent interview with the Director of Inpatient Services (DIS) and the Director of Surgical Services (DSS) was conducted. A facility document titled, “Consent to Surgery or Special Procedure,” dated March 27, 2025, was reviewed. The document indicated, “...attending physician...operation or procedure...Hemodialysis...Date: March 27, 2025...Time...9:45 a.m....Signature...Patient 27...” The document was not signed, dated, or timed by the provider. On April 1, 2025, at 12:35 p.m., an interview with the DIS was conducted. The DIS stated the provider does not have to sign the consent if they document the risk and benefits in the patients’ chart. The DIS further stated she reviewed the patients electronic medical record and did not see any documentation of the risk and benefits in the chart. On April 1, 2025, at 12:37 p.m., a record review was conducted with the DIS. A facility document titled “History and Physical,” dated March 26, 2025, was reviewed. The document indicated Patient 27 was admitted for altered mental status, and a history of End Stage Renal Disease (ESRD, kidneys are no longer working) and a history of dialysis (procedures that filters and cleans the blood). A facility undated document titled, “Order Inquiry” was reviewed. The document indicated, “...hemodialysis...Description...Dialysis Duration 3 hours...Start 3/27/25 [March 27, 2025]...stop 3/27/25 [March 27, 2025]...once...Routine...” A facility document titled, “Hemodialysis Treatment Flow sheet,” dated March 27, 2025, was reviewed. The document indicated dialysis started March 27, 2025, at 10:15 a.m., and ended March 27, 2025, at 1:15 p.m. A facility document titled, “Hemodialysis Treatment Flow sheet,” dated April 1, 2025, was reviewed. The document indicated dialysis started April 1, 2025, at 11:30 a.m., and ended April 1, 2025, at 3:30 p.m. A facility policy and procedure titled, “Informed Consent,” dated November 2024, was reviewed. The document indicated, “...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...””

“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: 50454 Based on interview and record review, the facility failed to implement their policy and procedure for nine of 30 sampled patients (Patients 1, 4, 5, 11, 12, 15, 21, 29, and 30) when: 1. For Patient 21, the critical laboratory results were not reported to the physician; 2. For Patients 1, and 11, pain medications were not provided timely after arriving at the Emergency Department (ED), with complaints of pain; 3. For Patients 4, 12, 15, and 30, no pain medication was provided when the patient stated they had pain; and 4. For Patients 5, and 29, there was no pain reassessment completed after pain medication was administered. These failures had the potential to cause patient harm, delay timely treatment, and for patient’s pain to not be addressed or treated in a timely manner. Findings: 1. On April 2, 2025, at 1:45 p.m., a review of Patient 21’s record was conducted with the Director of Inpatient Services (DIS). An untitled facility document, dated March 27, 2025, at 12:11 p.m., was reviewed and indicated Patient 21 was admitted to the facility on March 27, 2025, for acute hypoxic respiratory failure (a condition where the lungs fail to effectively provide oxygen to the body’s tissues). An untitled facility document dated March 27, 2025, was reviewed. The document indicated, “...Lactic Acid was Collected: 27-Mar [March]- 2025 at 09:25 [9:25 a.m.]...Called: 10:08 [10:08 a.m.] on 3/27/25 [March 27, 2025] by [name of laboratory tech]...” During an interview, on April 2, 2025, at 1:45 p.m., conducted with the DIS, the DIS stated, the critical lactic acid result was communicated to the nurse by the laboratory staff on March 27, 2025, as per facility policy. There was no documented evidence the nurse notified the physician of Patient 21’s critical lactic acid level after the nurse was notified by the lab. The facility policy and procedure (P&P) titled, “Critical Lab Values and Diagnostic Test Results; Notification,” dated May 2024, was reviewed and indicated, “...Purpose: To improve the effectiveness of communication among caregivers...To report critical results of tests and diagnostic procedures...The responsible physician...will be notified as soon as possible, but no later than, 60 minutes...Document responsible physician notification of the critical laboratory or diagnostic test result in the medical record...” 2a. On April 2, 2025, at 11 a.m., Patient 1’s medical record was reviewed with the Interim Emergency Room/Intensive Care Unit Director (I-ED/ICU Director). Patient 1 was seen in the ED after a fall at home. The facility document titled, “[Name of the facility] Triage Report,” dated March 17, 2025, at 8:36 p.m., was reviewed. The document indicated Patient 1 was triaged (sorting of patients (as in an emergency room) according to the urgency of their need for care) at 8:29 p.m., and reported pain of 10/10 (pain scale from 0-10 with 0 being no pain and 10 being worst pain ever). The document further indicated Patient 1 had a blood pressure of 205/98 (normal blood pressure 120/80). There was no documented evidence Patient 1 received any medication for the high blood pressure. The facility document titled, “ED Provider Notes”, dated March 17, 2025, at 9:05 p.m., was reviewed. It indicated Patient 1 was seen by the provider at 9:05 p.m. The document further indicated Patient 1 presented to the ED on March 17, 2025, with a chief complaint of left-sided headache, left neck pain, left chest pain, left hip pain, low back pain, left knee pain, and left shoulder pain after a fall at home. The facility document titled, “Vitals Inquiry,” dated March 17, 2025, at 8:20 p.m., indicated, “...03/17/2025 [March 17, 2025] 20:29 [8:29 p.m.]...Pain Score 10 Numeric hip, left...” The document further indicated the facility staff did not reassess pain after the initial assessment. The facility document titled, “Medication Administration Record,” dated March 17, 2025, was reviewed. The document indicated, “...Ketorolac - STAT - injectable...[30 MG/ML - unit of measurement]...Dose...15 mg...Start 03/17/2025 [March 17, 2025]...22:52 [10:52 p.m.] admin...23:02 [11:02 p.m.]...” Two hours 33 minutes after indicating Patient 1 had 10/10 pain. On April 02, 2025, at 11:14 a.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 1 should not have waited 2 hours and 33 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 33 min would not be timely. 2b. On April 3, 2025, at 12:30 p.m., Patient 11’s medical record was reviewed with the I-ED/ICU Director. It indicated Patient 11 was seen in the ED for complaint of bilateral (both) knee pain for three weeks. The facility document titled, “[Name of the facility] Triage Report,” dated April 1, 2025, at 10:23 a.m., was reviewed. The document indicated Patient 11 was triaged at 10:23 a.m., and reported pain of 10/10. The facility document titled, “CPOE Orders Report,” dated April 1, 2025, was reviewed. The document indicated, “...Drug... HYDROCODONE-ACETAMINOPHEN [pain medication]...5-325 MG...Start...04/01/2025 [April 1, 2025] 12:22 [12:22 p.m.]...” Order was placed one hour and 59 minutes after Patient 11 indicated she had 10/10 pain. The facility document titled, “ED Summary Report”, dated April 1, 2025, was reviewed. The document indicated, “...Chief Complaint...Hip Pain...Vital Signs...04/01/2025 [April 1, 2025]...10:45 [10:45 a.m.] pain 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain 10...Medication Orders...HYDROCODONE-ACETAMINOPHEN...Route...ORAL...Last Given...04/01/2025 [April 1, 2025] 12:38 [12:38 p.m.]...” This was two hours and 15 minutes after Patient 11 indicated she had 10/10 pain. The document further indicated. “...LIDOCAINE PATCH 5%...1 PATCH...Last given 12:39 [12:39 p.m.]. This was two hours and 16 minutes after Patient 11 indicated she had 10/10 pain. The facility document titled, “Vitals Inquiry,” dated April 1, 2025, at 10:23 a.m., indicated, “...04/01/2025 [April 1, 2025] 10:45 [10:45 a.m.]...Pain Score 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain Score 10...” On April 03, 2025, at 12:55 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 11 should not have waited 2 hours and 15 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 15 min would not be timely. 3a. On April 2, 2025, at 1:30 p.m., Patient 4’s medical record was reviewed with the I-ED/ICU Director. It indicated Patient 4 was seen in the ED after a fall. The facility document titled, “[Name of the facility] Triage Report,” dated March 18, 2025, at 1:13 p.m., was reviewed. The document indicated Patient 1 was triaged at 1:18 p.m., and had pain of 6/10. The facility document titled, “ED Summary Report”, dated March 18, 2025, was reviewed. The document indicated, “...Chief Complaint...Mechanical Fall...Problem List...Abdominal pain...Laceration of scalp...Vital Signs...Pain 6...” The document further indicated, “...Medication Orders...NO MEDICATION ORDERS DATA...” The facility document titled, “EMERGENCY PHYSICIAN RECORD,” dated March 18, 2025, at 1:30 p.m., was reviewed and indicated, “...03/18/2025 [March 18, 2025] TIME SEEN...13:30 [1:30 p.m.]...R [right] rib lower tender to palpation...Imaging Results...per radiologist as follows...questionable fx [fracture] of right 8th rib...15:35 [3:35 p.m.]...due to questionable fx of right ribs show on xray & possible lung nodule, further orders were placed for CT chest w/o [without] contrast. The facility document titled, “CPOE Orders Report,” dated March 18, 2025, was reviewed. There was no documented evidence of orders for pain medication. On April 2, 2025, at 2 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. The I-ED/ICU Director stated the policy was to address pain and Patient 4 should have gotten pain medication. 3b. On April 3, 2025, at 2 p.m., Patient 12’s medical record was reviewed with the I-ED/ICU Director. It indicated Patient 12 was seen in the ED for chronic back pain. The facility document titled, “Triage,” dated April 1, 2025, at 6:58 a.m., was reviewed. The document indicated Patient 12 was triaged at 6:58 a.m., and reported pain of 8/10 [8 being severe pain]. The facility document titled, “CPOE Orders Report”, dated April 1, 2025, was reviewed. The document indicated, “...TRAMADOL...50 MG ORAL...Start Date...04/01/2025 [April 1, 2025] 09:00 [9 a.m.]...” There was no documented evidence Patient 12 received medication for pain of 8/10. The facility document titled, “Vital Sign Report,” dated April 1, 2025, at 7 a.m., was reviewed. The document indicated patient had a pain score of 8. There was no documented evidence Patient 12’s pain was addressed. On April 3, 2025, at 2:15 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. The I-ED/ICU Director stated the policy was to address pain, and Patient 12 should have gotten pain medication that was ordered. 3c. On April 3, 2025, at 10 a.m., Patient 15’s medical record was reviewed with the Director Inpatient Services (DIS). It indicated Patient 15 was seen in the ED for evaluation of parasite infection, and soft stool. The facility document titled, “Emergency Department Record,” dated March 25, 2025, at 3:50 a.m., was reviewed. The document indicated Patient 15 was triaged and reported pain of 7/10 [7 being moderate pain]. The facility document titled, “Vital Sign Report,” dated March 25, 2025, at 3:06 a.m., was reviewed. The document indicated Patient 15 had a pain score of 7. There was no documented evidence Patient 15’s pain was addressed. The facility document titled, “CPOE Orders Report”, dated March 25, 2025, was reviewed. There was no documented evidence pain medications were ordered for pain scale of 7/10 for Patient 15. On April 3, 2025, at 10:15 a.m., an interview with the DIS was conducted. The DIS stated, there was no pain medications given or documented pain interventions for 7/10 pain when there should have been. 3d. On April 2, 2025, at 2:44 p.m., a concurrent record review and interview with the Tele 2 Charge Nurse (TCN) was conducted. A facility document titled, “History and Physical,” dated February 12, 2025, was reviewed. The document indicated Patient 30 was admitted February 11, 2025, for underlying alcohol, polysubstance used disorder, and presented for detox. A facility undated and untitled document was reviewed. The document indicated, “...2/14/25 [February 14, 2025]...20:28 [8:28 p.m.]...pain score...5...” A facility document titled, “Medication Administration Record” dated April 2, 2025, was reviewed. The document indicated no medication was given to Patient 30 on February 14, 2025, at 8:28 p.m., for reported pain of 5/10. There was no documented evidence the pain assessed on February 14, 2025, at 8:28 p.m. was reported and treated. On April 2, 2025, at 3:15 p.m., an interview with the TCN was conducted. The TCN stated based on the pain assessment the patient’s pain was 5/10. The patient should have been given pain medication. There was no documented evidence indicating Patient 30 was given any medication for pain. 4a. On April 2, 2025, at 3:35 p.m., Patient 5’s medical record was reviewed with the I-ED/ICU Director. It indicated Patient 5 was seen in the ED after a fall at home. The facility document titled, “[Name of the facility] Triage Report,” dated March 18, 2025, at 7:44 p.m., was reviewed. The document indicated Patient 5 was triaged at 7:11 p.m., and reported pain of 6/10 [6 moderate pain]. The facility document titled, “EMERGENCY PHYSCIAN RECORD,” dated March 18, 2025, at 7:30 p.m., was reviewed. The document indicated Patient 5’s chief complaint was left wrist pain, fall. The document further indicated, “...severity of pain...moderate...” The facility document titled, “ED Summary Report”, dated March 18, 2025, was reviewed. The document indicated, “...Chief Complaint...Mechanical Fall...Vital Signs...03/18/2025 20:50 [8:50 p.m.]...Pain...7...Medication Orders....OCYCODONE-ACETAMINOPHEN...ORAL...Last Given...03/18/2025 [March 18, 2025] 20:59 [8:59 p.m.]...” There was no documented evidence Patient 5 was reassessed for pain after Oxycodone-Acetaminophen was given. On April 2, 2025, at 3:44 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated the expectation was for staff to reassess for pain after pain medication was given. She further stated pain reassessment should have been completed within 15-60 minutes per policy. 4b. On April 2, 2025, at 1:15 p.m., Patient 29’s medical record was reviewed with the TCN. A facility document titled, “History and Physical,” dated April 2, 2025, was reviewed. The document indicated Patient 29 was admitted January 6, 2025, for underlying history of alcohol abuse and was being admitted for detox. A facility undated document titled, “Social Service/Case Management,” was reviewed. The document indicated, “...1/10/2025 [January 10, 2025]...pain score...6...” A facility undated document titled, “Medication Administration,” was reviewed. The document indicated, “...Medication...Ibuprofen [600 MG]...Tablet...Dose 600 MG [unit of measurement]...Route...Oral...admin [administration] time...1/10/25 [January 10, 2025] 2135 [9:35 p.m.]...Vitals...Pain Score...6...numeric general internal lateral...1/10/25 [January 10, 2025] 21:35 [9:35 p.m.]...” A facility undated, and untitled document was reviewed. The document indicated, “...Ibuprofen [600 MG]...Tablet...600 mg...Motrin...start...1/6/25 [January 6, 2025]...stop...1/13/25 [January 6, 2025]...oral three times a day as needed...[1 x 600 mg per dose]...indication: Pain...comment...PRN[pro re nata, as needed]” For Mild to Moderate Skeletal Pain...” There was no documented evidence Patient 29’s pain was reassessed after pain medication was administered on January 10, 2025, at 9:35 p.m. On April 2, 2025, at 1:40 p.m., an interview with the TCN was conducted. The TCN stated there was no documented evidence Patient 29’s pain was reassessment after the medication was administered on January 10, 2025, at 9:35 p.m. The TCN further stated the nurse should have assessed the pain an hour after the medication was administered. A review of the policy and procedure (P&P) titled, “PAIN MANAGEMENT,” dated October 2024, was conducted. The P&P indicated, “...To assure...patients receive an assessment and management of their pain...Patients have the right to pain management. It is the policy of [name of facility], to provide individualized pain management for all patients...patient’s stated level of pain is unique to the patient and it is the best indicator of the amount of pain he/she is experiencing...appropriate assessment and reassessment of a patient’s pain should be conducted...treatment and service provided in the specific care setting in which the patient is being managed...Achieving optimum pain management is a joint effort between the patient...the physician and interdisciplinary team...patient will be reassessed for the presence of pain no less frequently than the minimum requirements for the taking of vital signs in the care setting...In the ED...should also be reassessed at the time of discharge...in general...shall receive treatment for any active pain issue...when intensity exceeds their acceptable level...Reassessment Following Treatment for Pain...if a treatment intervention for pain is provided, the response to that intervention should be reassessed...Reassessment is recommended to occur within 15-60 minutes following treatment...Numeric Scale: 0-10: The numerical rating scale is designed to be used by those over age 9, 0 would mean the patient is experiencing no pain...Pain scored 7-10 would be considered severe pain...””

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure laboratory services were provided timely in accordance with the facility’s policy and procedure for three of 30 sampled patients (Patient 17, 23, and 25), when: 1. For Patient 23, send out labs (sending a patient’s blood/urine sample to a different, specialized location for testing when the primary lab in unable) were not sent out to the appropriate location timely; and 2. For Patient 17, and 25, a STAT (an order that requires immediate attention) order did not result timely. These failures resulted in delayed laboratory results for patient 17, 23 and 25. These failures also had the potential to prolong appropriate treatment and cause patient harm. Findings: 1. On April 2, 2025, at 1:40 p.m., a review of Patient 23’s record was conducted with the Director of Inpatient Services (DIS). An untitled facility document, dated February 10, 2025, at 2:04 a.m., was reviewed and indicated Patient 23 was admitted to the facility on February 10, 2025, for chest discomfort, shortness of breath (difficulty breathing), and generalized edema (fluid buildup in the body’s tissue). A facility undated document titled, “Test Request Form,” was reviewed for Patent 23. The document indicated, C3 Serum (a blood test that measures the amount of complement C3 protein in the blood) was ordered on February 11, 2025. A facility undated document titled, “Test Request Form,” was reviewed for Patient 23. The document indicated, ANCA screen (Antineutrophil cytoplasmic antibody-a blood test used to detect antibodies that target neutrophils, a type of white blood cell) was ordered on February 11, 2025. A facility undated document titled, “Test Request Form,” was reviewed for Patient 23. The document indicated, Complement CHC (a blood test that measures the levels and/or a group of proteins) was ordered on February 13, 2025. A facility undated and untitled document was reviewed for Patient 23. The document indicated, “C3 Nephritic factor [a system associated with various kidney disease] was received: 2/28/2025 [February 28, 2025] at 18:19 [6:19 p.m.] and reported: 03/05/2025 [March 05, 2025] at 08:11 [8:11 a.m.]...Set up schedule; Report available: 3 [three] days...” A facility undated, and untitled document was reviewed for Patient 23. The document indicated, “ANCA screen was received: 2/28/2025 [February 28, 2025] at 18:42 [6:42 p.m.] and reported: 03/05/2025 [March 05, 2025] at 14:05 [2:05 p.m.]...Set up: Mon [Monday]-Sat [Saturday] Report available: 3-5 [five] days...” A facility undated, and untitled document was reviewed for Patient 23. The document indicated, “C4 Serum [a blood test that measures the amount of C4 protein in your blood] was received: 2/28/2025 [February 28, 2025] at 18:30 [6:30 p.m.] and reported: 03/05/2025 [March 05, 2025] at 10:56 [10:56 a.m.]...Set up: Sun [Sunday]-Fri [Friday]: Report available: 2 [two]-3 days...” An interview was conducted on April 4, 2025, at 9 a.m., with the Director of Laboratory Services (DLS). The DLS stated the labs collected on February 11, 2025, for Patient 23 remained frozen until they were sent out on February 28, 2025. The DLS stated, due to having issues with the laboratory contract, “the results were delayed,” and should have been resulted three to five days later, on February 14, 2025, or February 15, 2025. 2a. On April 2, 2025, at 1:45 p.m., a review of Patient 25’s medical record was conducted with the DIS. An untitled facility document, dated February 21, 2025, at 10:31 p.m., was reviewed and indicated Patient 25 was admitted to the facility on February 21, 2025, for left leg pain and swelling (a condition where extra fluid gathers in the body’s tissue, causing it to be become enlarged). A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, “...CBC [Complete Blood Count-a common blood test that measures the different types and amounts of cells in your blood] was Ordered For: 20-Feb [February]- 2025 at 18:34 [6:34 p.m.]...Collected: 20-Feb-2025 at 18:45 [6:45 p.m.]...Released: 20-Feb-2025 at 20:06 [8:06 p.m.]...” A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, “...Erythrocyte Sed Rate [ESR-a blood test that measures the rate at which blood cells settle to the bottom of a tube over a period of one hour] was Ordered For: 20-Feb [February]- 2025 at 18:32 [6:32 p.m.]...Collected: 20-Feb-2025 at 18:45 [6:45 p.m.]...Released: 20-Feb-2025 at 20:06 [8:06 p.m.]...” A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, “...Partial Prothrombin Time [PT- a blood test that measures how long it takes for blood to clot], and Partial Thromboplastin Time [a blood test that times how long it takes a patient’s blood to form a clot as measured in seconds] was Ordered For: 20-Feb [February]- 2025 at 18:34 [6:34 p.m.]...Collected: 20-Feb-2025 at 21:50 [9:50 p.m.]...Released: 20-Feb-2025 at 22:25 [10:25 p.m.]...” An interview was conducted on April 2, 2025, at 1:45 p.m., with the DIS. The DIS stated the CBC and ESR results took over an hour to be released which goes against the STAT order timeframe. The DIS stated the PT and PTT was collected over an hour late which goes against the STAT collection timeframe. The DIS further stated, there was no documentation indicating why the results of the CBC and ESR were delayed, or why the collection of PT and PTT was delayed. 2b. On April 3, 2025, at 11 a.m., a review of Patient 17’s medical record was conducted with the DIS. A facility document titled, “History & Physical,” dated March 22, 2025, at 10:11 a.m., was reviewed and indicated Patient 17 was admitted on March 21, 2025, for cellulitis (bacteria infection of skin) for two open lesions. A facility untitled document dated March 21, 2025, was reviewed. The document indicated, “...Comprehensive Metabolic Panel...Ordered For...21-Mar-2025 16:18 [March 21, 2025 4:18 p.m.]...Collected...21-Mar-2025 16:15 [March 21, 2025 4:15 p.m.]...Priority STAT...Released...21-MR-17:29 [March 21, 2025 5:29 p.m.]...” This STAT lab draw resulted one hour and 11 minutes after it was ordered. A facility untitled document dated March 21, 2025, was reviewed. The document indicated, “...BLOOD ALC [Blood Alcohol]...Ordered For...21-Mar-2025 16:18 [March 21, 2025 4:18 p.m.]...Collected...21-Mar-2025 16:15 [March 21, 2025 4:15 p.m.]...Priority STAT...Released...21-MR-17:29 [March 21, 2025 5:29 p.m.]...” This STAT lab draw resulted one hour and 11 minutes after it was ordered. An interview was conducted on April 3, 2025, at 11:20 a.m., with the DIS. The DIS stated the labs collected on March 21, 2025, for Patient 17, resulted over an hour after the STAT order was placed and there was no documentation from the laboratory tech indicating why the results were delayed. The DIS further stated, the laboratory techs have the ability to make notes in the charting for notification purposes such as these. The facility policy and procedure (P&P) titled, “Requests for Laboratory Tests,” dated February 2024, was reviewed and indicated, “...requests for tests ordered as STAT will be collected within 10-15 minutes from the time they were ordered otherwise they will be drawn within 60 minutes...Reference Lab test...routine orders will be processed and completed within four (4) hour period of the time collected...Once received into the Clinical Laboratory, all STAT orders will be processed to completion in less than 60 minutes. When operational circumstances exist which prevent the Clinical Laboratory from satisfying the requirement...the originator of the laboratory order will be notified....strict adherence to this policy is of paramount importance for the efficient delivery of laboratory services and for the care of patients will indeed benefit by the speedy and accurate reporting of emergency laboratory testing...””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50454 Based on observation, interview, and record review, the facility failed to ensure an adequate method of communication was in place for two of four patient bathrooms in accordance with the facility’s policy and procedure. This failure had the potential for patient harm and delayed staff response during a routine or emergency situation. Findings: On April 1, 2025, at 10:20 a.m., a tour of the Medical Detox Unit (MDU-a unit that helps people safely withdraw from addictive substances, typically under the care of a healthcare professional) was conducted with the Director of Inpatient Services (DIS) and the Program Director of Medical Detox Unit (DMDU). During the tour, it was observed in a patient bathroom (Bathroom #1), the bathroom failed to have a pull-down cord for the emergency call light system near the toilet and in the shower. During the tour it was observed in a patient bathroom (Bathroom #2), the emergency call light was tested. During this test, the emergency cord pulled out of the wall and failed to activate the call light system. During an interview, on April 1, 2025, at 10:21 a.m., conducted with the DIS and DMDU, the DIS stated, there should be a pull-down call light in “every bathroom and every shower” regardless of if there is a patient in the room or not. The DMDU stated, the call light emergency cord was “not placed correctly” in bathroom #2. The facility policy and procedure (P&P) titled, “Nurse Call System Failure,” dated March 2021, was reviewed and indicated, “...The nurse call system provides audible communication between patients and nursing staff for assistance in routine or emergency situations...Warning signs or indicators of failure include: Lack of audible communication, call lights not illuminated, lack of system response...Reasons for nurse call system failure...Equipment malfunction, individual component failure...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to ensure available supplies were ready for use when: 1. Multiple expired supplies were found; 2. Crash cart log did not match the crash cart lock number in Unit A: and 3. The glucometer on Unit A was not ready for use when the quality control (QC) was not completed per policy. These failures had the potential to delay patient care and services and/or cause patient harm. Findings: 1a. A tour of Unit A was conducted on April 1, 2025, 10:20 a.m., with the Director of Impatient Services (DIS), and the Director of Surgical Services (DSS). During the tour on Unit 1, the following expired products and supplies were observed: -Curad Oil Emulsion Dressing 3x8 in (inches) (a primary wound dressing to provide or support a moist wound environment), with an expiration date of December 23, 2024; -Cathgrip tube securement device (a device used to keep tubes secured in place), with an expiration date of November 30, 2024; -Cathgrip tube securement device, with an expiration date of December 31, 2023; - Mens liberty acute external catheter re-application kit (directs urine away from the skin to avoid moisture -related skin breakdown), with an expiration date of February 29, 2024; and -Three packages of Mens liberty acute external catheter re-application kit, with an expiration date of July, 31, 2024. An interview was conducted on April 1, 2025, at 10:45 a.m., with the DIS. The DIS stated the supplies were expired and should have been removed from the supply carts. An interview was conducted on April 1, 2025, at 10:54 a.m., with the DSS. The DSS stated the supplies were expired and should not have been in the supply carts. The expired supplies should have been removed. 1b. On April 1, 2025, 11:43 a.m., a tour of Unit 2 was conducted with DIS and DSS. During the tour of Unit 2, the following expired products and supplies were observed. - Two packages of Y-type Minibore PCA Set (tubing used for a specific IV pump), with an expiration date of January 1, 2025; - Bardex IC 22ch/fr 30 cc/ml 3-way foley Cath Ribbed balloon (special catheter used to help reduce infection), with an expiration date of February 28, 2025; and - Bardex IC 24ch/fr 30 cc/ml 3-way foley Cath Ribbed balloon, with an expiration date of November 30, 2024. An interview was conducted on April 1, 2025, at 12:15 p.m., with the DSS. The DSS stated the supplies were expired and should not have been on the supply carts. She further stated the expired supplies should have been removed. 1c. A tour of the Medical Detox Unit (MDU- a facility that helps people safety withdraw from addictive substances, typically under the care of a healthcare professional) was conducted on April 1, 2025, at 10:20 a.m., with the DIS and DSS. During the tour of the Medical Detox Unit, in the clean utility room, the following expired products and supplies were observed: -Four Clorapreop prep clear (skin solution to help reduce the risk of infection by limiting the amount of bacteria on the skin), with expiration date of January 2024; -One CG4 + (a testing tool that aids in the diagnosis and monitoring of respiratory and metabolic conditions), with expiration date of June 21, 2023; -Two Chem 8 (a group of eight blood tests that assess kidney function, blood sugar levels, and electrolyte balance), with expiration date of November 2, 2023; -Two Point of Care testing (a laboratory test that allows for rapid results and timely treatment decisions), with expiration date of February 2, 2024; -Four blue top blood vacutainers (a tube that is used for collecting blood samples for clotting studies), with expiration date of November 20, 2024; and -Three gray top blood vacutainers (a tube that is used for collecting blood samples for glucose and lactate levels), with expiration date of January 1, 2025. An interview was conducted on April 1, 2025, at 10:20 a.m., with the DIS and DSS. The DIS stated the materials management department stocks and maintains the supply room. The DIS further stated, the items were expired and should not be in the storage room for patient use and should have been removed immediately. 1d. A tour of the Telemetry 2 Unit (a unit designed for cardiac monitoring) was conducted on April 1, 2025, at 11:43 a.m., with the DIS and DSS. During the tour of the Telemetry 2 Unit, in the clean supply room, the following expired products and supplies were observed: -Two Acute Dual Lumen Catheter Tray (a pre-packaged kit containing all the necessary supplies for inserting and maintaining the catheter), with expiration date of June 30, 2024; -One Cathgrip Tube Securement Device (a device that securely and comfortably holds different types of medical tubes in place), with expiration date of July 31, 2024; An interview was conducted on April 1, 2025, at 11:42 a.m., with the DIS and DSS. The DIS stated the materials management department stocks and maintains the supply room. The DIS further stated, the items were expired and should not be in the storage room for patient use and should have been removed immediately. 1e. A tour of the Laboratory was conducted on April 2, 2025, at 2:46 p.m., with the DIS and the Director of Laboratory Services (DLS). During the tour the following expired products and supplies were observed: -Two Hemoblast Bellows (a powered device used in surgery to control bleeding), with expiration date of July 5, 2023; and -Viral transport medium bottle (a solution used to preserve virus specimens), with expiration date of August 2024. An interview was conducted on April 2, 2025, at 2:26 p.m., with the DLS. The DLS stated the Hemoblast Bellows were expired and should not have been in the refrigerator for patient use. The DLS further stated, the Viral transport medium was expired and should not have been in the refrigerator. The facility policy and procedure (P&P) titled, “Central Supply-General Organization,” dated April 2024, was reviewed and indicated, “...Purpose: To provide general guidelines for the organization and maintenance of the Central Supply area within the hospital...It is the responsibility of the Materials Management Leader and the department’s personnel staff to ensure that the proper rotation of all supply items is maintained...All supply items are to be stored so as to ensure that the oldest items are used first. All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location...” A review of facility P&P titled, “Material Resource Management,” dated April 2024, was reviewed. The document indicated, “...All supply items are to be stored so as to ensure that the oldest items are used first...all supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location...” 2. A tour of Unit A was conducted on April 1, 2025, at 11:20 a.m., with the Deputy Regional Director of Quality (DRDQ). During the tour, Crash Cart #4’s lock number and the Crash Cart Main Pharmacy Seal Serial # (number) on the log were observed to not have matching lock numbers. The log indicated the lock number was 255414; the lock on the Crash Cart Main Pharmacy Seal Serial # (number) read 255699. The DRDQ stated the crash carts should have been checked daily and staff was expected to verify the number on the lock matched the number on the log. She further stated if there was a discrepancy, the staff should have called the pharmacy to inspect or swap out the crash cart. On April 1, 2025, at 11:25 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was the staff who checked crash cart #4 on April 1, 2025. RN 1 stated she might have not seen the numbers clearly when she verified the lock on crash cart #4. On April 4, 2025, at 10:35 a.m., an interview and concurrent record review of the facility document titled, “DAILY CRASH CART CHECK [NAME OF UNIT] MONTH: MARCH 2025,” was conducted with the DRDQ. The DRDQ stated this was the log for crash cart #4 for the month of March 2025. The document indicated the Crash Cart Main Pharmacy Seal Serial # (number) read 255414 from March 5, 2025, through March 31, 2025. The DRDQ stated staff was expected to verify the number on the lock when documenting in the log. She further stated it looked like RN 1 just copied the last entry of the March log and did not actually verify the number on the lock. A review of the facility’s policy and procedure titled. “Crash Cart,” May 2024, was conducted. The policy indicated, “...crash cart is stocked with supplies and equipment necessary to ensure the effectiveness of cardio-pulmonary resuscitation...When not in use, all crash carts are to be locked with two (2) plastic seals...Verification of the contents of the crash cart is to be checked according to the following...All twenty-four (24) hour nursing units are to do a crash cart checks every twelve (12) hours by a licensed Nurse or designated licensed personnel...Verification of completing the crash cart checklist will be documented on the Crash Cart Check Form once per shift...” 3. A tour of Unit A was conducted on April 1, 2025, at 11:27 a.m., with the DRDQ and Registered Nurse (RN) 1. The glucose monitor (a machine that is used to measure the sugar in patient’s blood) was observed in the dock station at the nurses station in Unit A. When the glucose monitor was turned on, the screen read “ACCU-CHEK...QC Due Immediately...” An interview was conducted on April 1, 2025, at 11:30 a.m., with Registered Nurse (RN) 1. RN 1 stated the glucometer is usually quality controlled by the night shift. She stated they hadn’t had any DKA (diabetic ketoacidosis-serious complication of blood sugar regualtion) patients on this unit lately, so the glucometer hadn’t been used and the quality control check had not been completed. An interview was conducted on April 1, 2025, with the DRDQ. The DRDQ stated this code meant the glucose monitor was not ready for use. She stated the glucose quality control needed to be completed before it was used on a patient. She further stated during an emergency like a code blue (emergency code called when a patient goes into cardiac arrest), this glucometer would not be ready to use. A review of the facility’s policy and procedure titled, “Blood Glucose Monitoring” dated February 2024, was conducted. The policy indicated, “...Performed by Registered Nurses (RN)...Quality Control (QC)...Quality Control is conducted...Every 24 hours (meter is set for 24-hour QC lockout)...No patient testing is allowed until both quality controls showed acceptable results (passed)...””

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 50454 Based on observation, interview, and record review, the facility failed to ensure temperature logs were maintained and dated for multiple laboratory refrigerators in accordance with the facility’s policy and procedure. These failures had the potential to negatively impact product efficacy and quality. Findings: On April 1, 2025, at 2:26 p.m., a tour of the laboratory department was conducted with the Director of Laboratory Services (DLS). A facility document titled, “Temperature QC [quality control] Monitoring Chart...Double Fridgen 1,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: -March 30, and 31, 2025. A facility document titled, “Temperature QC Monitoring Chart...Double Fridgen 2,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: -March 30, and 31, 2025. A facility document titled, “Temperature QC Monitoring Chart...Fridgen 3,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: -January 29, 30, 31, 2025; and -March 30, and 31, 2025. A facility document titled, “Temperature QC Monitoring Chart...ABG Fridge,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: March 30, and 31, 2025. A facility document titled, “Temperature QC Monitoring Chart...Bacti-Incubator,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: March 30, and 31, 2025. A facility document titled, “Temperature QC Monitoring Chart...Freezer,” dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log: March 30, and 31, 2025. On April 1, 2025, at 12:27 p.m., an interview was conducted with the DLS. The DLS stated, management is responsible for making sure all temperature logs are maintained. The DLS further stated, the refrigerator temperatures should be checked for accuracy and recorded on the logs, daily, including the weekends. The facility policy and procedure (P&P) titled, “General Laboratory,” dated August 2024, was reviewed and indicated, “...It is the policy of [Name of facility] to maintain proper temperature and humidity conditions for optimal instrument performance based on manufacturer’s guidelines and proper temperatures for all equipment (i.e., freezers, refrigerators, water baths, etc.) involving reagent and chemical storage...Record all temperatures on the Temperature Log Sheet...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50454 Based on observation, interview, and record review, the facility failed to ensure clean linen was stored properly, in accordance with the facility’s policy and procedure when the clean linen cart was observed uncovered while not in use. This failure had the potential for clean linens to be exposed to contamination. Findings: On April 1, 2025, at 11:43 a.m., a tour of the Telemetry 2 Unit storage room was conducted. During the tour, one linen cart was observed uncovered, along with pillows stacked on top of the linen cart. A facility sign located above the linen cart indicated, “Please keep linen covered at all times.” Another facility sign located above the linen cart indicated, “Keep top of linen chart clear of everything.” On April 1, 2025, at 11:45 a.m., an interview was conducted with the Director of Inpatient Services (DIS). The DIS stated, the linen carts should remain covered when not in use, and the top of the carts should be clear of all items, at all times. The facility policy and procedure (P&P) titled, “Clean Linen Storage,” dated May 2020, was reviewed and indicated, “...It is the policy of this facility to provide procedures for the proper storage of clean linen...General instructions are listed below...The storage area of clean linen is clean and secured...Clean linen will be covered when not in use...covered carts will be used for the delivery of all clean linen...””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48776 50304 Based on interview and record review, the facility failed to implement their discharge policy, for one of 30 sample patients (Patient 20), when Patient 20 was unsafely discharged without receiving services for a homeless patient. This failure had the potential to contribute to Patient 20 subsequently being struck by a car after the unsafe discharge and eventually expiring. Findings: On January 27, 2025, at 2:41 p.m., a review of Patient 20’s medical record was conducted with the Emergency Department Director (EDD). The “History and Physical,” dated January 18, 2025, indicated Patient 20 was seen in the Emergency Department on January 18, 2025, for general weakness with past medical history of Diabetes mellitus (a chronic disease that causes high blood sugar levels) and hypertension (high blood pressure). On January 28, 2025, at 2:24 p.m., a review of the facility document titled, “[Name of facility] Triage [the process of sorting and organizing patients in order to determine the urgency of their need or treatment] Report,” dated January 18, 2025, at 8:50 p.m., indicated, “...homeless female biba [brought in by ambulance] for weakness to BLE [bilateral lower extremity] from walking...” The untitled facility document, creation date, January 18, 2025, at 9 p.m., was reviewed and indicated, “...homeless who was brought by paramedics complain of generalized weakness from walking so much...social history: ...unemployed homeless...” On January 28, 2025, at 2:25 p.m., a telephone interview was conducted with the Doctor of Medicine (MD). The MD stated he saw Patient 20 on January 18, 2025, in the Emergency Department (ED). The MD stated Patient 20 was homeless. On January 28, 2025, at 2:24 p.m., an interview was conducted with the EDD. The EDD stated there was no documented evidence Patient 20 was offered a meal, patient had weather appropriate clothing prior to discharge, transportation to their discharge location within 30 miles or 30 minutes was offered, and a list of resources that are available in the area was provided. The EDD stated these should have been provided to Patient 20, and documented in the medical record. On January 28, 2025, at 4:03 p.m., a telephone interview was conducted with the Registered Nurse (RN). The RN stated she triaged Patient 20 on January 18, 2025, and that Patient 20 was homeless. The RN further stated she was the one that discharged Patient 20 on January 19, 2025. The RN stated she did not provide the homeless discharge services for Patient 20, at the time of discharge. A review of the facility document titled, “Discharge Assessment/ Summary Report, dated January 18, 2025, indicated, “...Patient Departed from the ED date and time 01/19/2025 01:49 [January 19, 2025, at 1:49 a.m.] ...Discharge Disposition...home...” A record review was conducted with the EDD on January 28, 2025. The facility policy and procedure titled, “Discharge of Homeless Patient,” dated August 2024, indicated, “ ...Each homeless patient will be offered the following services prior to discharge and documented in the patient’s medical record: ...the social worker (or if one is not available the nurse) will provide to the patient a list of resources that are available in the area...prior to discharging the homeless patient they will be offered a meal...the hospital is responsible for assuring that the patient has weather appropriate clothing prior to discharge...the homeless patient will be offered vaccinations...the homeless patient will be offered transportation to their discharge location within 30 miles or 30 minutes of the hospital this will be documented on the discharge assessment...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48776 Based on interview, and record review, the facility failed to ensure the facility’s policy and procedure (P&P) for pain management was implemented, for four of 30 sample patients (Patients 4, 9, 14, and 15), when: 1. For Patient 4, pain medication was not administered for two and a half hours when the pain score (numerical pain tool where mild pain is scored 1-3, moderate pain is scored 4-6, and severe pain is scored 7-10) was 10; 2. For Patient 9, pain score was 9, and pain medication was not administered; 3. For Patient 14, pain score was not assessed and documented; and 4. For Patient 15, pain score was not documented prior to discharge. This failure had the potential to impact the health and treatment of the patients, and cause delays in patient care. Findings: 1. On October 29, 2024, at 2 p.m., Patient 4’s medical record was reviewed with the Chief Quality Officer (CQO). The facility document titled, “Emergency Department Record,” dated October 3, 2023, indicated Patient 4 presented to the Emergency Department (ED) for evaluation of abdominal pain. The facility document titled, “Vital Sign Report,” indicated, “...10/03/2023 17:41 [October 3, 2023, at 5:41 p.m.] ...Pain Score: 10...10/03/2023 18:16 [October 3, 2023, at 6:16 p.m.] ...Pain Score: 10...10/03/2023 20:12 [October 3, 2023, at 8:12 p.m.] ...Pain Score 10...” The facility document titled, “Medication Administration Record,” indicated, Patient 4 was administered “...Fentanyl Citrate [a medication used for pain management]...50 mcg/1ml [micrograms per one milliliter, unit of measurement] ...10/03/23 20:12 [October 3, 2023, at 8:12 p.m.]. An interview was conducted with the CQO on October 29, 2024, at 2:15 p.m. The CQO stated Patient 4 should have received medication for pain management sooner than two and half hours. 2. On October 29, 2024, at 3:20 p.m., Patient 9’s medical record was reviewed with the CQO. The facility document titled, “Emergency Department Record,” dated October 6, 2023, indicated Patient 9 presented to the ED with difficulty breathing, abdominal distention (swelling), and had a history of cirrhosis (a condition that occurs when the liver becomes damaged, making it difficult to function properly) of liver. The facility document titled, “Triage [sorting of patients according to the urgency of their need for care] Report,” dated October 6, 2023, at 9:20 p.m. indicated, “...Pain Assessment [evaluation]...9...” An interview was conducted with the CQO on October 29, 2024, at 3:30 p.m. The CQO stated there was no documentation Patient 9’s pain was addressed, and no pain medication was administered to alleviate Patient 9’s pain. 3. On October 30, 2024, at 11 a.m., Patient 14’s medical record was reviewed with the CQO. The facility document titled, “Emergency Department Record,” dated October 25, 2023, indicated Patient 14 presented to the ED on a 5150 hold (allows the involuntary psychiatric hold of individuals considered a danger) after assaulting his mother. The facility document titled, “Triage Report,” dated October 25, 2023, at 10:59 p.m., indicated Patient 14’s pain assessment was not documented. The facility document titled, “Vital Sign Report,” dated October 25, 2023, through October 30, 2023, indicated Patient 14’s pain assessment was not documented. An interview was conducted with the CQO on October 30, 2024, at 11:10 a.m. The CQO stated Patient 14’s pain assessment should have been documented and this was not done. 4. On October 30, 2024, at 11:15 a.m., Patient 15’s medical record was reviewed with the CQO. The facility document titled, “Emergency Department Record,” dated October 30, 2023, indicated Patient 15 presented to the ED with abdominal pain and nausea. The facility document titled, “Triage Report,” dated October 30, 2023, at 12:23 p.m., indicated, “...Pain Assessment...10...” The facility document titled, “Medication Administration Record,” indicated Patient 15 was administered “...Morphine [a medication used for pain management]...4 mg/1ml [milligrams per one milliliter, unit of measurement]...10/30/23 14:19 [October 30, 2023, at 2:19 p.m.]...” The facility document titled, “Vital Sign Report” dated October 30, 2023, through October 31, 2023, indicated Patient 15’s “...Pain Score...8...10/30/2023 14:19 [October 30, 2023 at 2:19 p.m.]...” An interview was conducted with the CQO on October 30, 2024, at 11:25 a.m. The CQO stated there were no additional pain assessments documented for Patient 15, and a reassessment of pain should have been completed prior to Patient 15’s discharge and this was not done. A review of the facility P&P titled, “[Name of Facility] Pain Management,” dated November 2021, was conducted and indicated, “...Patients seen in the Emergency Department [ED] shall receive a screen during the triage or initial assessment process to identify the presence of pain... If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer...When provided, treatment shall be consistent with the patient’s clinical presentation and objective findings. The treatment modality selected shall be appropriate for the patient’s needs. Treatment is to be provided in a timely manner...If a treatment intervention for pain is provided, then the response to that intervention must be assessed. Reassessment is recommended to occur within 15 -60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the time of discharge or transfer...””