Eastern Plumas Hospital - Portola Campus

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the emergency battery backup lighting units. This was evidenced by the failure to test the emergency lighting units. This affected the Emergency Room, Operating Room and Generator enclosure and could result in a failure to provide backup lighting in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 19.2.9 Emergency Lighting. 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 7.9 Emergency Lighting. 7.9.2 Performance of System. 7.9.2.1 * Emergency illumination shall be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 11/ 2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 7.9.2.3 * The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Findings: During a tour of the facility, record review and interview with Engineering Staff on 7/15/25, the emergency lighting was observed and records reviewed. 1. At 2:24 p.m., the Emergency Room and the Operating Room were observed with battery backup emergency lighting units mounted on the wall. The facility failed to provide documentation that monthly 30 second functional tests on the emergency lighting units during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing. 2. At 2:24 p.m., the Emergency Room and the Operating Room were observed with battery backup emergency lighting units mounted on the wall. The facility failed to provide documentation that the annual 90-minute functional test had been conducted on the emergency lighting units during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing. 3. At 2:26 p.m., the generator enclosure was observed with a battery backup emergency lighting unit mounted on the wall above the generator. The facility failed to provide documentation that the annual 90-minute functional test was conducted on the emergency lighting unit during the last 12 months. Upon interview, ES3 stated that he was not aware that those units required testing.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by corridor doors that failed to latch. This affected five of five patients and one of three smoke compartments and could result in the spread of smoke and fire. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the hazardous enclosure areas were observed. At 12:23 p.m., the double corridor doors the central supply storage room was observed. The latch bolt had been removed from the doors latching hardware, preventing the doors from positively latching. Upon interview, ES2 acknowledged that the doors were missing the latch bolt and failed to latch when tested.”

“Anesthetizing Locations CFR(s): NFPA 101 Anesthetizing Locations Areas designated for administration of general anesthesia (i.e., inhalation anesthetics) are in accordance with 8.7 and NFPA 99. Zone valves are: located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Area alarm panels are provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems. Panels are at locations that provide for surveillance, indicate medical gas pressure decreases of 20 percent and vacuum decreases of 12 inch gauge HgV, and provide visual and audible indication. Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone box valve assemblies. The EES critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits, and EES equipment system supplies power to ventilation system. Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer’s instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 19.3.2.3 (LSC) 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to provide records of relative humidity (RH) and temperature documentation. This affected the operating room and could result in the increased risk of a hazardous condition and fire. Findings: During record review and interview with Maintenance Staff on 7/15/25, the temperature and RH logs were requested. At 11:10 a.m., the facility failed to provide temperature and RH logs for the single operating room (OR) in the facility. Upon interview, ES1 stated that there was a sensor on the wall in the OR that alerts the engineering department when the temperature was out of range. ES1 further stated that nursing staff would have access to the temperature and RH logs. Nursing staff were contacted over the phone and stated that temperature and RH were logged in an online program. ES1 stated that he did not have access to that program and was unable to provide the logs.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 43380 Based on record review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to conduct semiannual inspections, replace failed fire alarm control panel (FACP) batteries and test the notification devices. This affected five of five patients and three of three smoke compartments and could result in the delay of notification to emergency forces in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition Chapter 14 Inspection, Testing, and Maintenance 14.1 Application. 14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter. 14.3 Inspection. 14.3.1 * Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. 14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction. 14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance. Table 14.3.1 Visual Inspection Frequencies-semiannually 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. Table 14.4.5 Testing Frequencies. 14.4.5 * Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. Table 14.4.5 Testing Frequencies- Annually 1. Control equipment - building systems connected to supervising station (a) Functions (b) Fuses (c) Interfaced equipment (d) Lamps and LEDs (e) Primary (main) power supply (f) Transponders Batteries - fire alarm systems 6. (d) Sealed lead-acid type (1) Charger test: (Annually.) (2) Discharge test (30 minutes): Annually (3) Load voltage test: Semiannually 8. Fiber-optic cable power 9. Control unit trouble signals 12. In-building fire emergency voice/alarm communications equipment 14. Remote Annunciators 15. Initiating Devices* (a) Duct detectors (b) Electromechanical releasing device (c) Fire extinguishing system(s) or suppression system(s) switches (d) Fire-gas and other detectors (e) Heat detectors (The requirements of 14.4.5.5 shall apply.) (f) Manual fire alarm boxes (h) System smoke detectors - functional test (j) Single- and multiple-station smoke alarms (The requirements for monthly testing in accordance with 14.4.6 shall also apply.) (k) Single- and multiple-station heat alarms 20. Alarm notification appliances (a) Audible devices (b) Audible textual notification appliances (c) Visible devices 14.6.2 Maintenance, Inspection, and Testing Records. 14.6.2.1 Records shall be retained until the next test and for 1 year thereafter. 14.6.2.4 * A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of property (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representative of approving agency(ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9)* Functional test of required sequence of operations (10) Check of all smoke detectors (11) Loop resistance for all fixed-temperature, line-type heat detectors (12) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturer’s published instructions (17) Other tests as required by the authority having jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place) Findings: During a tour of the facility, record review and interview with Maintenance Staff on 7/15/25, the FAS was observed and records reviewed. 1. At 2:41 p.m., the annual FAS testing and inspection documentation dated 5/7/25 was reviewed. The documentation indicated two sealed lead acid batteries in the FACP had failed the load voltage test. No repair record was provided. Upon interview, ES2 stated that the vendor was going to replace both batteries. 2. At 2:45 p.m., the annual FAS testing and inspection documentation dated 5/7/25 was reviewed. The documentation indicated the notification appliances were not tested during the annual testing and inspection. Upon interview, ES2 acknowledged that the notification appliances were not tested. 3. At 2:52 p.m., the facility failed to provide a semiannual fire alarm inspection documentation. The annual maintenance and inspection were conducted on 5/7/25 and the inspection conducted previous was on 8/26/24. Upon interview, ES2 stated that their vendor was out at the end of last year and he would get the records from them. The facility was given until 10:00 a.m. on 7/16/25 to provide the FAS records to the California Department of Public Health (CDPH). At 10:00 a.m. on 7/16/25, CDPH did not receive the FAS records from the facility.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the interim fire measures. This was evidenced by incomplete fire watch policy and procedure. This affected five of five patients and three of three smoke compartments and could result in the facility not notifying the authority having jurisdiction (AHJ) during a fire watch event. Findings: During record review and interview with Maintenance Staff on 7/15/25, the interim fire measures and policies were reviewed. At 1:44 p.m., the facility’s fire watch policy was reviewed. The policy failed to include directions that the facility would notify the California Department of Public Health (CDPH) when a fire watch was implemented during a failed fire alarm system. Upon interview, the ES1 acknowledged the policy was missing instructions to notify CDPH when a fire watch was implemented.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing an identification sign. This affected five of five patients and three of three smoke compartments and could result in a delay to identifying the main control valve. NFPA 101: Life Safety Code, 2012 Edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 6.7.4 * Identification of Valves. 6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the fire sprinkler system was observed. At 11:37 a.m., the main control valve on the fire sprinkler riser located in the boiler/mechanical room was observed. The main control valve was missing an identification sign. Upon interview, ES2 acknowledged that the sign was missing.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire sprinklers. This was evidenced by an obstructed fire sprinkler head. This affected five of five patients and one of three smoke compartments and could result in the malfunction of the sprinklers in the event of a fire. NFPA 101: Life Safety Code, 2012 Edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. 8.10.6.3.1 Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the automatic sprinkler system was observed. At 12:41 p.m., the storage room near the Nurse Station was observed. Two cardboard boxes on the top shelf of the closet were approximately seven inches below the single sprinkler head in the closet. Upon interview, the ES2 acknowledged that the sprinkler was obstructed.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the interim fire measures. This was evidenced by incomplete fire watch policy and procedure. This affected five of five patients and three of three smoke compartments and could result in the facility not notifying the Authority Having Jurisdiction (AHJ) during a fire watch. Findings: During record review and interview with Maintenance Staff on 7/15/25, the interim fire measures policies were reviewed. At 1:45 p.m., the facility’s fire watch policy was reviewed. The policy failed to include directions that the facility would notify the California Department of Public Health (CDPH) when a fire watch was implemented during a failed automatic fire sprinkler system. Upon interview, the ES1 acknowledged the policy was missing instructions to notify CDPH when a fire watch was implemented.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch and were obstructed from closing. This affected five of five patients and three of three smoke compartments and could result in the spread of fire or smoke in the event of a fire. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the corridor doors were observed. 1. At 11:54 a.m., the corridor door to the Biohazard closet failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch. 2. At 11:55 a.m., the corridor door to the Physical Therapy Room was obstructed from closing. A rubber wedge was under the door leaf, holding the door in the fully open position. Upon interview, ES2 acknowledged that the door was obstructed from closing. 3. At 11:56 a.m., the corridor door to the Physical Therapy Room failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch. 4. At 12:14 p.m., the corridor door to the Employee Break Room failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, ES2 acknowledged that the door failed to latch. 5. At 12:37 p.m., the corridor door to the emergency room was obstructed from closing. Two plastic bags and a backpack were stored on the floor directly in front of the door, preventing it from being closed. Upon interview, ES2 acknowledged that the door was obstructed from closing.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in the smoke barrier wall in the attic. This affected five of five patients and two of three smoke compartments and could result in the spread of smoke to adjacent smoke compartments during a fire. NAPA 101, Life Safety Code, 2012 Edition 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac). (B) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. 8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the smoke barrier walls were observed. 1. At 12:49 p.m., the smoke barrier wall above the 90-minute fire barrier doors between the Lobby and the Acute side of the Hospital were observed. Approximately two-inch diameter metal conduit was observed running through the smoke barrier wall. Two wires were run through the conduit and the conduit was not sealed at the end to resist the passage of smoke. Upon interview, ES2 acknowledged the penetration. 2. At 12:50 p.m., the smoke barrier wall above the 90-minute fire barrier doors between the Lobby and the Acute side of the Hospital were observed. An approximately half-inch penetration was observed with low voltage wires running through it, in the smoke barrier wall. The penetration was not sealed to prevent the passage of smoke. Upon interview, ES2 acknowledged the penetration.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to the portable space heater. This was evidenced by the failure to follow manufacturer’s directions on space heaters. This affected the nursing administration office and one of three smoke compartments and could result in an increased risk of fire. Findings: During a tour of the facility and interview with Maintenance Staff on 7/15/25, the space heaters were observed. At 11:46 a.m., a portable space heater was observed under the Nutritionist’s desk in the Nursing Administration Office. The space heater was plugged into an uninterruptable power supply. According to the manufacturer’s instructions on a caution label on the portable space heater, the heater should be plugged directly into a wall electrical outlet. Upon interview, ES1 acknowledged that the space heater was not plugged into an electrical outlet.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the operating room (OR) electrical system components. This was evidenced by the failure to provide testing records. This affected the OR and one of three smoke compartments and could result in an increased risk of an electrical malfunction in the OR. NFPA 99 Health Care Facilities Code, 2012 edition 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. Findings: During a tour of the facility, record review, and interview with Maintenance Staff on 7/15/25, the facility’s electrical system components were observed, and maintenance records were requested. At 3:46 p.m., the facility was observed with a line isolation monitor (LIM) located in the corridor outside of the OR suite. The test switch on the unit was actuated and nothing happened. The facility failed to provide testing records for the OR’s line isolation monitor. Upon interview, ES1 stated that the OR had not been in used since January of 2025 and that he was not aware of the line isolation monitor testing requirements.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to provide continuing education to staff on oxygen cylinders handling procedures. This was evidenced by missing training records. This affected Patients that require oxygen and could result in staff mishandling oxygen equipment. Findings: During record review and interview with Respiratory Staff on 7/15/25, the oxygen cylinder training records were requested. At 2:35 p.m., the facility failed to provide a record of a continuing education program that included safety guidelines and usage requirements for personnel concerned with the application, maintenance and handling of medical gases and cylinders. Upon interview, the Respiratory Staff acknowledged that there were no records available for review.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 42448 Based on observation, interview and record review, the facility failed to ensure maintenance of the Food and Nutrition Services (FANS) areas when: 1. Engineering/maintenance related equipment in the FANS department, such as ceiling vents, walk-in refrigerator condenser fan area and fire sprinkler was not sanitary. 2. Walls had holes, missing/worn paint and large cracks. 3. There was mold growth on the caulking of the backsplashes at the handwashing sink and dish room. 4. There was no system or checklist in place for the Engineering department to regularly inspect the FANS department to identify and repair any maintenance or preventive maintenance issues. 5. The facility had no policies and procedures in place regarding the Engineering department’s scope of work at the facility, nor regarding their work order process and expected timelines for completion. 6. The facility’s kitchenette was not sanitary, and was not cleaned according to food safety practices or chemical manufacturer’s instructions. These failures had the potential to result in cross contamination and foodborne illnesses (illnesses that result from ingesting contaminated foods) for patients, and staff who received food from the kitchen, and to decrease the lifespan of expensive equipment in the kitchen. Findings: Review of the 2022 FDA (Food and Drug Administration) Food Code 4-601.11 showed (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Review of the 2022 FDA Food Code § 6-101.11 showed indoor floor, wall, and ceiling surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted. During the initial tour in the kitchen on 7/7/25 from 11:40 am to 1:00 pm, multiple areas requiring the services of the facility engineering/maintenance department were unsanitary: the dry storage ceiling vent was thick with dust; the walk-in refrigerator had dust/grime on the fire sprinkler, on the condenser fan and on the walls/ceiling around it. The wall above the hood had visible grime and accumulated dust as well as a large glob of black grease. The handwash sink had orange and black mold growth along top of the backsplash, and there was also black mold growth along top of dish machine area backsplash. The walls around the dish machine area had holes and peeling paint, rendering them uncleanable with increasing potential for microbial growth. (Cross Reference C-1208). During an interview with the Food Service Supervisor (FSS) on 7/7/25 at 12:35 pm, she agreed the black and orange growth along the top of backslashes at the hand washing sink and dish room areas were mold. She stated she sent an email work order to the maintenance department requesting repair, but it hadn’t been done yet. Review of an email document addressed to “Plantops@ephc.org,” titled, “Spring Cleaning,” dated 1/13/25, requested the caulking and paint around the dish room area to be scraped and reapplied. During further observations of the kitchen on 7/8/25 from 10:40 am to 10:55 am, there were large cracks in walls around the custodian closet door and above the hood, and thick dust accumulated around the custodian closet door jamb and entrance door jamb. The air vents in the ceiling had a buildup dust and grime, with potential to cross-contaminate food from above (three above patient tray line, one above the dish room, one above the entrance to the kitchen, one in the dry food storage room). During an interview with the Engineering/Maintenance Supervisor (ES) on 7/9/25 at 8:10 am, stated they had no process in place for regular inspection and maintenance of the food services area, but they were in the kitchen often. ES agreed any work that required a ladder would be his department’s responsibility. He described their responsibility as ensuring the hood and Ansel systems were cleaned and maintained regularly (contracted out). He stated his department looked for issues like missing paint, holes, soiled air vents, etc. in the rest of the facility but they didn’t go into the food services department as much. He stated it had probably been 5 or 6 months since they went into the Dietary Department to address those things. “They don’t want us in there if we don’t have to be.” ES stated they had a new email work order/ticket system (~2 years old) that went to the maintenance computers and phones. Staff reviewed and prioritized them daily. Non-emergent work orders usually took one to two days to complete. When asked about the FANS work order dated, 1/13/25 for mold growth along top of backsplashes for dish machine area and handwashing sink, the ES stated the problem was still present so they apparently missed the work order somehow, and he wondered if the work order was correctly addressed to “Plant Ops.” The ES stated the facility had no policy regarding Engineering/Maintenance responsibilities, and they had no process or preventive maintenance checklists in place for his department to provide regular inspection and maintenance of the food services areas. They also had no policy and procedure regarding the facility’s work order system and expected timelines for completion. When asked about their pest control system and the flies observed daily in the kitchen, ES stated the pest control service came quarterly but only treated the outside of the facility. He guessed the flies came into the kitchen when the back door was propped open during deliveries. During an interview with the Plant Operations Director (POD) on 7/10/25 at 8:00 am, stated they had no checklist or system to regularly inspect the kitchen. POD agreed they should have one, that it would help establish appropriate preventive maintenance assignments, and that maintenance of the kitchen was as important as other areas of the facility in provision of patient care. The facility’s kitchenette was not sanitary and was not cleaned according to food safety standards of practice or chemical manufacturer’s instructions. (Cross Reference C-1208). Review of the Navigator 3x Renegade One-Step Disinfectant directions for use showed, “For visibly soiled areas, a preliminary cleaning is required. Rinse all surfaces that come into contact with food such as countertops, appliances, tables and stovetops with potable water before reuse. Do not use on utensils, glassware and dishes.” “Do not use in food preparation, food handling and food storage areas.” “This product is a sanitizer for hard, non-porous non-food contact surfaces at 1:256 dilution (1/2 oz. per gallon).” During continued interview with the POD on 7/10/25 at 8:00 am, stated his area of responsibility included the housekeeping department. He stated housekeeping staff cleaned the exterior surfaces in the facility’s kitchenette, but his function with housekeeping was administrative and he didn’t know much more about it. He stated the housekeeping manager/supervisor was on vacation but would know what the process should be for staff to clean the kitchenette. He agreed the kitchenette should be cleaned according to food safety standards.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 13095 Based on review of the hospital’s Pharmacy and Therapeutics (P&T) agendas, review of the hospital’s Medical Staff By-Laws, as well as the hospital’s Rules and Regulations, interview with the hospital’s Chief Nursing Officer (CNO) and the hospital’s Emergency Room Manager, the hospital failed to create and establish, complete and comprehensive minutes (or any meeting minutes at all), for the hospital’s P&T Committee and to develop a policy and procedure which outlined the function of the hospital’s P&T Committee, as well as who were the required members of the hospital’s P&T Committee. This failure had the potential to prevent the hospital from having opportunities to improve the hospital’s overall Pharmacy Services and efficacy. Findings: During an interview with the hospital’s CNO and the hospital’s Emergency Room Manager on 7/8/2025 at 3:30 pm, the CNO shared the facility’s P&T records from the last 4 years. Review of these records revealed that the hospital’s P&T Committee had not taken any meeting minutes from 1/2024 to present (for the last 1 and ½). During the interview, the CNO indicated that they did not have anyone who had been taking meeting minutes during these meetings. The CNO was only able to provide “generalized agendas,” which were not complete/detailed enough to serve as minutes for these P&T meetings. Review of the hospital’s Medical Staff By-Laws and Rules and Regulations, dated 10/2020, and approved by the Hospital’s Board of Directors, read: “(f) maintaining a record of all activities relating to pharmacy and therapeutics functions ... 9.6-3 ...It shall maintain a record of its proceedings ...” No records of the P&T Committee meetings activities had been captured, regarding the P&T Committees actual discussions, decisions, approved items, and any tabled items for their next meetings. These P&T agendas did not reflect any closure for any of the items on the agendas, had to any of the P&T agenda items. Further interview with the CNO on 7/8/2025, regarding the P&T Committee, revealed that no policy and procedure had been developed or put into place, to establish who the required P&T Committee members were for this committee.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 13095 Based on inspection of the hospital’s Drug Storage Room Medication refrigerator/freezer, and one of the hospital’s clinic office (Graegale), and interview with hospital’s nursing staff and the clinic’s Nursing Director, the facility failed to ensure that expired medications were not available for patient administration. The facility also failed to follow its policy and procedure regarding “Medication Management: Administration”, for the examination and administration of patient’s home medications, while the patient was in the hospital. This failure created the opportunity for nursing staff to administer expired medications and for unverified home medications to be administered to patients who were receiving medications within the hospital. Findings: 1. Inspection of the hospital’s Drug Storage Room freezer on 7/7/2025 at 2:10 pm revealed: 2 boxes (10 single dose prefilled syringes per box) of Covid-19 Vaccine MRNA Spikevax for the 2024-2025 formula. These 2 boxes of Covid-19 Vaccine had an expiration date of 6/14/2025. Concurrent interview with Emergency Room Registered Nurse (RN) C, confirmed these expiration dates on these vials. 2. Inspection of the hospital’s Drug Storage Room refrigerator on 7/7/2025 at 2:55 pm revealed: 6 vials of Infliximab (Remicade), used to treat autoimmune diseases, with 100 mg (milligrams) of the drug in each vial. Each vial had the following expiration date: 8/31/2024. Concurrent interview with RN C, confirmed these expiration dates on these vials. 3. Inspection of one of the hospital’s Medical Clinics on 7/9/2025 at 10:00 am revealed 2 bottles of Sodium Chloride 0.9 % irrigation solution, with 1000 ml (milliliters) of solution in each bottle. Both bottles had an expiration date of 01/2025. Concurrent interview with the Clinic’s Nursing Director confirmed these expiration dates on the bottles. 4. Inspection of one of the hospital’s Medical Clinics on 7/9/2025 at 10:45 am revealed 2 Sodium Chloride 0.9 % syringes with an expiration date of 6/30/2025. Concurrent interview with the Clinic’s Nursing Director confirmed these expiration dates on the syringes. 5. Review of hospital’s policy and procedure, entitled, “Medication Management: Administration,” which had been dated: “4/2025, read: “J. Medications brought form home by the patient/family shall not be administered to the patient unless all of the following conditions are met: “ ... 3. The contents of the container have been examined and positively identified by the admitting physician ...”. During an interview with Registered Nurse (RN) B on 7/9/2025 at 4:00 pm, was asked if the hospital had developed any system which would allow the hospital Nursing staff to know if a physician had examined and verified each patient’s home medications, prior to Nursing staff administering any home medications, to the patients in the hospital. Concurrent inspection of the hospital’s Drug Storage Room and a review of each patient’s own home medication revealed the hospital had not developed any system to let the hospital nurses know that each patient’s home medication, had be positively examined and identified by a physician prior to the administration of each patient’s home medication. During the inspection of the hospital’s Drug Storage Room, 17 different bottles of patient own home medications had been found, which were currently in use. Each bottle was examined by the hospital’s Nursing staff and the State Surveyor, to see if the hospital had developed any system which would have allowed the hospital’s Nursing staff to know that these medications had been examined and positively identified prior to Nursing staff administering these medications to the patients, as identified in the hospital’s policy and procedure above. RN B reiterated that the hospital had not developed any system which would have allowed hospital Nursing staff to know that these home medications had been identified and examined by a physician according to the hospital’s policy and procedure.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 42448 Based on observations, interviews and record reviews, the facility failed to ensure its alternate menu choice served at lunch on 7/8/25 provided equivalent protein for patients as compared to the nutrient analysis. There was not a system in place to help cooks know appropriate portion sizes to serve to meet patient nutrition needs using alternate menu choices. These failures had the potential to result in the provision of meals that did not meet the nutritional needs of patients to promote healing and wellness. Findings: Review of a policy titled, “Menu Planning,” dated 2021, showed, “Nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well-balanced diets, unless contraindicated by medical needs.” “Regular and therapeutic menus will be written to provide a variety of foods ...and in adequate amounts at each meal to satisfy recommended daily allowances ...Suitable and nourishing alternative meals ...are of similar nutritive value as the meals ...normally scheduled and are consistent with the individual’s care plan.” Review of the document titled, “Diet Extensions: Tuesday, Week 4, EPHC Spring/Summer Menus 2025,” showed the standard regular lunch meal for 7/8/25 included ½ cup French fries or Cottage Fries, 1 wheat dinner roll, 3 ounces butterfly shrimp, ½ cup coleslaw, 1 tablespoon cocktail sauce, ½ cup gelatin. During an observation of lunch tray line (meal tray assembly process) and concurrent document review on 7/8/25 at 11:40 am, Food Service Worker 1 (FSW) 1 posted a paper above tray line for reference. The list was titled, “Meal Options,” dated lunch, 7/8/25, and listed the facility’s three patients and twenty six residents, including their diet orders, food preferences, special food-related needs, and the patient/residents’ choice of menu entrée or alternative choice, and portion size (regular/small/large). The second page listed the standard menu for that day as Tempura Shrimp, French Fries, Coleslaw and Gelatin Jewels. It listed the alternate option as Cheese Ravioli with Sauce, Coleslaw, and Gelatin Jewels. Sixteen of the 29 skilled nursing facility residents acute care patients requested small portions. Review of multiple documents provided by the facility regarding portion sizes provided conflicting guidance for staff: A policy titled, “Portion Sizes,” dated 2018, showed, “The small and large portion servings will be served as printed on the cook’s spreadsheets for every meal ...The food server is to give the ½ size portion of the regular diet for the food on the main plate - entrée, vegetable and starch. Regular portions will be given for the soup, bread, salad, dessert and beverage, unless otherwise stated by the Dietitian.” A document titled, “Portion Sizes not on Cook’s Spreadsheets, ½ (half) Size Portions and Double Portions,” dated 2018, showed patients/residents requesting half portions should be provided with half size portions of meat/entrée, starch and vegetable. An undated document posted in the Food Service Manager’s (FSM) office directed this for small portions: the entrée/protein portion should be regular size, with the starch and vegetable portion half size. A document titled, “Diet Extensions: Tuesday, Week 4, EPHC Spring/Summer Menus 2025,” showed, “Small portions: serve regular protein, half portion starch, vegetable and dessert. Small portion is equivalent to 1800 calorie.” During further observation of tray line, FSW1 provided either three ounces of shrimp or four raviolis with sauce on each plate (unless otherwise noted per preference or texture), along with the starch and vegetable as appropriate. The cook was not observed to serve any different serving size of raviolis other than four raviolis to regular texture diets. Review of the facility’s recipe titled, “Ravioli Cheese and Spinach with Marinara (Ravioli Cheese and Spinach),” dated/printed 7/9/25 showed the serving size as 12 ounces. Review of the Nutrition Facts in the US Foods product information list titled #8813171, Ravioli, Spinach & Cheese 3 Way Medium Square Plain Pasta Cooked Frozen showed one container provided 20 servings, and defined one serving as ten pieces of raviolis. It further showed 10 pieces of raviolis provided 270 calories and 13 grams of protein. Further calculation showed four pieces of Raviolis (as served by FSW1) provided five grams of protein and 108 calories. Review of a document titled, “Daily Nutrient Summary: Tuesday, Week 4, EPHC Spring/Summer Menus 2025,” for regular diet and texture, Choice 1, showed the daily nutrient totals should range 1800 to 2400 calories, with 46 to 120 grams of protein. It showed that day’s standard menu actually provided 1920 calories and 85 grams of protein. The second page for “Choice 2” had no nutrient data calculated for the alternate menu choices. During an interview with the Food Service Director/ Registered Dietitian (FSD/RD) on 7/9/25 at 12:30 pm, the nutrient analysis for the 7/8/25 menu was reviewed. The FSD/RD agreed the four raviolis served at lunch, and without any additional high protein food included on the meal tray, did not provide adequate calories and protein and was not equivalent or close in nutrition content with the standard menu. The FSD/RD was asked how the cook was supposed to know what the serving size was supposed to be for the alternate menu choices, and she stated they would work on that.”

“LABORATORY SERVICES CFR(s): The CAH provides basic laboratory services essential to the immediate diagnosis and treatment of the patient that meet the standards imposed under section 353 of the Public Health Service Act (42 U.S.C. 236a). (See the laboratory requirements specified in part 493 of this chapter.) The services provided include the following: (i) Chemical examination of urine by stick or tablet method or both (including urine ketones). (ii) Hemoglobin or hematocrit. (iii) Blood glucose. (iv) Examination of stool specimens for occult blood. (v) Pregnancy tests. (vi) Primary culturing for transmittal to a certified laboratory. This Standard is not met as evidenced by: 49418 Based on interview and record review, the facility’s laboratory (lab) had not updated their Policy and Procedure (P&P) titled, “Hospital Computer System Down,” a procedure crucial for maintaining patient care and safety during computer system outages, since 2016. This deficient practice had the potential to delay documentation and communication of critical lab test results and lead to negative patient health outcomes for all patients during a computer system outage. Findings: Review of facility P&P titled, “Hospital Computer System Down,” dated 3/2016, indicated lab tests would be sent to the lab and processed in a “non-computer environment” during a computer system outage. The P&P indicated labs would be ordered and results documented manually until the “Healthland” computer system returned to normal operation, and nursing personnel would be notified by lab personnel when the computer system was back online. Review of document titled, “Clinical Laboratory Medical Director (LMD), Delegation of Duties,” dated 7/6/25, indicated the LMD was responsible for overall operation of the lab. The document indicated LMD reviewed and approved all new P&Ps and substantial changes to existing documents before implementation. Tasks delegated to Lab Manager (LM) included (A) overseeing the Administrative and effective quality management procedures and (B) ensuring an approved procedure manual was available to all personnel responsible for all aspects of the testing process. Tasks delegated to the Clinical Lab Scientists (CLSs) included assisting with writing and implementing P&Ps. During concurrent interview with CLS A and record review on 7/8/25 at 10:20 am, CLS A was asked what the lab protocols were for running tests and reporting results during a computer system outage. CLS A stated he wasn’t sure of all the proper downtime steps, but he knew where to look. CLS A provided a downtime protocol binder which included a blank “Laboratory Requisition” form, dated 1/2022, a P&P titled, “Hospital Computer System Down,” dated 3/2016, and downtime results for several patients, dated 2023. The downtime results forms indicated the results had been “Checked in Cerner” (an electronic health record or EHR system designed to manage patient information and streamline healthcare operations) after the system was restored. Asked if there was a newer version of the P&P, CLS A stated he did not know but the LM would. During an interview with LM on 7/9/25 at 10:10 am, LM stated, “We lose power a lot.” LM acknowledged the facility P&P “Hospital Computer System Down” should have been reviewed and updated to reflect the current EHR (Cerner) and lab equipment and to ensure the lab was following the most current nationally recognized procedures.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. This Standard is not met as evidenced by: 39942 Based on interview and record review, the facility failed to maintain an accurate list of all services furnished under contracts or agreements, and to ensure that the list included the nature and scope of the services provided. Findings: A facility policy titled, “Contracts: Processing & Execution Thereof,” last approved 3/1/25, was reviewed. The policy indicated that a contract must have been in place before a Vendor (an individual or company that sold goods and services to another) provided goods or services. Contracts were required to be reviewed annually. The Executive Assistant and/or Administrative Assistant were responsible for maintaining a current list of all contracts and expiration dates. On 7/8/25, at 4:24 pm, the Chief Financial Officer (CFO) provided a list with the words, “Contract Services” handwritten across the top. The list contained 109 company names, in alphabetical order, in a left-sided column labeled, “contract.” Three more columns were labeled, “description,” “Nature and Scope,” and “Department Responsible.” There were no dates on the list. Companies that were known by the survey team to provide food, produce, Biomedical Engineering services (maintenance of hospital equipment), and fire extinguisher inspections for the facility were not on the list. During an email communication, on 7/9/25, at 3:04 pm, the CFO wrote that most of the vendors on the list provided were not formally contracted and were not for patient care services. CFO asked if the contracted services on the list should be related to patient care, and if so, CFO would need to modify the list. Review of a revised list of names of contracted services indicated it contained no dates, and the brief, “Nature and Scope” descriptions on the list consisted of only one to six words each. During an interview, on 7/9/25, at 2:25 pm, CFO stated they did not have a current list of contracts for the vendors and agreed they should have one.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 13095 Based on review of the hospital’s “Pharmacy Contractor Agreement” and interview with the hospital’s Chief Nursing Officer (CNO), the hospital failed to ensure that each item, (which had been outlined in the hospital’s agreement/contract), had been completed by the Pharmacy Contractor, based on an agreement which had been created for 1/1/2024. Further review of the hospital’s Pharmacy and Therapeutics (P &T) Committee agendas (no minutes available), Monthly Pharmacy Reports, and review of the hospital’s Pharmacy Quality Assurance Performance Improvement (QAPI) data, the hospital failed to ensure that the hospital had been receiving all of the services, which the hospital had contracted for. This failure had the potential to prevent the hospital from having opportunities to improve the hospital’s Pharmacy Services. Findings: Review of the “Pharmacy Contractor’s Agreement,” dated 1/1/2024, read: “Eastern Plumas Health Care (EPHC), operates a critical care access hospital ...and in conjunction therewith maintains Pharmacy services for all patients located at the above facility. EPHC is in need of an experienced, qualified consultant pharmacist in order to meet State and Federal regulations pertaining to monthly Pharmacy and Therapeutics Committee meetings, ...outdate tracking for hospital and medical clinics (Portola Medical Clinic, Loyalton Medical Clinic, Graeagle Medical Clinic), quarterly clinic visits, drug formulary review, ...development of policies and procedures, and narcotic inventory and discrepancy tracking ....Section 1: Engagement, The company hereby engages the Consultant Pharmacist to render the following: ...Monthly narcotic inventory and discrepancy tracking for acute care and drug outdate tracking. Annual review of drug formulary ...Quarterly clinic visit which include inspection of drug storage areas for proper storage, outdate tracking and maintain records ....”. Review of the hospital’s Pharmacy and Therapeutics Committee agendas (no minutes available), Monthly Pharmacy Reports, and review of the hospital’s Pharmacy QAPI (Quality Assurance & Performance Improvement) data, revealed that the hospital’s “Pharmacy Contractor,” had not been providing all of the Pharmacy Services, which the hospital had contracted out for. For example, the Pharmacy Contract/agreement above indicated that “drug outdate tracking,” was to be completed by the contracted Pharmacy. However, during an interview with the hospital’s CNO, review of the hospital’s P&T Committee agendas, and review of the Pharmacy provider’s monthly reports on 7/10/2025 at 8:45 am, revealed that the facility had no records or logs of any “drug outdate tracking,”which had been completed by the hospital’s “Pharmacy Contractor” from 1/1/2024 to present and provided to the hospital. During a concurrent interview with the hospital’s CNO, she was asked if she was aware of the hospital’s “Contracted Pharmacy” having completed an: “An Annual review of the hospital’s drug formulary” or if she was able to provide any evidence that an annual review had been completed. The CNO indicated that she was not aware of any annual review of the hospital’s drug formulary, which had been completed by the hospital’s “Contracted Pharmacy.” Review of the hospital’s policy and procedure titled, “The Formulary,” dated 10/2023 read: “6. The established formulary shall be reviewed in its entirety ...by the Pharmacy and Therapeutics Committee.” The hospital was unable to provide any evidence that the P&T committee had reviewed the hospital’s drug formulary in its entirety, as outlined in the hospital’s policy and procedure above. Further concurrent interview and record review with the hospital’s CNO on 7/10/2025 that the Pharmacy’s monthly reports and the hospital’s P&T agendas revealed that the contracted Pharmacy had not consistently completed the Quarterly clinic visits as outlined in the hospital’s “Pharmacy Contract”. Review of the hospital’s P&T agendas and the hospital’s Pharmacy monthly reports revealed that between 1/1/2024 to present, the Pharmacy contractor had only visited the hospital’s clinics on the following dates (which was not quarterly). “1. Visit to Graeagle clinic had been made by 7/31/2024 (7 months or more than 2 quarters into the first year), 2. A second visit had been made to Graeagle clinic by 9/19/2024 (two months later), 3. A third visit was made by 5/21/2025 to the Loyalton clinic. Out of the 18 months (which made up 6 quarters), the Pharmacy only documented 3 visits to the hospital’s clinic for these 6 quarters, contrary to the hospital’s Pharmacy contract above, which stated Quarterly visits. These Quarterly visits to the hospital’s clinics had not been completed on a quarterly basis. Also, contrary to the hospital’s Pharmacy contract above, the hospital also did not “maintain records, for all of the tasks,” which may have been completed, as specifically outlined in the hospital’s Pharmacy agreement/contract.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 49418 Based on interview and record review, the facility failed to have a system in place to meet the care needs of patients with an arteriovenous fistula (AVF - a surgically created artery-vein connection for access to hemodialysis, a treatment that filters and cleans the blood for failing kidneys) when: a, Policies and Procedures (P&Ps) were not developed for nursing assessment and care of an AVF and; b. Nursing staff were not trained and oriented to the care needs of AVF patients. This deficient practice created the potential for harm and negative health outcomes due to lack of oversight in the management of care for all patients with AVFs. Findings: A review of document retrieved from Lippincott Procedures, (web-based nursing guidance with step-by-step instructions for standardized care) titled, “Hemodialysis patient assessment,” dated 8/19/24, indicated hemodialysis was a “life-saving procedure” that removed waste and excess fluids from the blood. The document indicated, AVFs were placed for permanent dialysis access for patients with stage 5 chronic kidney disease (CKD 5- the most severe stage, where the kidneys have nearly or completely failed, requiring dialysis or kidney transplant for survival). The document directed nursing staff to: 1. Assess the AVF for signs and symptoms of infection (redness, warmth, tenderness, swelling), abnormalities in shape (ballooning or bulging); feel for the presence of a thrill (a palpable vibration) and listen for a bruit (a “rushing noise”) to determine access is not obstructed. Staff were directed to use a Doppler ultrasound (non-invasive technique using sound waves to assess blood flow within vessels) if a bruit could not be heard with a stethoscope. 2. Never measure a patient’s blood pressure (BP) on an extremity (arm/leg) with an AVF because “doing so may damage the arteriovenous access.” 3. Assess skin, heart rate, and pulses distal (farthest away from center) to the AVF for changes in color, temperature, and sensation because “circulation may be impaired.” 4. Assess respiratory rate, rhythm, and pattern, and blood oxygen levels with pulse oximetry (device placed on finger to measure oxygen in bloodstream). 5. Weigh the patient at the same time daily to assess the body’s fluid balance and assess mucous membranes and skin for dryness, which may indicate decreased fluid in the blood and tissues (dehydrated). 6. Documentation of hemodialysis patient assessment should include pain, daily weight, vital signs, fluid intake (drinking, intravenous or IV fluids) and output (urination, vomit, feces, sweating), signs of fluid imbalance, AVF site complications, communication with the provider, and education provided to the patient (and family, if applicable) to include the patient’s understanding of the teaching and follow-up teaching needed. A review of facility P&P titled, “Care Planning,” dated 11/2024, indicated nursing care plans provided direction for individualized, organized, and updated care for patients. The P&P directed nursing staff to use assessment findings to develop a patient’s plan of care and allow members of the healthcare team to identify and prioritize patient problems. A review of “Emergency Department (ED) Note Physician” by Medical Doctor (MD) B, dated 3/8/25 at 5:44 pm, indicated Patient 19 was brought in by ambulance for foot pain, weakness, and cough. MD B diagnosed Patient 19 with possible bilateral (both sides) pneumonia and dehydration. Patient 19 had a notable history of neoplasm (an abnormal mass or growth) of the kidney, surgical removal of the right kidney 11/25/20, stage 4 chronic kidney disease (CKD 4), and hypertension (high blood pressure) with renal (kidney) disease. MD B documented that Patient 19’s one “major medical problem was renal insufficiency” with “a shunt (AVF) placed in the right arm for possible future dialysis.” The note indicated the AVF had been there for three years but had not been used, and Patient 19 had “18% function” of her left kidney. MD B documented normal physical exam findings in head, neck, heart, lungs, abdomen, and skin and noted “av fistula L (left) forarm [sic] with palp (palpable) frill [sic].” Assessment/Plan (A&P) indicated diagnoses of renal insufficiency (no mention of AVF), dehydration, and syncope (fainting episode). Patient education and nursing care orders for this CKD 4 patient with an AVF were not documented. A review of “ED Note Physician” by MD C, dated 3/9/25 at 10:56 pm, indicated Patient 19 received Nephrology (kidney specialists) care in a nearby city and had had “av fistula placement for future dialysis.” MD C documented normal physical exam findings for neck, heart, skin, and abdomen with notable musculoskeletal system (bones and muscles) findings of mild edema (swelling) and tenderness in the anatomic snuffbox (back of hand at base of thumb), tenderness in the bottoms of the feet, with “no edema or deformity of extremities.” AVF was not documented in the exam. A&P indicated a diagnosis of CKD 4; the AVF was not addressed. Patient education and orders for nursing care of this CKD 4 patient with AVF were not documented. A review of “History and Physical” by MD C, dated 3/9/25 at 10:56 pm, indicated Patient 19 had a history of hypertension, nephrectomy (kidney removed) for renal (kidney) cancer three years ago, and CKD 4 with AV fistula placement for future dialysis. Lab evaluation was performed to evaluate for worsening kidney function and dehydration. An AVF assessment and patient education were not documented. The A&P did not address the AVF; however, CKD 4 was noted with “GFR of 18 ... improved from a value of 14 yesterday” (in CKD 5 range). Patient education and orders for nursing care of this CKD 4 patient with AVF were not documented. A review of “Nursing Narrative Note,” dated 3/10/25, indicated, “Assessment done” at 12:44 am and “[Patient 19] has fistula in right FA (forearm), and hearing aids, also has clothing from home no other belongings [sic].” An AVF assessment and patient education were not documented. A review of “Progress Note - Physician” by MD C, dated 3/10/25 at 11:55 am, indicated Patient 19 “had a dialysis fistula placed in anticipation of dialysis.” Documentation of physical exam did not indicate assessment of the AVF. A&P indicated Patient 19 had CKD 4, one kidney and poor renal function, with a plan to “monitor closely.” New orders for nursing care included taking vital signs every four hours and the patient’s weight measured every 72 hours. A review of “Progress Note - Physician” by MD B, dated 3/11/25 at 11:06 am, indicated Patient 19’s kidney function was being followed. MD B documented physical exam findings; however, an AVF assessment was not documented. A&P indicated Patient 19 had CKD 4, “chronic stable.” An addendum dated 3/11/25 at 11:25 am by MD B indicated “renal function will be followed closely.” A review of “Nursing Narrative Note,” dated 3/11/25 at 11:41 pm, indicated Patient 19’s assessment was completed at 7 pm, noting peripheral intravenous access (PIV - thin tube placed in a vein to administer fluids and/or medications) in the left forearm (LFA), dressing clean, dry and intact (CDI). The note indicated Patient 19’s IV was flushed and infiltrated (fluid leaks into tissues instead of the vein) at 8 pm with a new IV 22 gauge (g - unit of measure for needle size) “placed to RLF” (acronym unclear). IV antibiotics were given as ordered at 9 pm, and Patient 19 was in bed, resting, with no changes in patient status from 10 pm to 4 am. An AVF assessment and patient education were not documented. A review of record titled, “Interactive View Print Request: Peripheral IV” revealed Patient 19 had three different IVs documented for the left arm throughout her stay from 3/8/25 to 3/14/25. The “Dialysis Access” column contained no documentation. A review of “Progress Note - Physician” by MD B, dated 3/12/25 at 5:25 pm, indicated documentation of a physical exam without assessment of the AVF. A&P indicated Patient 19 had CKD 4, “stable chronic.” No new orders for nursing care of AVF were documented. A review of “Nursing Narrative Note, dated 3/12/25 at 7:40 pm, indicated, “Assessment completed” at 8 pm, VS within normal limits, and “PIV 22g to LFA.” An AVF assessment was not documented between 6 pm and 5 am. A review of “Discharge Summary” by MD B, dated 3/13/25 at 9:27 am, indicated: “Your Diagnosis” included hypoxemia (low blood oxygen levels), bilateral pneumonia, dehydration, hypertension with renal disease, bilateral foot pain, post-viral disorder (lingering effects of prior viral infection), CKD 4, and pain in left foot. “Problems Ongoing - Any problem that you are currently receiving treatment for” indicated CKD 4 and AVF. Education for care of AVF after discharge was not documented. A review of Patient 19’s “Care Plan” for their admission from 3/8/25 to 3/14/25 indicated no plan of care for the AVF. During a concurrent interview with Registered Nurse (RN) A and record review on 7/9/25 at 10:40 am, RN A stated they had been a nurse for 12 years, at this facility for three to four years. When asked about AVF care, RN A stated they would not access (insert dialysis tubing into the AVF to help remove and “clean” blood with dialysis equipment) the AVF without a provider order. RN A stated an AVF assessment would include feeling for a thrill, listening for a bruit, feeling for pulses below the AVF, and looking for edema at the AVF site and in the extremity. RN A stated signage “should be placed over the patient’s bed or in their room” so all staff know not to take blood pressures or place IVs on the AVF arm. RN A stated nursing care policies were in their P&P manager on their computers and could be viewed at any time. When asked to find a policy for AV fistula care, RN A stated they could not locate one in the P&P manager. RN A stated if a P&P was not in place, nursing staff had computer access to Lippincott Procedures as a resource. RN A noted they would also call the administrators if a policy could not be found. During a concurrent interview with RN B and record review on 7/9/25 at 11 am, RN B stated they had been a nurse for 20 years. When asked about AVF care, RN B stated they did not remember “ever” seeing a patient with an AVF and initially stated they would “call the doctor” if one was assigned to them. When asked what they remembered about AVF care, RN B stated they “know not to squeeze the [AVF] arm or do an IV.” RN B stated they had Lippincott access and could look there, and they could also ask the Emergency Department Manager (EDM). During a concurrent interview and record review with Chief Nursing Officer (CNO) and EDM on 7/9/25 at 11:20 am, CNO stated a nursing AVF assessment should include confirming blood flow by assessing for thrill and bruit. EDM and CNO acknowledged there was not a P&P for AVF care but stated RNs had access to Lippincott Procedures on their computers. EDM and CNO stated nursing staff “know” that “even if the AV fistula is not working, don’t touch it.” Reviewed Patient 19’s medical records and discussed nursing narrative documentation of a new IV placed in “RLF” at 8 pm on 3/11/25, though “Interactive View Print Request: Peripheral IV” indicated a left wrist IV was removed and a new IV placed in the left forearm on 3/12/25 at 1:04 am. Asked if “RLF” indicated right lower forearm, EDM stated she believed RLF was documented in error; CNO and EDM acknowledged they could not be certain from the documentation on which side the IV had been placed. Asked about nursing documentation of AVF assessment, CNO stated there was no place in Cerner (the facility’s electronic health record system) to chart an AVF assessment unless it had been accessed; CNO stated nursing staff could document in their nursing narrative notes. EDM stated students from a local community college would sometimes do their clinical rotations at the facility, and students were monitored by a preceptor provided by the college. Asked how the facility assured that a student knew how to care for an AVF, EDM stated the preceptor would monitor and educate them. Asked how staff should be informed a patient has an AV fistula, EDM and CNO stated AVFs should be reported during nurse-to-nurse shift report, and signage should be placed above the bed to indicate not to use the AVF extremity for vital signs (BP) and IV placement. EDM stated signage was “easily done” and “I will make signs now.” CNO and EDM acknowledged an AVF should be assessed “every shift” as part of a patient assessment. CNO and EDM acknowledged the facility did not have a process in place for care of patients with an AVF. During a concurrent interview with MD A and Patient 19’s medical record review on 7/10/25 at 8:20 am, MD A stated he had not cared for Patient 19 during their visit and that AVFs are “rare.” MD A stated he would look up the assessment and care of patients with AVFs in UpToDate (a physician-authored resource for healthcare providers). MD A stated he knew to feel for a thrill and noted he would look at the patient’s history and Nephrology contacts. Asked what if any orders he might place, MD A stated he would need to research it. MD A stated he thought assessments should be performed daily as part of a physical exam, and the expectation would be for AVF assessment to be documented. MD A stated the AVF should also be listed in the Assessment and Plan problem list. MD A acknowledged the ER Provider Note of 3/9/25 and the History and Physical 3/10/25 by MD C did not contain documentation of an AVF assessment. MD A acknowledged the 3/11/25 and 3/12/25 Progress Notes by MD B mentioned the patient having only one kidney, but no assessment of AVF was documented. MD A acknowledged the Discharge Summary of 3/13/25 by MD B indicated assessment findings of thrill in the AVF. MD A stated he cannot say not assessing Patient 19’s AVF was “a lapse in care” as the patient was not there for CKD/dialysis but for pneumonia. However, MD A acknowledged it was a good idea to assess the AVF site anyway. During an interview on 7/10/25 at 9:03 am, MD A stated he had spoken with MD C on the phone. MD A stated MD C remembered caring for Patient 19 and he “definitely” assessed it but simply forgot to document the assessment.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49418 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide safe and sanitary environment to prevent the development and transmission of diseases or infection when: 1. The facility’s Water Management Program (WMP) did not have a system to identify the presence or absence of Legionella bacteria and other pathogens that may contaminate the facility’s water supply which was identified by Public Health authorities. This failure had the potential to allow Legionella bacteria and other harmful waterborne pathogens to cause preventable diseases/infections in patients and staff. 2. One of seven sampled employees, Respiratory Therapist (RT) A did not have proof of annual tuberculosis (TB - a contagious bacterial infection that affects the lungs) testing and/or TB symptoms questionnaire per facility policy. This failure had the potential to delay treatment of undetected tuberculosis and allow transmission to patients and staff. 3. Did not have adequate policies and procedures (P&P), and systems in place to ensure infection prevention in the Food and Nutrition Services (FANS) Department when: a. multiple kitchen food preparation areas and equipment were not clean to sight and/or touch. b. staff did not use professional standards of practice or follow chemical manufacturers’ instructions to clean food contact surfaces. c. staff did not consistently perform professional standards of practice to prevent cross contamination of food, including covering facial hair, removal of jewelry, storage of aprons, and inadequate changing of gloves. d. the facility’s kitchenette was used to provide food to residents, was not sanitary, and did not receive any oversight from the facility’s food professionals to ensure food safety. Staff responsible for sanitation of the kitchenette were not trained to clean it using a food-safe processes. e. There was not an effective pest control system in place when flies were present daily in the kitchen during the survey. These failures had the potential to result in cross contamination and foodborne illnesses (illnesses that result from ingesting contaminated foods) for patients and staff who received food from the kitchen. Findings: 1. Review of All Facilities Letter (AFL - a letter from the California Department of Public Health to health care facilities) 18-39, dated 9/17/18, indicated “Subject: Reducing Legionella Risks in Health Care Facility Water Systems.” The AFL indicated it served as notification of a requirement by facilities to reduce the risk of Legionella in facility water systems. The AFL indicated facilities “must develop and adhere to Policies and Procedures (P&Ps) that inhibit microbial (microorganisms, especially disease-causing bacteria) growth” and the spread of Legionella and other “opportunistic pathogens” (can cause infection when a patient’s immune system is compromised) in building water systems, for example: a. “Pseudomonas (bacteria found in soil and water), b. Acinetobacter (a drug-resistant “superbug” found in soil and water, potentially fatal), c. Burkholderia (bacteria found in soil and water), d. Stenotrophomonas (multi-drug resistant bacteria found in water and hospital equipment like inhalers and mechanical ventilators), e. nontuberculous mycobacteria (an atypical bacteria found in soil, water, and dust worldwide), and f. fungi (organisms such as yeast and molds).” Review of facility P&P titled,”Infection Prevention and Control Plan (IPCP),” dated 11/2024, indicated the goal of the plan was to reduce the risk of acquiring and transmitting healthcare-associated infections (HAIs) and to investigate and manage communicable disease outbreaks in the community. Duties of the Infection Control Committee included reviewing surveillance data monitoring for trends in infections, clusters (a group of infections linked by time, location, or shared characteristic), infections due to unusual pathogens, and/or any occurrences of HAIs. Review of facility P&P titled,”Water Management Plan (WMP),” dated 7/2025, indicated it was facility policy to adhere to a WMP that took steps to minimize growth and spread of “Legionella and other waterborne pathogens” in building water systems that may be harmful to patients and staff. Testing protocols were not addressed. During a concurrent interview with the facility’s Infection Preventionist (IP) Nurse and record review on 7/8/25 at 2:45 pm, IP indicated she had been in the IP position since 2019. When asked about Legionella testing of the facility’s water supply, the IP stated the facility did not check for Legionella. During an interview with Engineering Supervisor (ES) on 7/9/25 at 8:08 am, the ES stated the facility used to test for Legionella but now used water analysis results from testing performed by the City. The ES stated the facility used the city’s water supply and did not use an independent water source or well. During an interview with the IP on 7/9/25 at 8:59 am, the IP stated the facility developed their WMP with advice from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE - an international society that develops and publishes standards and guidelines for building systems, indoor air quality, and WMPs) and using the Centers for Disease Control (CDC) “toolkit.” Review of the CDC’s “Developing a WMP to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards,” dated 6/24/21, indicated environmental testing for Legionella is “useful to validate the effectiveness of control measures.” The toolkit indicated factors that might make testing for Legionella more important included “being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires’ disease (see Appendix B).” Appendix B indicated: a. The most likely sources of infection include water used for showering (potable or drinkable water), cooling towers/parts of large air conditioning systems, decorative fountains, and hot tubs. b. Risk factors for developing Legionnaires’ disease included age greater than 50 years old, current or past history of smoking, chronic lung disease, immune system disorders, systemic malignancy (cancer), and underlying illnesses such as diabetes and kidney/liver failure. During a telephone interview with the Chief Operator (CO) of the City on 7/9/25 at 9:34 am, CO stated the City tests their water at the distribution sources for the presence or absence of “all coliform” (bacteria present in the digestive tracts of humans and animals and found in their waste). CO stated the City was not required to test water sources at the facility and did not test there; however, CO stated they could test at the facility if asked, and they would coordinate with a laboratory to collect samples, transport, and analyze them. CO stated the City also did not test for Legionella, Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, or fungi. CO stated if total coliform was absent from the water analysis report, they “reasonably assume the others aren’t present.” During an interview with Registered Nurse (RN) B on 7/9/25 at 11 am, RN B stated she runs the water in the pipes and flushes the toilet before settling a new patient in a room that has not been used for a while. RN B stated, “I know the pipes are old. Who knows what’s in there?” RN B stated she runs the water per facility policy, “for about 5 minutes,” looking at the color, smell, and water temperature. RN B stated she would call Housekeeping or Maintenance if something was amiss. During an interview with the IP on 7/10/25 at 10:35 am, the IP acknowledged the City water analysis results for 2023 (the latest report received) did not show evidence of testing for Legionella, so the facility was not in compliance with the California Department of Public Health recommendations. 2. Review of facility P&P titled,”Infection Prevention and Control Plan (IPCP),” dated 11/2024, indicated the Employee Health Program included screening for “annual TB testing and/or questionnaires (with chest x-rays when indicated) for all employees working in the skilled nursing facility, every three years for all other staff.” During an interview with the IP on 7/8/25 at 2:45 pm, IP stated it was the facility’s policy, approved in committee, to test hospital employees for TB every three years and skilled nursing facility employees every year. Review of Respiratory Therapist (RT) A’s employee health records titled,”New Hire Questionnaire,” dated 12/6/21, indicated RT A had a negative TB test in 2/2021. Review of attached laboratory results, dated 2/5/2021, indicated RT A had a negative Quantiferon TB Gold Plus (TB blood test) that was negative indicating “Mycobacterium (M.) tuberculosis complex infection unlikely.” Further review of RT A’s employee health files did not indicate TB testing or questionnaire after 2/2021. During an interview with the IP on 7/10/25 at 11:59 am, IP stated she could not find proof of RT A’s most recent TB test. IP stated she believed she received it but could not locate it and would present it when she found it. Proof of RT A receiving a TB test after 2021 was not provided before the end of survey. 42448 3. A review of the 2022 FDA (Food and Drug Administration) Food Code indicated: “Non-food-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance” (FDA Food Code 2022, §4-202.16). “Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris” (FDA Food Code 2022, §4-601.11). “Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues” (FDA Food Code 2022, §4-602.13). “The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code 2022 Annex 3, §4-602.13). Review of a policy titled, “Employee Sanitary Practices,” showed “Equipment and work areas should be cleaned and sanitized after use ...Follow all federal, state and local requirements.” 3a. Multiple kitchen food preparation areas and equipment were not clean to sight and/or touch. * Unaddressed Engineering/Maintenance areas in the kitchen were a sanitation problem: During the initial tour in the kitchen on 7/7/25 from 11:40 am to 1:00 pm, multiple areas requiring the services of the facility engineering/maintenance department were unsanitary or in disrepair including ceiling vents, mold growth above backsplashes of handwashing sink and dish machine area, worn/peeling paint, holes and cracks in walls, dust accumulation on walk-in refrigerator fire sprinkler, condenser fan cover and surrounding ceiling/walls, and pests (flies) in the kitchen daily. These deficiencies had the potential to cross contaminate food (Cross Reference C-0914). During an interview with the Engineering/Maintenance Supervisor (ES) on 7/9/25 at 8:10 am, he agreed the areas cited above were his department’s responsibility. He stated his department did not perform regular inspections of FANS to ensure it was well-maintained, but they were often in the kitchen. He did not have a checklist for preventive maintenance of FANS, and the facility did not have a policy/procedure regarding Engineering’s responsibilities at the facility or in the FANS department. They did not have a policy/procedure regarding their work order system, how it was prioritized, or how long it should take for work orders to be addressed. *Unsanitary food storage areas. During the initial tour on 7/7/25 from 11:40 am to 1:00 pm, food storage areas including gray utensil bins in the cold prep area, black storage bins in the sandwich prep area, blue storage bins in the reach in freezer and freezer shelves, black condiment bins near tray line, and the disposable service-ware storage cabinet in the cook’s island had debris and were not clean. * Some equipment was not clean or had porous, uncleanable wood surfaces. Damaged equipment was not removed from service. Review of the FDA Food Code 2022, Annex 3, §4-401.11 showed “Multiuse equipment is subject to deterioriation because of its nature, i.e., intended use over an extended period of time ...Inability to effectively wash, rinse, and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food.” Review of the FDA Food Code 2022 §4-501.12 showed “Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. Annex 3, 4-501.12 explained “Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.” During the initial tour on 7/7/25 from 11:40 am to 1:00 pm, multiple pieces of equipment were not clean: Six out of six condiment bins were soiled and contained food debris. In a concurrent interview, the FSS agreed they were not clean. Two out of two bake pans on the counter in the dish room had burnt on grime. The wood cutting board surface in front of the steam tables on tray line was scored, worn, and uncleanable. The wood handles of cooking utensils (1 carving fork also missing handle bolt, one masher, three strainers, two pancake turners, two whips) were worn and uncleanable. One wooden spoon was severely degraded and uncleanable. Four out of five rubber spatulas had chunks of rubber missing out of their edges - a potential food contaminant. The knife rack and four out of nine knives in the knife rack in the cook’s area were not clean. In a concurrent interview with FSW 3, he agreed they were not clean and took them to the dish room to be cleaned. Nine out of nine blue plastic bins in the reach-in freezer, containing mostly meat, were unclean and with assorted debris in the bottom. One bin was cracked and uncleanable. Four out of fourteen rubber cutting boards were worn or had deep scoring/cuts. The can opener had a buildup of black grime around the mount and around the blue rectangular area where the shaft of the can-opener slid up and down. During an observation of the cold food prep area on 7/7/25 at 12:10 pm, seven out of seven skillets had burned on grease. The counter-top mixer and wall behind it were spattered with food. The knife rack behind the mixer was also spattered, with one out of five knives and one out of one metal spatula soiled. In a concurrent interview, the Food Service Manager (FSM) agreed the knife rack, knives, spatula, mixer, and wall were not clean. Review of a policy titled, Cleaning and Sanitation of Dining and Food Service Areas showed the Food and Nutrition Services (FANS) staff were to maintain cleanliness and sanitation of food and dining areas through compliance with a written, comprehensive cleaning schedule; staff would be trained on frequency of cleaning and would be held accountable for completion of their cleaning assignments. Review of six documents titled, Daily/Weekly Cleaning Schedule and Checklist, dated 5/26/25 through 7/6/25 showed task completion by Cooks. Diet Aide assignments were either not completed, not signed off, or were documented on a separate checklist not provided. The cook’s checklists contained “cleaning and sanitizing” tasks including but not limited to the can opener, knife rack and knives, tray line, all food prep surfaces. The checklists did not include cleaning the mixer, utensil bins, freezer bins. Cooks were assigned 14 tasks daily (98 tasks/week). Sixty-one out of 588 (90%) daily cleaning tasks were signed off as completed. Most non-completions were indicated by blanks or X’s and no initials on cleaning the range and grill. There were also 14 weekly cleaning tasks aligned next to the cook’s assignments but not clearly assigned. One out of 84 (1%) of weekly cleaning tasks were signed off as completed. During an interview with the Food Service Director/RD (FSD/RD) on 7/9/25 at 9:05 am, she stated her role in FANS was to oversee acute care and skilled nursing facility food services and clinical nutrition. She stated she did not inspect the kitchen, but the FSM inspected it periodically. She stated she did not review any inspections reports. She stated the department had no Quality Assurance/Performance Improvement activities in place because they didn’t have any problems to correct. Review of one document provided by the FSM was dated 1/9 (no year). It showed no issues in the kitchen except the mixer had cake dust in it, and the walls behind work tables were not clean. The FSM stated it was the only inspection performed in the past year. *3b. Staff did not use professional standards of practice or follow chemical manufacturers’ instructions to clean food contact surfaces. Review of a policy titled General Sanitation of Kitchen, dated 2021 showed cleaning tasks would be assigned to specific positions using a cleaning schedule, including frequency of cleaning, and methods/cleaning compounds to be used. Employees would be trained in how to perform the cleaning tasks. Review of the 2022 FDA Food Code §4-603.15, §4-603.16, §4-701.10, and §4-701.11 showed fixed equipment (equipment that cannot go through the dish washer or 3-compartment sink such as counters, cabinets, carts, small appliances, etc) shall be disassembled and washed with a detergent solution, receive a distinct rinse with potable water to remove abrasives and cleaning chemicals, and then shall be sanitized. Review of a policy titled Cleaning Instructions: Cabinets and Drawers, Dated 2021, directed this process for cleaning: Remove contents, clean with clean cloth soaked in mild detergent and water, rinse, sanitize, and air dry. No other facility policies and procedures were provided that would show staff the cleaning process for fixed equipment they should follow as required by the 2022 FDA Food Code §4-603.15, §4-603.16, §4-701.10, and §4-701.11. Review of the instructions for the kitchen’s Sani-T-Plus food contact surface sanitizer showed “Food Contact Surface Sanitizing Directions: Prior to application, remove gross food particles ...thoroughly wash or flush objects with a good detergent or compatible cleaner followed by a potable water rinse before applications of the sanitizing solution. During an interview with FSW 3 on 7/8/25 at 10:25 am, he stated that at the end of each they clean all food preparation surfaces, appliances, the cook’s island, backsplashes, oven doors, etc. They refer to their cleaning checklists. In continued interview, FSW3 stated the process used to clean fixed equipment (counters, carts, small appliances, etc) was: They removed any crumbs, and moved everything as they cleaned underneath it. They changed their sanitizer buckets out every two hours or if the color of their special Sani-T-Plus cleaning cloths changed color from yellow to blue. The sanitizer was supposed to stay wet on equipment surfaces for 30 seconds. When asked if they ever washed any of the fixed equipment with soap, FSW 3 replied yes, but couldn’t think of any equipment it was ever used on. During an interview in the kitchen with FSW 6 on 7/8/25 at 3:20 pm - Kitchen she was asked about cleaning done in the kitchen. She replied they cleaned behind themselves throughout the day, cleaned the carts when empty, polished equipment at end of day, cleaned the floors. She described this process to clean fixed equipment: clear debris, test ppm (parts per million concentration) in sanitizer bucket, wipe equipment down with sanitizer, leave wet for 30 seconds. She stated they never used soap to clean fixed equipment. They wiped down all surfaces with sanitizer. During an observation on 7/9/25 at 11:55 am, the sanitizer bucket near the dish room looked cloudy and soiled, and the cloth had turned blue. In a concurrent observation and interview, FSW 3 was asked to test the concentration of the sanitizer in the bucket. He tested it and the test strip read zero ppm - too low to be effective. He confirmed the acceptable range for sanitizer was 200-400 ppm. During an additional observation on 7/9/25 at 11:58 am, the sanitizer bucket in the cook’s area also looked cloudy and soiled. FSW 3 was asked to test it, and it showed 100 ppm. FSW changed out both sanitizer buckets. *3c Staff did not consistently perform professional standards of practice to prevent cross contamination of food, including covering facial hair, removal of jewelry, storage of aprons, and inadequate changing of gloves. * Hair Restraints and Jewelry Review of a policy titled Food Safety and Sanitation, dated 2021, showed “Hair restraints are required and should cover all hair on the head; Beard nets are required when facial hair is visible.” Review of a facility policy titled Employee Sanitary Practices, dated 2021, showed “All (food and nutrition services) employees will 1) Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food ... 4) Keep jewelry to a minimum. Only a plain band ring such as a wedding band and watch can be worn.” This policy concurs with the Food and Drug Administration (FDA) Food Code 2022, §2-303.11. During observations on 7/7/25 at 12:15 pm, and 7/8/25 at 10:25 am, the mustache, beard, and long sideburns Food Service Worker 1 (FSW 1) and FSW 3 were not covered. FSW 3 wore a face mask below his mouth and it did not fully cover his facial hair. In a concurrent interview, FSW 3 stated he wore the face mask to cover his beard. He explained the department had beard nets, but they were too big for his facial hair. During an observation in the kitchen on 7/8/25 at 11:40 am, the Food Service Supervisor (FSS) wore stone stud earrings, three large highly textured metal rings on her right hand, and an additional highly textured ring on her left hand. During a follow-up interview on 7/9/25 at 10:40 am, the FSS stated she was unaware her jewelry was a problem. * Aprons During the initial tour in the kitchen on 7/7/25 from 11:40 am to 1:00 pm, aprons hung from a hook next to handwashing sink, touching trash can, and with potential additional cross contamination from splash and paper towels. During an interview with the FSM on 7/7/25 at 12:35 pm, she agreed the location of the aprons created a potential for cross contamination with trash, the sink, splash from the sink, and contaminated paper towels. * Glove Use Review of a policy titled Bare Hand Contact with Food and Use of Plastic Gloves, dated 2021, showed “Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.” “Gloves are like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed.” During an observation in the cook’s area on 7/8/25 at 11:15 am, FSW 1 wore gloves as he touched a pencil, clipboard, pot lid, went to the dishroom, touched the oven door handles, removed food from ovens, began tray line (assembly process for patient meals), went to the dish room for a serving utensil, mashed cauliflower, and then continued to serve with tray line all while wearing the same gloves. During an observation of tray line on 7/8/25 at 11:25 am, FSW 5 wore gloves while getting ready for trayline. She touched the handle of the walk-in refrigerator, entered, then exited pushing food cart. She continued to wear the same gloves as she placed food on patient trays. She again entered/exited the walk-in refrigerator (same gloves), then went to the salad prep area and retrieved pudding cups from reach-in refrigerator (same gloves touching handles). FSW 5 then went to the department office and touched her shirt and bare elbow with her (same) gloved hands as she spoke with the supervisor. She returned to patient tray line carrying a patient meal card and holder, and used a pen to write on the meal card (same gloves). FSW 5 proceeded to make additional meal trays, touching trays, silverware and napkins (same gloves). She continued to wear the same gloves as she removed clean dishes from the dish machine and put the equipment away throughout the kitchen. During an interview with the Food Service Director/RD (FSD/RD) and FSM on 7/9/25 at 9:45 am they were asked about when staff should change their gloves. The FSM stated they should wash their hands before gloving, and when gloves are removed. Gloves should be changed when moving to a different task, or at least every 3-4 hours, or if gloves are torn or contaminated. * Other Cross Contamination During an observation in the cooks/tray line area on 7/8/25 at 11:40 am, FSW 1 wiped his food thermometer with an alcohol wipe, then put the thermometer probe up close to his mouth and blew on it. During continued observation, FSW 1 dropped his clipboard containing food safety logs on to the floor. FSW 5 wore gloves as she picked the clipboard up and put it back in place by tray line without washing the clipboard. FSW 5 did not change her gloves or wash her hands before returning to her tray line duties, placing food on trays, touching plate covers, and putting meals in the meal cart. *d. The facility’s kitchenette was not sanitary, was used to provide food to residents, did not receive any oversight by food services staff, and staff responsible for the kitchenette were not trained to clean it using food-safe chemicals or procedures. During an observation of the facility-wide ice machine in the SNF dining area, accompanied by the Engineering Supervisor (ES) and Food Service Manager (FSM), it was noted the SNF kitchenette and equipment were unsanitary: Drawers were unclean with soil and debris, soiled equipment and soiled pot holders. In a concurrent interview, the Activities Director (AD) stated she prepared food for resident’s activities there, and she was responsible for cleaning the kitchenette. She stated housekeeping cleaned the exterior surfaces if the ice machine, cabinets, counter, and floor. The FSM stated the FANS department had no involvement or oversight of the kitchenette. During an interview with the Food Service Supervisor (FSS) on 7/9/25 at 10:40 am, she stated the facility had no policy on cleaning the kitchenette. She provided a general policy on cleaning cabinets. She stated FANS did not clean or oversee the kitchenette, but they did wipe down the tables in the dining room with sanitizer between meals. During an observation of the kitchenette and concurrent interview with AD on 7/10/25 at 8:40 am, the AD was cleaning the interior of the kitchenette drawers and it’s equipment. She stated “I don’t have the (sanitizing) solution from (the FSM) yet.” During an interview with Housekeeper 1 (HSK1) in the nursing unit hallway on 7/9/25 - 10:55 am, she stated housekeeping’s responsibilities in the kitchenette were: they scrubbed the sink, took the trash out, cleaned the exterior counters, cabinets and ice machine using housekeeping’s Navigator 3x Renegade One-Step Disinfectant. Review of the Navigator 3x Renegade One-Step Disinfectant directions for use showed, “For visibly soiled areas, a preliminary cleaning is required. Rinse all surfaces that come into contact with food such as countertops, appliances, tables and stovetops with potable water before reuse. Do not use on utensils, glassware and dishes.” “Do not use in food preparation, food handling and food storage areas.” “This product is a sanitizer for hard, non-porous non-food contact surfaces at 1:256 dilution (1/2 oz. per gallon).” During an interview with HSK2 in the nursing unit hallway on 7/9/25 - 11:45 am, she stated, to clean the kitchenette, she first used a duster to dust the area, then used the 3x Renegade chemical and a microfiber cloth to wipe down every exterior surface she could reach. When asked about the wet time, she stated it usually took 1-2 minutes to dry. She stated she never rinsed it after application. She stated she did the exterior of the ice machine last, wrote it down on the log, then mopped and removed trash. Review of a facility document titled Cleaning and Sanitizing Ice Machines dated 2025 showed “EVS performs surface cleaning daily, including ice machine tray and spout using Environmental Protections Agency (EPA) approved hospital cleaner/disinfectant.” Housekeeping staff did not follow the Navigator 3x Renegade One-Step Disinfectant instructions for use on food contact surfaces in the kitchenette. During an observation and concurrent interview in the kitchenette on 7/10/25 at 8:40 am, with the Director of Plant Operations/Engineering/Maintenance (POD) regarding the facility-wide ice machine, he opened the lower cabinet next to the ice machine to show the ice machine plumbing and filters. The cabinet also contained a bag of condiments and multiple sleeves of disposable cups. The POD stated nothing should be stored in a cabinet with plumbing, especially food supplies, and he had previously placed signs there to say that. *e. There was not an effective pest control system in place when flies were present daily in the kitchen during the survey. The habits of flies favor the spread of bacteria and other disease-causing organisms. Flies often feed and lay eggs on garbage and manure before contaminating human foods and food preparation surfaces by landing on them. When feeding, house flies regurgitate their stomach contents onto food to liquefy it before ingesting it. They also may contaminate food and surfaces by defecating on them. All flies are attracted to moist organic material upon which they lay their eggs. (Illinois Department of Public Health https://dph.illinois.gov/topics-services/environmental-health-protection/structural-pest-control/house-flies-other-filth-flies.html) Review of the facility policy and procedure titled, “Pest Control,” dated 2021, showed “Routine pest control procedures will be in place ...appropriate action will be taken to eliminate any reported pest situation in the department.” Flies were observed in the kitchen: 7/7/25 at 12:10 pm in the Cold Food Prep area, fly buzzing around 7/7/25 at 12:35 pm, fly buzzing around, settled on box of food preparation gloves mounted on the dish room wall. 7/9/25 at 3:50 pm, fly buzzing around, landed on potholders in cook’s area. During an interview with the Engineering/Maintenance Supervisor (ES) on 7/9/25 at 8:10 am, he was asked about the flies in the kitchen. He stated their pest control service came quarterly, but they only treated the outside of the facility. He suspected the flies probably came in when the back door was left open during deliveries. Review of a report from the pest control vendor dated 7/18/25 showed the exterior of the facility was inspected. “No new contributing conditions. Inspected and previous conditions still exist.” There was no further explanation about “previous conditions,” nor mention of any intervention for flies.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures. This Standard is not met as evidenced by: 42448 Based on observation, interview and record review, the facility failed to provide adequate training, competency and monitoring to Food and Nutrition Services (FANS) staff to ensure infection prevention and control in the FANS department when: 1. Staff did not use professional standards of practice or follow chemical manufacturers’ instructions to clean food contact surfaces. 2. Staff did not consistently wash hands and change gloves when gloves became contaminated. 3. Staff did not follow dress code regarding covering of facial hair or wearing jewelry. 4. Activities and housekeeping staff did not clean the facility’s kitchenette using food-safe standards of practice, and did not follow their chemical manufacturer’s instructions for cleaning and sanitizing food-contact surfaces. These failures had the potential to result in food-borne illness or inadequate nutrition for patients, residents and staff consuming food from the facility. Findings: Review of a policy titled, “Employee Sanitary Practices,” showed “10. Equipment and work areas should be cleaned and sanitized after use ...Follow all federal, state and local requirements.” Review of a policy titled, “General Sanitation of Kitchen,” dated 2021 showed cleaning tasks would be assigned to specific positions using a cleaning schedule, including frequency of cleaning, and methods/cleaning compounds to be used. Employees would be trained in how to perform the cleaning tasks. During the initial tour on 7/7/25 from 11:40 am to 1:00 pm, multiple pieces of equipment were visibly not clean including but not limited to the can opener mount, condiment bins, pots and pans, bake pans, utensil storage drawers, black storage bins in salad prep area, two out of two knife racks, four out of nine knives, and blue plastic bins in the reach-in freezer, the side of the cooks’ island near the trash can, and the interior of cabinets (Cross Reference C-1208). Review of six documents titled, “Daily/Weekly Cleaning Schedule and Checklist,” dated 5/26/25 through 7/6/25 showed 90% of assigned daily cleaning tasks and 1% of weekly cleaning tasks were completed by Cooks, including but not limited to the can opener, knife rack and knives, tray line, all food prep surfaces. The checklists did not include cleaning the mixer, utensil bins, condiment bins or freezer bins. (Cross Reference C-1208). During an interview with the Food Service Director/Registered Dietitian (FSD/RD) and the Food Service Manager (FSM) on 7/9/25 at 9:45 am, staff training and competency processes were described: new staff completed Relias training through Human Resources (HIPPA, fire safety, etc) and then onboarded with the department. New staff were teamed up with “seasoned staff” to train, but the FSM also worked with them. The FSM stated their department used a training checklist with verbal (topic discussed), verbalized (new hire described correctly), and demonstrated (hands-on performance) evaluations of progress, as well as annual competencies. She stated she also observed staff as they worked to determine any need for re-education. The FSM stated she tried to provide in-services every four months “but I’ve been lacking.” She stated she determined in-service topics by observing staff, food trends and regulation changes. She stated in-services included a staff sign-in sheet, lesson plan, and usually a quiz or verbal rounding for competency. During a follow-up interview on 7/10/25 at 9:53 am, the FSM stated she had no documentation of any in-services provided in the past year. Evidence of FANS staff training and competency completion was requested for Food Service Worker 1 (FSW1), FSW3, and FSW6. Training checklists were only provided for FSW2 but completed annual competency tests were provided for FSW1, FSW3, and FSW6. Review of three training documents for FSW2 were titled Employee Orientation Checklist, Equipment Competency, and Verification of Job Competency Demonstration - Cooks: The Employee Orientation Checklist showed FSW was hired 7/7/25 and completed the orientation on 7/9/25. The checklist contained 21 topics including dress code (hair coverings; jewelry, aprons); hand washing and glove use; cleaning schedule; cleaning and sanitizing solutions; use, cleaning and sanitizing of equipment; serving sizes, portioning, etc. The Equipment Competency for FSW2, showed it completed by FSW2 on 7/9/25, and was required for new employees and then annually by all staff. It listed 16 pieces of kitchen equipment including the ovens, grill, mixer, steamer, dish machine, etc. The Verification of Job Competency Demonstration - Cooks, showed it was completed by FSW2 on 7/8/25, and contained 31 topics including portion sizes, use of alternates per recipes and spreadsheets, apron use and storage, hair coverings use including facial hair, glove use in food preparation and service, sanitizing solution and how to clean and sanitize equipment/countertops. All topics were signed off as competency verified by FSW 3 (the seasoned employee providing training) on the second day after hire. During further interview with the FSD/RD and FSM on 7/9/25 at 9:45 am, the FSM stated all FANS employees completed an annual written competency test. Review of documents for FSW1, FSW3, and FSW6 titled, “Competency Test for Cooks and Dietary Staff,” showed it contained 39 fill in, true/false, or multiple-choice questions, with topics including but not limited to sanitizer concentration, handwashing, glove use (when to change them). It did not contain any questions about professional standards to wash, rinse, sanitize and air-dry fixed equipment (equipment that cannot go through the dishwasher or 3-compartment sink, such as counters, carts, and small appliances). There was no indication the documents were reviewed by the FSM or other leaders after completion for accuracy of responses to questions. Further review of the annual competency for FSW1, dated 4/25/24 showed question #10 regarding reheating temperature for leftover foods was not answered. *1. Staff did not use professional standards of practice or follow chemical manufacturers’ instructions to clean food contact surfaces. Review of the 2022 FDA Food Code §4-603.15, §4-603.16, §4-701.10, and §4-701.11 showed fixed equipment (equipment that cannot go through the dish washer or 3-compartment sink such as counters, cabinets, carts, small appliances, etc) shall be disassembled and washed with a detergent solution, receive a distinct rinse with potable water to remove abrasives and cleaning chemicals, and then shall be sanitized. Review of a policy titled, “Cleaning Instructions: Cabinets and Drawers,” dated 2021, directed staff to remove contents, clean with a mild detergent solution, rinse, sanitize, and air dry. No other facility policies and procedures were provided that showed the cleaning process staff should follow to clean fixed equipment as required by the 2022 FDA Food Code §4-603.15, §4-603.16, §4-701.10, and §4-701.11. Review of the instructions for the kitchen’s Sani-T-Plus food contact surface sanitizer showed “Food Contact Surface Sanitizing Directions: Prior to application, remove gross food particles ...thoroughly wash or flush objects with a good detergent or compatible cleaner followed by a potable water rinse before applications of the sanitizing solution. During interviews with FSW 3 on 7/8/25 at 10:25 am, and FSW 6 on 7/8/25 at 3:20 pm, the process used to clean fixed equipment was to remove any crumbs, ensure sanitizer was at correct concentration, wipe with sanitizer cloth and allow to stay wet on equipment surfaces for 30 seconds. When asked if they ever washed any of the fixed equipment with soap, FSW 3 replied yes, but couldn’t think of any equipment it was ever used on; FSW 6 stated they never used soap to clean fixed equipment. They just wiped down all surfaces with sanitizer (Cross Reference C-1208). Further review of the document titled Verification of Job Competency Demonstration - Cooks for FSW2, dated 7/8/25, showed that while she was deemed competent in the topic of cleaning and sanitizine equipment/countertops, her trainer and evaluator of competency was FSW3 who did not know the cleaning process required by the FDA Food Code (above). Further review of the document titled “Competency Test for Cooks and Dietary Staff,” completed by staff on 4/25/24, showed it did not contain any questions about the cleaning process required by the FDA Food Code (above), and two out of two seasoned staff did not know the process. 2. Staff did not consistently wash hands and change gloves when gloves became contaminated, creating potential for cross-contamination. Review of a policy titled Bare Hand Contact with Food and Use of Plastic Gloves, dated 2021, showed “Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.” “Gloves are like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed.” During an observation in the cook’s area on 7/8/25 at 11:15 am, FSW 1 wore gloves as he touched a pencil, clipboard and attached papers, pot lid, went to the dish room, touched the oven door handles, removed food from ovens, began tray line (assembly process for patient meals), went to the dish room again, mashed cauliflower, and then continued to serve with tray line all while wearing the same gloves. During an observation of tray line on 7/8/25 at 11:25 am, FSW 5 wore gloves while getting ready for tray line (meal tray assembly process). While wearing her gloves she touched multiple potentially contaminated items such as the handle of the walk-in refrigerator, food carts, reach-in refrigerator handles, her shirt, her bare elbow. She continued to wear the same gloves while as she placed food on patient trays, and to make additional meal trays, touching trays, silverware and napkins (same gloves). She continued to wear the same gloves as she removed clean dishes from the dish machine and put the equipment away throughout the kitchen before returning to complete her work on tray line, wearing the same gloves. During an interview with the Food Service Director/RD (FSD/RD) and FSM on 7/9/25 at 9:45 am they were asked about when staff should change their gloves. The FSM stated they should wash their hands before gloving, and when gloves are removed. Gloves should be changed when moving to a different task, or at least every 3-4 hours, or if gloves are torn or contaminated. During continued observation on 7/8/25 at 11:25 am, FSW 1 dropped his clipboard containing food safety logs on to the floor. FSW 5 wore gloves as she picked the clipboard up and put it back in place by tray line without washing the clipboard. FSW 5 did not change her gloves or wash her hands before returning to her tray line duties, placing food on trays, touching plate covers, and putting meals in the meal cart. During an interview with the FSM on 7/9/25 at 9:45 am, she stated hands should be washed before gloving, and also when gloves are removed. They should change gloves when changing tasks, or at least every 3-4 hours, or if gloves are torn or contaminated. Further review of the document titled Competency Test for Cooks and Dietary Staff, completed by staff 4/28/25 showed three questions related to glove use, including the need for handwashing before and after, requirement to wear when handling ready-to-eat foods, gloves are not a replacement for handwashing, and when gloves need to be changed and hands washed. Yet staff continued to not comply with this training. 3. Staff did not follow the dress code regarding covering facial hair or wearing jewelry, creating potential for cross-contamination. Review of a policy titled Food Safety and Sanitation, dated 2021, showed “Hair restraints are required and should cover all hair on the head; Beard nets are required when facial hair is visible.” Review of a facility policy titled, “Employee Sanitary Practices,” dated 2021, showed “All (food and nutrition services) employees will 1) Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food ... 4) Keep jewelry to a minimum. Only a plain band ring such as a wedding band and watch can be worn.” This policy concurs with the Food and Drug Administration (FDA) Food Code 2022, §2-303.11. During observations on 7/7/25 at 12:15 pm, and 7/8/25 at 10:25 am, the mustache, beard, and long sideburns FSW 1 and FSW 3 were not covered. FSW 3 wore a face mask below his mouth, and it did not fully cover his facial hair. In a concurrent interview, FSW 3 stated he wore the face mask to cover his beard. He explained the department had beard nets, but they were too big for his facial hair. During an observation in the kitchen on 7/8/25 at 11:40 am, the Food Service Supervisor (FSS) wore stone stud earrings, three large highly textured metal rings on her right hand, and an additional highly textured ring on her left hand. During a follow-up interview on 7/9/25 at 10:40 am, the FSS stated she was unaware her jewelry was a problem. 4. Activities and housekeeping staff did not clean the facility’s kitchenette using food-safe standards of practice, and did not follow their chemical manufacturer’s instructions for cleaning and sanitizing food-contact surfaces. During an observation of the facility-wide ice machine in the facility dining area, accompanied by the Engineering Supervisor (ES) and Food Service Manager (FSM), it was noted the facility kitchenette and equipment were unsanitary: Drawers and equipment were soiled and contained debris. In a concurrent interview, the Activities Director (AD) stated she prepared food for resident’s activities there, she was responsible for cleaning the kitchenette, and housekeeping cleaned the exterior surfaces if the ice machine, counter, cabinets and floor. The FSM stated the FANS department had no involvement or oversight of the kitchenette. During an interview with the Food Service Supervisor (FSS) on 7/9/25 at 10:40 am, she stated the facility had no policy on cleaning the kitchenette. She provided a general policy on cleaning cabinets. She stated FANS did not clean or oversee the kitchenette, but they did wipe down the tables in the dining room with sanitizer between meals. She did not describe a wash, rinse, sanitize, air dry process for cleaning tables where residents ate. During an observation of the kitchenette and concurrent interview with AD on 7/10/25 at 8:40 am, the AD was cleaning the interior of the kitchenette drawers and it’s equipment. She stated, “I don’t have the (sanitizing) solution from (the FSM) yet.” During an interview with Housekeeper 1 (HSK1) in the nursing unit hallway on 7/9/25 - 10:55 am, she stated housekeeping’s responsibilities in the kitchenette were: they scrubbed the sink, cleaned counters and the exterior of the cabinets and ice machine using housekeeping’s Navigator 3x Renegade One-Step Disinfectant. Review of the Navigator 3x Renegade One-Step Disinfectant directions for use showed “For visibly soiled areas, a preliminary cleaning is required. Rinse all surfaces that come into contact with food such as countertops, appliances, tables and stovetops with potable water before reuse. Do not use on utensils, glassware and dishes.” “Do not use in food preparation, food handling and food storage areas.” “This product is a sanitizer for hard, non-porous non-food contact surfaces at 1:256 dilution (1/2 oz. per gallon).” During an interview with HSK 2 in the nursing unit hallway on 7/9/25 - 11:45 am, she stated, to clean the kitchenette, she first used a duster to dust the area, then used the 3x Renegade chemical and a microfiber cloth to wipe down every exterior surface she could reach. When asked about the wet time, she stated it usually took 1-2 minutes to dry. She stated she never rinsed it after application. She stated she did the exterior of the ice machine last, wrote it down on the log, then mopped and removed trash. Review of a facility document titled Cleaning and Sanitizing Ice Machines dated 2025 showed “EVS performs surface cleaning daily, including ice machine tray and spout using Environmental Protections Agency (EPA) approved hospital cleaner/disinfectant.” Housekeeping staff did not follow the Navigator 3x Renegade One-Step Disinfectant instructions for use on food contact surfaces in the kitchenette. During an observation and concurrent interview in the kitchenette on 7/10/25 at 8:40 am, with the Director of Plant Operations/Engineering/Maintenance (POD) regarding the facility-wide ice machine, he opened the lower cabinet next to the ice machine to show the ice machine plumbing and filters. The cabinet also contained a bag of condiments and multiple sleeves of disposable cups. The POD stated nothing should be stored in a cabinet with plumbing, especially food supplies, and he had previously placed signs there to say that.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 13095 Based on interview and record review, the hospital failed to ensure and maintain an effective, ongoing, hospital-wide, data driven quality assurance (QA) program when: 1. The hospital did not establish a complete and comprehensive Quality Assurance Performance Improvement (QAPI) for the items/issues, which had been discussed in the hospital’s Patients and Therapeutics (P&T) Committee. This failure had the potential to prevent the hospital from having opportunities to improve the hospital’s Pharmacy Services. 2. The Food and Nutrition Services (FANS) Department did not participate in quality assurance activities that evaluated their contributions to patient care services and reported it up through the organization’s quality processes as evidenced by; *a. Multiple kitchen food preparation areas were not clean to sight and/or touch. *b. There was no system in place for regular inspection of food service areas by Dietary leadership or by the Engineering/Maintenance Department to identify and ensure the cleanliness, function, prevention and correction of food safety and sanitation issues in the kitchen and kitchenette. *c. There were no QAPI activities in process to ensure resolution of food safety, sanitation, staff training or patient care concerns in the FANS Department. These failures had the potential to result in patient satisfaction and patient safety issues, and decreased quality of care related to unidentified and unresolved food safety and sanitation practices and regulatory compliance issues. Findings: 1. Review of the hospital’s Medical Staff By-Laws and Rules and Regulations dated: 10/2020 and approved by the Hospital’s Board of Directors, read: “ ...These may include mechanisms to: (i) establish systems to identify potential problems in patient care, (ii) set priorities for action on problem correction; (iii) refer priority problems for assessment and corrective action to appropriate services or committees; (iv) monitor the results of quality assessment activities throughout the hospital; and (v) coordinate quality assurance activities ...”. Interview with the hospital’s Chief Nursing Officer (CNO) who was in-charge of the hospital’s QAPI on 7/8/2025 at 4:00 pm, revealed that no Pharmacy data (for the hospital’s contracted Pharmacy provider (Pipeline), who validated the hospital’s medication orders or for the hospital’s local Pharmacy Contractor), from 1/2024 to present had been used by the hospital’s QAPI. The hospital had not additionally summarized any of the hospital’s Pharmacy QAPI data, for the past year, so that the hospital could see any trends or patterns which might have existed, for the purpose of re-evaluating the hospital’s Pharmacy services in its entirety. As outlined in the hospital’s policy and procedure titled, “Quality Assessment and Performance Improvement Plan (QA/PI), dated: 6/2020, which read: “The effectiveness of the QA/PI program and this plan are measured and assessed annually ...”. Yet the hospital was unable to provide any evidence of an annual QAPI review which had been conducted, by the hospital. 42448 2. Review of a policy titled, “Quality Assessment and Performance Improvement Plan,” dated 6/2020, showed “Processes ...and performance improvement requires a planned, collaborative effort ...The governing board 3. Recognizes that performance improvement is a continuous, never-ending process.” “Management is responsible for ongoing performance improvement activities in their departments ...Managers are expected to do the following:...2. Develop process improvement initiatives for areas of responsibility.” “Performance Improvement projects are identified and prioritized through various mechanisms including: A. Frequent, ongoing rounds conducted throughout the facility; B. Comparison of aggregated data against benchmarks and other reported data; C. QA indicators developed within the departments; D. QI indicators identified during surveys.” Review of one document titled, “Dietary Quality Improvement Report 2024,” showed the FANS department participated in one QAPI project regarding documentation of Skilled Nursing Refrigerator temperatures twice daily by FANS staff in July through September 2024 when 97% compliance occurred. No further evidence of QAPI efforts was provided. *a. Multiple kitchen and kitchenette food preparation areas were not clean to sight and/or touch (Cross Reference C-1208 and C-0914). A review of the 2022 FDA (Food and Drug Administration) Food Code §4-601.11 showed: “Equipment food-contact surfaces and utensils shall be clean to sight and touch.” FDA Food Code 2022, §4-602.13 showed: “Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.” During the facility’s recertification survey that occurred from 7/7/25 at 11:15 am through 7/10/25 at 1:45 pm, the Food and Nutrition Services (FANS) department and the facility kitchenette were observed with unsanitary work areas and soiled or uncleanable equipment. In addition, the FANS kitchen lacked facility maintenance when ceiling vents were crusted with dust and grime, dish machine area and hand washing sink areas grew mold along the tops of backsplashes, walls were in disrepair with holes, large cracks and worn, peeling paint (Cross Reference C-1208 and C-0914). In addition, FANS staff, and housekeeping/activities staff did not clean food service areas according to professional standards of practice, or per their chemical manufacturers’ instructions (Cross Reference C-1208 and C-0914). *b. There was no system in place for regular inspection of food service areas by Dietary leadership or Engineering/Maintenance to identify and ensure the cleanliness, function, prevention and correction of food safety and sanitation issues in the kitchen, and there were no Quality Assurance/ Performance Improvement projects in place to ensure resolution of issues identified. During an interview with the Engineering/Maintenance Supervisor (ES) on 7/9/25 at 8:10 am, he agreed the areas cited above were his department’s responsibility. He stated his department did not perform regular inspections of FANS to ensure it was well-maintained, but they were often in the kitchen. He did not have a checklist for preventive maintenance of FANS, and the facility did not have a policy/procedure regarding Engineering’s responsibilities at the facility or in the FANS department. They did not have a policy/procedure regarding their work order system, how it was prioritized, or how long it should take for work orders to be addressed (Cross Reference C-0914). During an interview with the Food Service Director/ Registered Dietitian (FSD/RD) on 7/9/25 at 9:05 am, stated her role in the department was to oversee acute care and skilled nursing facility food services and clinical nutrition. She stated she did not inspect the kitchen, and while the FSM did some kitchen inspections, the FSD/RD did not review them. She stated the department didn’t have any QAPI activities in progress because they didn’t have any problems or processes to solve. During an observation of the kitchenette and a concurrent interview with the Food Service Manager (FSM) on 7/8/25 at 3:10 pm, the kitchenette and its equipment were not clean. The FSM stated the FANS department had no responsibility or oversight of the kitchenette. During a concurrent interview with the Activities Director (AD), she stated she was responsible for cleaning the kitchenette, but housekeeping staff were responsible for cleaning all exterior surfaces (cabinets, counter, ice machine exterior, trash, floors). Review of one document provided by the FSM was dated 1/9 (no year) showed no issues in the kitchen except the mixer had cake dust in it, and the walls behind worktables were not clean. The FSM stated it was the only inspection performed in the past year. It did not include inspection of the kitchenette.”