Glenn Medical Center

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 47442 Based on interview and record review, the facility failed to implement and update care plans for three of 10 sampled patients (Patient 1, Patient 2, and Patient 5). This failure had the potential for patient care needs and goals to go unmet, with potential and actual negative health outcomes. Findings: A review of a facility policy titled, “Patient Care Planning,” rev 11/16/23, indicated individualized plans of care are developed in order to meet patient care goals, including the implementation and maintenance of the medical treatment plan and keeping the patient comfortable and safe during the hospital stay. The care planning process includes patient assessment, goal setting, intervention, referrals to other health care professionals, evaluations of patient response to treatment, and revision of care and treatment in order to meet the patient’s needs. Patient needs are determined through the patient assessment process; the registered nurse will complete the initial patient assessment and determine the patient’s needs in relation to their diagnosis and treatment plan. Nursing staff document and review the nursing care plan daily and make changes as needed throughout the patient’s hospital stay. A review of a facility policy titled, “Suggested Wound care Algorithm Stage 1 Pressure Ulcer,” (according to the National Pressure Injury Advisory Panel, a pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence) undated, provided interventions of keeping the skin clean and dry, using a draw sheet to lift or turn patients, inspecting skin every 4 to 8 hours, repositioning the patient every hour while in a chair or every two hours while in bed, encouraging the patient to get out of bed, encouraging fluid or nutrition within physician orders, keeping the bed free of foreign material and wrinkles, positioning the head of bed as low as possible within physician orders, using skin barrier cream. Review of the facility’s policy and procedure, “Skin Integrity Management,” dated 8/23/23, indicated the purpose was to provide nursing staff guidelines for skin integrity management including maintenance and treatment of skin conditions. Specific interventions are made based on patient assessment, risk assessment, skin condition and identification of specific skin findings. The role of the nurse is to assess the patient for skin integrity risks and implement preventative measures. When the patients skin is compromised, the role of the nurse is to perform a complete wound assessment, photo document the wound, obtain initial orders and implement basic wound care. Notify the provider (physician or nurse practitioner) and communicate when the wound condition changes. The policy indicated licensed nurses may initiate and direct the implementations of nursing interventions to prevent skin injury or skin breakdown as part of routine patient care. Interventions may include but are not limited to routine positioning, pressure off-loading measures, float heels with pillows under calf, routine skin checks each shift, and foam protective dressings to areas at risk for skin injury (pressure points). Review of the facility’s policy and procedure, “Patient Care Planning,” dated 11/16/23, indicated an individualized plan of care for each patient is developed by the registered nurse to meet the following goals: implement and maintain the medical treatment, keep the patient safe and comfortable, complete education and have discharge plan. The care planning process includes patient assessment, goal setting, intervention, evaluation of patient response to treatment and revision of care and treatment to meet the patient’s needs. Nursing staff documents and reviews the nursing car plan daily and makes changes as needed per the patient’s needs. 1. Review of Patient 1’s record, “History and Physical,” dated 2/27/2025, Family Nurse Practitioner (FNP) A indicated Patient 1 was admitted to the facility on 2/27/25 with diagnoses that included severe dementia, high blood pressure and urinary retention (unable to urinate) requiring a Foley catheter (tube placed into the bladder to drain the urine). Patient 1 was confused. Patient 1 had warm dry intact skin with no rashes or lesions. Review of Patient 1’s nursing record, “Patient Progress Notes,” dated 3/28/2025 at 1:21 am, Registered Nurse (RN) G indicated Patient 1 had intact skin. Review of Patient 1’s care plan record, “Problem Activity,” dated 2/28/2025, indicated Patient 1 was at risk for impaired skin integrity (skin breakdown). The intervention was to monitor the skin and encourage a good diet. The goal of the interventions was to prevent any skin breakdown. Review of Patient 1’s record, “Patient Progress Note,” dated 3/10/25 at 10:24 am, Wound Care Nurse (WCN) indicated Patient 1 had red, blanchable skin (skin temporarily turns white when you press on it and returns to normal skin color when pressure is released; normal circulation) to the sacral area (tail bone area). Review of Patient 1’s care plan record, “Problem Activity,” dated 3/10/2025, indicated there was no nursing diagnosis or interventions added to the care plan to prevent further damage to the skin on Patient 1’s sacral area when the skin was red. Review of Patient 1’s nursing record, “Patient Progress Notes,” dated 3/14/25 at 1:43 am, RN F indicated Patient 1’s sacral area had an open blister. Review of Patient 1’s record, “Order Chronology,” dated 3/14/2025, indicated Patient 1 had no new orders to treat the open blister on the sacral area. Review of Patient 1’s care plan record, “Problem Activity,” dated 3/14/2025, indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1’s sacral area. Review of Patient 1’s record, “Order Chronology,” dated 3/17-3/22/2025 and 3/24/2025 indicated Patient 1 had no new orders to treat the open blister on the sacral area. Review of Patient 1’s care plan record, “Problem Activity,” dated 3/17-3/22/2025 and 3/24/2025 indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1’s sacral area. Review of Patient 1’s record, “Wound Care Note,” dated 3/25/2025 at 9:22 am, WCN indicated Patient 1 had an unstageable deep tissue injury (also refers as unstageable pressure injury to a wound where the full extent of tissue damage is obscured by slough or eschar preventing staging) on the sacral area. Review of Patient 1’s record, “Wound Care,” dated 3/25/2025 at 5:29 pm, Medical Doctor (MD) A (wound care doctor) indicated Patient 1 had an unstageable deep tissue injury on the sacral area and small wound to the perianal area. MD A indicated the cause of the sacral wound was pressure. MD A recommended to keep pressure of the sacral wound, dietary consult, low air loss mattress, reposition per facility protocol, physical therapy consult for offloading (prevent pressure), vitamin C 500 mg by mouth twice daily, zinc sulfate 220 mg by mouth once daily for 14 days. Review of Patient 1’s care plan record, “Problem Activity,” dated 3/25/2025 indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1’s sacral area as mentioned above from the ordering physician MD A. Review of Patient 1’s record, “Wound Care Note,” dated 3/28/2025 at 3:00 pm, WCN indicated Patient 1’s sacral wound had increased in size and redness. WCN indicated Patient 1 had been up in wheelchair for most of the day yesterday. Wound measurements were; length 6.0 cm; width 6.5 cm; depth not measurable. WCN recommended when up in a wheel chair or Geri chair (medical reclining chair designed to provide comfortable and supportive seating for individuals with limit mobility that can recline and has a tray table). Review of Patient 1’s nursing records, “Patient Progress Notes,” dated 2/27/2025-3/28/2025 indicated Patient 1 was confused and tried to climb out of bed on different occasions. Patient 1 would be placed in a Geri chair at the nurse’s station frequently for safety. During an interview on 6/19/2025 at 1:30 pm with Certified Nursing Assistant (CNA), CNA stated Patient 1 would sit up in the Geri chair during the day by the nurse’s station. CNA stated the Geri chair would recline and Patient 1 would sleep in the chair at times while in the nurses’ station. During an interviw on 6/19/2025 at 10:45 am with RN H, stated the nurse was expected to review the care plans everyday and added interventions depending on the pateint’s needs and assessment. RN H stated if a patient had a new wound the nurse should informed the wound care nurse, documented what the wound looked like in the chart and updated the care plan with a nursing diagnosis and interventions. RN H stated the wound care nurse would be verbally informed or texted when a patient needed a wound conult and then the wound care nurse would place the order in the computer. RN H stated if the wound care nurse was not available she would enter the wound consult order in the computer, measured and photographed the wound. RN H stated the facility process that if a patient had a blister on the sacral area, nursing staff should have ordered a wound consult, documented in the chart and updated the care plan with a nursing diagnosis and interventions. During a phone interview on 6/20/2025 at 3:25 pm with MD A, MD A stated the most important interventions the nursing staff should implement to prevent skin breakdown would be to monitor the skin frequently, reduce pressure and reduce sheering. MD A stated each facility had there own policies and the nursing staff should follow them to prevent skin breakdown. MD A stated his role that he had to do assessment of the patients at the facility every 1-2 weeks and as needed. MD A stated the facility had their own policies indicating how frequently the wound care nurse should follow up with the patients and the wound care nurse should follow the facility policy. Review of Patient 1’s nursing record, “Patient Progress Notes,” dated 2/27-3/28/2025, indicated there was no documentation by the nursing staff that Patient 1 had a cushion/pillow to reduce pressure to his sacral area while up in the Geri chair or was repositioned/stood up every 1 hour while in the Geri chair. This was according to their facility policy and procedure to implement. During an interview on 6/19/2025 at 1:30 pm with WCN, stated she would make rounds on a patient every one to two weeks and as needed depending on the severity of the wound. WCN stated she assessed Patient 1’s wound on 3/10/2025 and did not reassess Patient 1’s wound again until 3/25/2025. WCN agreed she should have reassessed Patient 1’s wound before 3/25/2025. WCN stated she was not informed by the bedside nurse there was a change in Patient 1’s sacral wound until 3/25/2025. WCN confirmed the nursing staff did not implement preventive interventions to prevent skin breakdown in the care plan on admission or updated the care plan when nursing staff identified skin breakdown to Patient 1’s sacral area. WCN confirmed that their facilty’s policy to update and implement care plans were not followed. During an interview on 6/19/2025 at 1:45 pm with Director of Nursing (DON), stated Patient 1 liked to be up in the Geri chair by the nurse’s station. DON confirmed the nursing staff did not implement preventative interventions to prevent skin breakdown on admission or after new pressure injuries were identified. DON confirmed the nursing staff did not make a nursing diagnosis with interventions related to Patient 1’s pressure injuries and did not follow the facility’s presure injury and care plan polices. 2. Review of Patient 2’s record, “History and Physical,” dated 2/26/2025, indicated Patient 2 was admitted to the facility with deconditioning, chronic pain, high blood pressure and diabetes. Patient 2 had no pressure injuries to her skin. Review of Patient 2’s nursing record, “Progress Note,” dated 2/26/2025, indicated Patient 2 had clean dry intact skin. A concurrent interview and record review on 6/26/2025 at 2:30 pm with DON, nursing “Progress Notes,” dated 3/3-3/25/2025 were reviewed. The nursing “Progress Notes,” indicated Patient 2 had redness to her sacral area and was at risk for skin breakdown. DON confirmed the nursing staff were charting redness to Patient 2’s sacral area and was at risk for skin breakdown. Review of Patient 2’s record, “Wound Care,” MD A indicated Patient 1 had a stage 2 pressure injury (damage to the skin and underlying tissue typically caused by prolonged pressure of friction) of the left buttocks. A concurrent interview and record review on 6/26/2025 at 2:30 pm with DON, Patient 2’s nursing care plans dated 3/3-3/25/2025 were reviewed. The nursing care plans indicated nursing staff did not update Patient 2’s nursing care plans with interventions suggested on the facility policy to prevent further skin breakdown. DON confirmed the care plans were not updated per facility policies. DON confirmed the nursing staff were expected to update the care plans as indicated in the facility policies. 41567 3. A record review of Patient 5’s record indicated she was admitted on 1/3/25 at 5:05 pm with diagnoses that included deconditioning (decline in physical function and strength resulting from a period of inactivity or reduced physical activity), dementia (a general term for a progressive decline in thinking, behavioral and social skills that affects a person’s ability to function), coronary artery disease (reduced blood flow to the heart muscle due to build-up of plaque in the arteries of the heart), atrial fibrillation (disorder of the heart that effects its ability to pump normally), and for rehabilitation following femoral neck fracture, closed reduction with percutaneous pinning (surgery to repair her right hip). A review of Patient 5’s care plans dated 1/3/25 6:31 pm, by RN B, indicated that a care plan was initiated for the potential impairment of skin integrity. A review of Patient 5’s care plans dated 1/3/25 10:26 pm, indicated RN B updated the care plan for the potential impairment of skin integrity with two interventions: monitoring for skin breakdown, and keeping the (surgical site) dressing clean and intact. A review of Patient 5’s record found no entries by either day or night shift nurses on 1/4/25 addressing Patient 5’s care plans. A review of Patient 5’s progress notes dated 1/5/25 at 9 am, indicated RN D documented redness to the sacral area. (a generalized term for area on the buttocks between the hip bones and above the coccyx, or tailbone) A review of Patient 5’s care plans dated 1/5/25 11:19 am, indicated RN D did not update the care plan for potential impairment of skin integrity and no interventions were documented. A review of Patient 5’s care plans dated 1/5/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity and no interventions were documented. A review of Patient 5’s record found no entry by day shift nurses on 1/6/25 addressing Patient 5’s care plans. A review of Patient 5’s orders dated 1/6/25 2:52 pm, indicated FNP B ordered in low air loss mattress, heel protectors and knee pillow when turning, turning every two hours, and zinc oxide ointment 40% one topical application twice a day. A review of Patient 5’s care plans dated 1/6/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity to reflect Patient 5’s pressure injury nor reflect the orders created 1/6/25 at 2:52 pm, and no interventions were documented. A review of Patient 5’s record found no entry by day shift nurses on 1/7/25 addressing Patient 5’s care plans. A review of Patient 5’s care plans dated 1/7/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity and no interventions were documented. A review of Patient 5’s wound care note dated 1/6/25 2:53 pm, indicated WCN A performed an initial assessment of Patient 5’s right hip surgical incision, and buttock. WCN A documented this as a stage 1 pressure injury (stage 1 indicates the injury is in initial stages of progression, with intact skin surface). WCN A documented Patient 5 was to be placed on a low air loss mattress (a medical grade mattress designed to prevent/treat pressure injuries). A review of Patient 5’s medical progress note by Medical Doctor (MD) A, dated 1/7/25, indicated Patient 5 had a stage 1 pressure injury to the buttock, duration of one day, measuring 0.5 centimeters (cm, a unit of measure) in length and width, and ordered treatment with zinc oxide (a topical ointment) twice daily. During a concurrent interview and record review, on 6/26/25 at 3 pm, the DON reviewed Patient 5’s care plans from 1/3/25 to 1/12/25. DON stated that, after developing the initial care plan, the nursing staff needed to improve documentation as interventions and changes that affect care were not addressed “like they should be.” During a follow-up concurrent interview and record review on care planning on 7/1/25 at 11:45 am, the DON stated that the expectation was for nurses to write their interventions.”

“EXERCISE OF RIGHTS CFR(s): The patient or their representative (as allowed under state law) has the right to make informed decisions regarding their care. The patient’s rights include being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47442 Based on interview and record review, the facility failed to ensure that psychotherapeutic medications (drugs that affect the brain and nervous system to treat mental health disorders) were not administered without first obtaining informed consent from the patients and/or their representatives for two of 10 sampled patients. (Patient 1 and Patient 8) This deficient practice prevented Patients 1 and 8 and/or their representatives from understanding the potential risks, benefits, and alternatives to the psychotherapeutic medications given and violated their right to make informed decisions about their treatment and care. Findings: A review of facility Policy and Procedure (P&P) titled, “Psychotherapeutic Medication: Use and Consent,” dated 4/5/19, indicated facility staff were directed to verify documentation of informed consent was present in the patient’s health record “before initiating the administration of psychotherapeutic drugs.” The P&P indicated documentation of informed consent was reflected by a signed ‘Consent to Receive Psychotherapeutic Medications’ form. A review of “Patient Rights,” dated 1/2022, (provided to patients in their admission packet) indicated, “You have the right to:” 5. “Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment.” A review of “Consent to Receive Psychotropic (affecting the brain and nervous system) Medications,” dated 11/1/22, indicated a voluntary patient was not to be treated with antipsychotic medications (used to treat psychotic disorders and stabilize mood) until “such person has been informed of his or her right to accept or refuse such medications and has consented to the administration of such medications.” Signing the consent indicated the patient (or authorized signer) acknowledged having had an opportunity to read and ask questions about the medication, their questions had been answered to their satisfaction, and they gave consent to the use of the medication as prescribed. The consent form indicated the patient must be provided the following with “sufficient information by the provider” prescribing the medication: 1. The nature of the patient’s mental condition, 2. The reason for taking the medication, including the likelihood of improvement or not, and that consent may be withdrawn at any time, 3. Reasonable alternative treatments available, 4. The type of medication (antidepressant, antianxiety, antipsychotic, or stimulant) prescribed, how often (daily, twice daily) and how long (weeks, months) it would be given, the amount, the method (pill or injected into a vein), and 5. Probable commonly known side effects and any side effects likely to occur with the particular patient. The document also contained signature lines for licensed nurse “Witness” and “House Supervisor Review.” 1. Review of Patient 1’s record, “History and Physical,” dated 2/27/25, indicated Patient 1 was admitted to the facility on 2/27/25 with diagnoses that included severe dementia (confusion), high blood pressure and urinary retention (unable to urinate) requiring a Foley catheter (tube placed into the bladder to drain the urine). Review of Patient 1’s record, “Order Chronology,” dated 2/28/25 at 9:25 am, indicated the Family Nurse Practitioner (FNP) A ordered Haldol (psychotropic medication used to treat various mental health conditions) 5 milligrams (mg) by mouth daily for Patient 1. Review of Patient 1’s record, “Medication Record,” indicated Patient 1 was given Haldol 5 mg by mouth on 2/28/25 at 9:33 am and 3/1/25 at 11:36 am. During an interview on 6/17/25 at 2:35 pm with Family Member (FM) 1, FM 1 indicated Patient 1’s wife was Patient 1’s responsible party and had legal responsibility to make medical decisions for Patient 1’s health care decisions. FM 1 stated Patient 1 was started on Haldol the first night at the facility. FM 1 stated Patient 1’s responsible party was not notified and did not want Patient 1 started on Haldol. Review of Patient 1’s records, “Progress Notes,” dated 2/28/25, indicated there was no documentation made by FNP A indicating why Patient 1 was ordered Haldol or that Patient 1’s wife was notified and consented for Haldol to be given to Patient 1. Review of Patient 1’s record, “Progress Note,” dated 3/2/25 at 10:34 am, FNP A indicated Patient 1’s family was questioning why Patient 1 was on Haldol. During an interview on 6/18/25 at 11:30 am with Director of Nursing (DON), confirmed Patient 1’s wife was Patient 1’s responsible party. DON confirmed there was no documentation made by FNP A or nursing staff indicating Patient 1’s wife was notified when Patient 1 was given Haldol. DON confirmed Patient 1’s wife should have been notified before Haldol was ordered and given to Patient 1. 49418 2. A review of “History and Physical,” dated 1/9/25, indicated Patient 8 was transferred from another facility following surgery for an “unstageable decubitus ulcer” (severe pressure injury) with necrosis (dead tissue) at the base of the spine/left buttock region. Patient 8 was admitted for treatment of “deconditioning” (decline in physical and/or mental abilities) and wound care. Patient 8 also had a history of diabetes (chronic high blood sugar), high blood pressure, dyskinesia (a disorder that causes involuntary, erratic muscle movements), “gravely disabled,” and posttraumatic stress disorder (PTSD). The plan was to treat the wound, provide rehabilitation therapies, and continue Vraylar, an antipsychotic medication he was taking for PTSD prior to admission. A review of “Medication Record,” dated 1/9/25 to 6/26/25, indicated Patient 8 received Vraylar daily from 1/10/25 to 2/17/25, when the order was stopped. A review of “Order Chronology” of active Pharmacy orders, dated 1/9/25 to 6/25/25, indicated FNP A ordered lurasidone hydrochloride (Latuda - an atypical antipsychotic medication that helps normalize brain activity and reduce depressive episodes), one 40-milligram (mg - a unit of measure) tablet to be taken at bedtime, for Patient 8 on 2/24/25. The record indicated Patient 8 was also taking several medications to control diabetes: insulin, Actos, Farxiga, and Metformin. A review of Lexidrug (Trademark) (a drug information resource), indicated potential Latuda side effects included increased mortality (death) in elderly patients, suicidal thoughts and behaviors, drug-induced movement disorders (dyskinesia), blood cell abnormalities, high blood sugar, drowsiness, weight gain, temperature dysregulation (fluctuations), and potential drug-drug interactions with diabetes medications. A review of “Medication Record,” dated 1/9/25 to 6/26/25, indicated Patient 8 received Latuda 121 times from 2/24/25 to 6/25/25. During an interview with the DON on 7/1/25 at 9:30 am, a copy of Patient 8’s signed ‘Consent to Receive Psychotherapeutic Medications’ for Latuda was requested. DON stated she would attempt to locate it. During a concurrent interview with Doctor of Pharmacy (PharmD) A and review of Patient 8’s medical records on 7/1/25 at 10:40 am, PharmD A stated Patient 8 received his home medication Vraylar for PTSD for approximately one month following admission to the facility. PharmD A stated Patient 8 had severe hand tremors (dyskinesia) on admission that made it difficult to perform activities of daily living (eating, drinking, grooming, dressing, toileting). PharmD A stated the Interdisciplinary Team (IDT - a team of members from different disciplines who work together to set patient goals and make care decisions) discussed it and changed Vraylar to Latuda due to the possibility that Vraylar was causing Patient 8’s significant tremors. PharmD A acknowledged that Latuda also had the potential to cause dyskinesia. During an interview with DON on 7/1/25 at 12:15 pm, DON stated she could not find documentation in Patient 8’s medical records of a signed ‘Consent to Receive Psychotherapeutic Medications’ for Latuda and acknowledged there should have been one per facility policy.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include a strategy for a risk assessment. This affected 21 of 21 Patients and could result in the facility not being prepared for an earthquake emergency. Findings: During record review and interview with the Quality/Risk Director on 1/18/24, the EPP was reviewed. At 9:26 a.m., the facilities Hazardous Risk Assessment (HVA) listed earthquake as a risk for the facility. The EPP failed to include a strategy that addressed earthquakes. Upon interview, the Quality/Risk Director acknowledged that the EPP failed did not address earthquakes strategies.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a communication plan that did not include vendor contact information. This affected 21 of 21 Patients and could result in a delay in response in the event of an emergency. Findings: During record review and interview with the Quality/Risk Director on 1/18/24, the emergency preparedness plan was reviewed. At 10:04 a.m., the communication plan failed to include contact information for entities providing services under contract. There was no vendor contact information included in the communication plan. Upon interview, the Quality/Risk Director acknowledged that the facility was missing vendor contact information in their EPP.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include contact information for emergency preparedness staff. This affected 21 of 21 Patients and could result in a delayed response to an emergency situation. Findings: During record review and interview with the Quality/Risk Director on 1/18/24, the emergency communication plan was reviewed. At 10:06 a.m., the emergency preparedness plan failed to include contact information for Federal and State emergency preparedness staff. Upon interview, the Quality/Risk Director acknowledged that the communication plan was missing contact information.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in the ceiling. This affected one of nine smoke compartments and could result in the spread of smoke in the event of a fire. Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the walls and ceilings were observed. At 10:26 a.m., a one and a half inch by two-inch penetration was observed in the ceiling around a fire sprinkler in room 810. Upon interview, Maintenance Staff 1 acknowledged the penetration in the ceiling.”

“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 obstructed doors, doors that failed to latch and missing self-closing devices. This affected four of nine smoke compartments and could result in the spread of smoke and fire. Findings: During a tour of the facility with Maintenance Staff 1 on 1/17/24, the hazardous enclosure areas were observed. 1. At 10:14 a.m., the corridor door to room 702 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. The room was approximately 400 square feet and contained shelves along all four walls that stored clean linens. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch. 2. At 10:21 a.m., the self-closing device on the corridor door to the Central Supply Room, room 800 was observed. The self-closing device was not functional and would not automatically close the corridor door. The room was approximately 450 square feet and was used to store non-medical related supplies for the hospital. Upon interview, Maintenance Staff 1 acknowledged that the door self-closing device was not working. 3. At 10:38 a.m., the corridor door to the purchasing Room, room 811 was observed missing a self-closing device. The room was approximately 300 square feet and stored cases of paper, cases of paper masks, cases of gloves and office supplies. Upon interview, Maintenance Staff 1 acknowledged that the corridor door was missing a self- closing device. 4. At 11:11 a.m., the North side corridor door to the Boiler Room in the 500 hall was tested. The door was a sliding metal-clad fire type door on a wall mounted incline track. When tested, the door failed to close all the way, leaving approximately six inches between the leading edge of the door and the frame. Upon interview, Maintenance Staff 1 acknowledged that the door failed to close all the way. 5. At 11:30 a.m., the door to storage room 513B was observed missing a self-closing device. The room was approximately 500 square feet and contained eight full shelved of paper medical records. Upon interview, Maintenance Staff 1 acknowledged that the door failed to close all the way. 6. At 1:16 p.m., the door to room 310A was observed missing a self-closing device. The room was approximately 120 square feet and contained shelves along the walls storing paper files with X-Ray records. Upon interview, Maintenance Staff 1 acknowledged that the door was missing a self-closing device.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the kitchen hood fire suppression (Ansul) system. This was evidenced by the failure to provide one of two semiannual Ansul maintenance records. This affected one of nine smoke compartment and could result in the malfunction of the Ansul system. NFPA 101. Life Safety Code, 2012 Edition 19.3.2.5 Cooking Facilities. 19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition 11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing Systems. 11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. 11.2.8 Where required, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction. Findings: During a tour of the facility, record review and interview with Maintenance Staff 1 on 1/17/24, the kitchen Ansul system was observed, and records reviewed. At 3:37 p.m., the facility failed to provide one of two semiannual kitchen hood fire suppression inspection and maintenance record within the last 12 months. The last inspection was dated 5/17/23. Upon interview, Maintenance staff 1 acknowledged the Ansul had only been inspected once within the last 12 months.”

“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, record review and interview, the facility failed to maintain the fire sprinklers. This was evidenced by foreign material on sprinklers and missing sprinkler gauge and valve inspection records. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in the malfunction of the sprinklers in the event of a fire. NFPA 101 Life Safety Code, 2012 edition 19.3.5.1 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 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 6.2.6.2 * Painting. 6.2.6.2.1 Sprinklers shall only be painted by the sprinkler manufacturer. 6.2.6.2.2 Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition 4.1.1 * Responsibility for Inspection, Testing, Maintenance, and Impairment. The property owner or designated representative shall be responsible for properly maintaining a water-based fire protection system. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.4 Gauges. 5.2.4.1 * Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. 13.3 Control Valves in Water-Based Fire Protection Systems. 13.3.2 Inspection. 13.3.2.1 All valves shall be inspected weekly. 13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. Findings: During a tour of the facility, record review and interview with Maintenance Staff 1 on 1/17/24, the automatic sprinkler system was observed, and records reviewed. 1. At 8:36 a.m., five of five sprinklers under the exterior overhang above the main lobby entrance were observed with foreign material on the frames and deflectors. Upon interview, Maintenance Staff 1 acknowledged that the sprinklers were covered in foreign material. 2. At 12:59 p.m., the single sprinkler head in the walk-in freezer was observed with foreign material on the frame, sensing bulb and deflector. Upon interview, Maintenance Staff 1 acknowledged that the sprinkler was covered in foreign material. 3. At 2:05 p.m., a sprinkler in the bathroom of room 105 was observed. Half of the deflector had been painted the same color as the ceiling. Upon interview, Maintenance Staff 1 acknowledged that the sprinkler had been painted. 4. At 3:48 p.m., the facility failed to provide fire sprinkler gauge and valve inspection records for 11 of the last 12 months. The only inspection record available for review was from December 2023. Upon interview, Maintenance Staff 1 stated that a staff had left in November 2023 and they were having trouble locating maintenance documentation.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a free-standing fire extinguisher. This affected one of nine smoke compartments and could result in an increased risk of damage to the fire extinguisher. NFPA 101: Life Safety Code, 2012 Edition 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1 9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition 6.1.3 Placement. 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. 6.1.3.4 * Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means: (1) Securely on a hanger intended for the extinguisher (2) In the bracket supplied by the extinguisher manufacturer (3) In a listed bracket approved for such purpose (4) In cabinets or wall recesses Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the fire extinguishers were observed. At 12:45 p.m., a fire extinguisher was observed free standing on a shelf in Room 513C. Upon interview, Maintenance Staff 1 stated that it was mounted in the room but was moved and had not been permanently remounted.”

“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 were obstructed from closing and corridor doors that failed to latch when tested. This affected five of nine 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 1 on 1/17/24, the corridor doors were tested. 1. At 9:27 a.m., the corridor door to the women’s restroom in the lobby was observed held open by a wooden wedge. Upon interview, Maintenance Staff acknowledged that the door was held open by a wedge. 2. At 9:42 a.m., the corridor door to room 402 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch. 3. At 9:59 a.m., the corridor door to room 714 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch. 4. At 10:24 a.m., the corridor door to room 806 failed to latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, Maintenance Staff 1 acknowledged that the door failed to latch. 5. At 10:34 a.m., the corridor door to room 815 failed to latch when tested. Upon interview, Maintenance Staff 1 stated that latching hardware for the door handle was missing preventing the door from latching. 6. At 10:39 a.m., the corridor door to room 811 failed to latch when tested. Upon interview, Maintenance Staff 1 stated that latching hardware for the door handle was missing preventing the door from latching. 7. At 2:03 p.m., the corridor door to room 109 was obstructed from closing by a walker. Upon interview, Maintenance Staff 1 acknowledged that the walker was obstructing the door from closing. 8. At 2:32 p.m., the corridor door to room 218 failed to latch when tested. Tape was observed on the latch bolt and strike plate that prevented the door from latching. Upon interview, Maintenance Staff 1 acknowledged the tape was preventing the door from latching.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the emergency gas shutoff valve. This was evidenced by the failure to have a means available for the shut of the gas valve. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in a delay to shutting off the gas supply to the building in the event of an emergency. NFPA 101 Life Safety Code, 2012 Edition 19.5.1 Utilities 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1 Utilities. 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 54, National Fuel Gas Code, 2012 Edition 7.9 Manual Gas Shutoff Valves. 7.9.2.3 Emergency Shutoff Valves. An exterior shutoff valve to permit turning off the gas supply to each building in an emergency shall be provided. The emergency shutoff valves shall be plainly marked as such and their locations posted as required by the authority having jurisdiction Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the gas meter and shutoff valve was observed. At 9:22 a.m., the gas meter and shutoff valve on the exterior of the 400 hall was observed. There was no wrench readily available to turn the gas valve off. Upon interview, Maintenance Staff 1 stated that they have a wrench in the shop but did not have it readily available.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the integrity of the heating, ventilation, and air-conditioning (HVAC) system. This was evidenced by deficiencies noted on their fire damper inspection report. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in the spread of smoke in the event of a fire. NFPA 101: Life Safety Code, 2012 Edition 19.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ’ s specifications, unless otherwise modified by 19.5.2.2. 9.2 Heating, Ventilating, and Air-Conditioning. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition 5.4.8 Maintenance. 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition 19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. 19.4 * Periodic Inspection and Testing. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Findings: During record review and interview with Maintenance Staff 1 on 1/17/24, the fire dampers inspection records were reviewed. At 4:14 p.m., a document labeled “Fire Damper Inspection Report” was reviewed. The inspection report indicated the fire dampers were inspected on 8/26/23 and had failed because of two missing fire dampers. Upon interview, Maintenance Staff 1 stated that they were not sure why the dampers were not replaced.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain fire drills. This was evidenced by the failure to conduct 12 of 12 fire drills in the past 12 months. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in staff being untrained and unaware of their roles and responsibilities in the event of a fire. Findings: During record review and interview with Maintenance Staff 1on 1/17/24, the fire drill records were reviewed. At 11:39 a.m., the facility failed to provide documentation for an AM and a PM shift drills for the first quarter (January, February, March) of 2023, and the PM shift for the third quarter (July, August, September) of 2023. Upon interview, Maintenance Staff 1 acknowledged the missing fire drill records.”

“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 maintain portable space heaters. This was evidenced by the failure to follow manufacturer’s directions and space heater plugged into power strips. This affected four of nine smoke compartments and could result in causing a fire. Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the space heaters were observed. 1. At 9:31 a.m., a portable space heater was observed at the desk of the Referral Coordinator in room 406. The space heater was plugged into a power strip and was approximately three inches away from a cloth box containing clothes. 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 and no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heater was plugged into a power strip and less than three feet away from flammable furnishings. 2. 10:10 a.m., a portable space heater was observed in the Radiology Managers Office, room 704. The space heater was plugged into a wall outlet and was less than three feet away from a printer, desk and wall of the room. According to the manufacturer’s instructions on a caution label on the portable space heater, the heater should be no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heater was less than three feet away from flammable furnishings. 3. At 10:33 a.m., a portable space heater was observed in room 815. The space heater was plugged into a power strip. 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, Maintenance Staff 1 acknowledged that the space heater was plugged into a power strip. 4. At 1:46 p.m., two portable space heaters were observed in the Doctors Sleep Lounge, room 339. The first space heater was approximately three inches away from a garbage can and the second space heater was plugged into a power strip. According to the manufacturer’s instructions on a caution label on both portable space heaters, the heaters should be plugged directly into a wall electrical outlet and no less than three feet from flammable furnishings. Upon interview, Maintenance Staff 1 acknowledged that the space heaters were plugged into a power strip and less than three feet away from flammable furnishings.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 43380 Based on observation, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by the failure to provide a permanent working emergency backup generator. This affected 21 of 21 Patients and nine of nine smoke compartments and could result in a loss of power due to a generator malfunction during an emergency power outage. NFPA 99, Health Care Facilities Code, 2012 Edition. 6.4 Essential Electrical System Requirements - Type 1. 6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition. 4.4.3 All equipment shall be permanently installed. Findings: During a tour of the facility, and interview with Maintenance Staff 1 on 1/17/24, the EPSS was observed. At 8:36 a.m., a temporary trailer mounted 200-Kilowatt (KW) diesel generator was observed onsite and was connected to the automatic transfer switch (ATS). The temporary generator was located on the North side of the building and was stationed on a wheeled platform, protected by concrete parking barriers, and was secured to the barriers by metal cables. A new diesel generator was observed onsite, outside of the 500 hall, not connected. The facility was in the process of replacing the old failed generator with the new diesel generator onsite. Upon interview, Maintenance Staff 1 stated that the temporary generator has been in use for approximately three to four years.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of extension cords, daisy chained and suspended power strips. This affected three of nine smoke compartments and could result in causing a fire. NFPA 101 Life Safety Code, 2012 Edition 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 National Electrical Code, 2011 Edition 400.8 Uses Not Permitted. unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals. Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable. Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the electrical equipment was observed. 1. At 9:58 a.m., an orange extension cord was observed powering a power strip in room 714. The extension cord was plugged into another power strip that was plugged into a wall outlet. Upon interview, Maintenance Staff 1 acknowledged the extension cord. 2. At 10:07 a.m., a white power strip was observed suspended approximately three inches above the floor in the Workers Compensation office, room 706. The power strip was next to a two-drawer file cabinet and was suspended by the power cord to a coffee maker that was on top of the cabinet. Upon interview, Maintenance Staff 1 acknowledged the suspended power strip. 3. At 1:08 p.m., a power strip was observed suspended approximately three inches above the floor in room 301. The power strip was next to a small refrigerator and was suspended by the power cord to a microwave that was on top of the refrigerator. Upon interview, Maintenance Staff 1 acknowledged the suspended power strip. 4. At 2:11 p.m., a power strip was observed daisy chained to an uninterrupted Power Supply type power strip under the Infection Control desk in the infection control/Activities office, room 201. The power strip was powering computer and phone equipment. Upon interview, Maintenance Staff 1 acknowledged the daisy chained power strips.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the oxygen cylinder storage. This was evidenced by full and empty oxygen tanks that were not segregated, and a free-standing tank that was not secured. This affected the outdoor oxygen tank storage area and could result in confusion or delay if a full cylinder is needed in a rapid manner and the increased risk of fire. NFPA 99: Health Care Facilities Code, 2012 Edition 11.3 Cylinder and Container Storage Requirements. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1)Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2)Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3)Cylinders shall be protected from tampering by unauthorized individuals. (4)Cylinders or cylinder valves shall not be repaired, painted, or altered. (5)Safety relief devices in valves or cylinders shall not be tampered with. (6)Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7)A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8)Sparks and flame shall be kept away from cylinders. (9)Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10)Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11)Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12)Cylinders shall not be supported by radiators, steam pipes, or heat ducts. 11.6.5 Special Precautions - Storage of Cylinders and Containers. 11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Findings: During a tour of the facility and interview with Maintenance Staff 1 on 1/17/24, the oxygen storage was observed. 1. At 9:04 a.m., the oxygen storage cage on the exterior of the 300 hall was observed. There were approximately 48 E type oxygen tanks stored in the cage. Approximately two empty E tanks were observed mingled together with the full E tanks. There was no signage indicating which area to store full and empty tanks. Upon interview, Maintenance Staff 1 acknowledged that the E tanks were not segregated in the cage. 2. At 9:40 a.m., a free-standing E type oxygen tank was observed in the Cardiopulmonary Room, room 402. The tank was under a table and against the wall. Upon interview, Maintenance Staff 1 acknowledged that the tank was free standing.”

“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: 47442 Based on observation, interview, and record review, the facility failed to have a preventive maintenance program to ensure that all essential mechanical, electrical and patient-care equipment was maintained in a safe, sanitary, and operating condition in the dietary department when: 1. The ice machine was not maintained in sanitary condition. 2. The walk-in freezer had thick frost on shelving, food containers, plastic food packages, walls, pipes, and two motor fans. 3. Two food preparation sinks did not have an air gap (space to separate a water-supply outlet from any potentially contaminated source from backflow). These failures had the potential to cause food borne illnesses within the medically vulnerable population of 18 patients, who received food prepared in the kitchen. Findings: 1. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review, of the facility’s policy and procedure titled, “Equipment Maintenance Program,” dated 11/28/18, it indicated that the proper maintenance of the dietary, and all equipment is the responsibility of the Director of the Dietary Department in cooperation with the facility’s maintenance department, and subject to policies and procedures set forth by the facility’s administration. The Director of the Dietary Department is informed of all routine, periodic and critical maintenance work done in the kitchen, or with its equipment. To ensure that all equipment is in safe operating condition, an equipment inspection program is followed. During an interview, on 1/9/24 at 3 pm with Plant Maintenance (PM) 2, reported that the ice machine was cleaned every three-months, and they did not have the manufactures’ manual. PM 2 stated, that he did not know where the paper was indicating how to clean the ice machine, or where the maintenance logs were located indicating when the ice machine was cleaned, or maintained by the maintenance staff. During a concurrent observation, and interview, on 1/9/24 at 3:20 pm, in the kitchen with PM 1, whitish flakey mineral deposits were observed on the ice machine, above the ice chute and surrounding areas. PM 1 removed the ice chute, and white crusty discoloration and brownish substance on the rim of the chute was observed. PM 1 confirmed, that this was was not clean. PM 1 stated, that the ice machine was cleaned every three-months, and they did not have the manufactures’ manual with instructions showing the procedure for maintaining and cleaning the ice machine. PM 1 stated, he did not know where the maintenance records were located indicating the dates the ice machine was cleaned, or maintained by the maintenance staff. During an interview, on 1/10/24 at 2:15 pm with PM 3, they stated, that the ice machine should be cleaned monthly and deep cleaned every three months. PM 3 did not know if the facility had a policy and procedure specifically for cleaning the ice machine, or logs indicating the dates the ice machine was cleaned, or maintained by the maintenance staff. 2. During a concurrent observation, and interview, on 1/9/2024 at 3:10 pm, in the walk-in freezer located in the kitchen, with PM 1, an accumulation of thick frost on the walls, shelving, food storage bins, plastic bags containing food products, pipes and two motor fans was observed. PM 1 stated, that he was aware of the frost; it had been there for a while, and the frost build up on the motor fans appeared worse. PM 1 stated, that he had someone look at the walk-in freezer, but could not remember who, or when, and had no records of it. PM 1 stated, that he did not have a checklist, or logs indicating when the walk-in freezer was cleaned, or maintained by maintenance staff. PM 1 confirmed the walk-in freezer should not have a build up of frost on all the surfaces or the two motor fans. 3. According to the FDA Food Code Annex 2022: 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. According to the FDA Food Code 2022, Section 5-402.11 Backflow Prevention. Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. During a concurrent observation, and interview, on 1/10/24 at 1:55 pm, with PM 3, in the kitchen, two food preparation sinks with no air gaps were observed. PM 3 confirmed, that the two food preparation sinks currently did not have an air gap.”

“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: 41567 41600 Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored properly according to the facility’s policies and procedures or manufactures’ specifications and requirements for a census of 19, when: 1. Two injectable vials of epinephrine (an emergency medication to treat life-threatening medical conditions), located in the pharmacy were not protected from light in accordance with manufacturer’s storage requirements, with the risk for potential medication degradation. 2. A bag of 10% dextrose injection (a sterile solution of dextrose [a type of sugar] in water for intravenous [in the vein] administration), located in the Emergency Department (ED) patient supply room, was found to be expired and therefore no longer guaranteed to be sterile. 3. Two bottles of 3% hydrogen peroxide (a cleansing antimicrobial solution), located in the wound supply cart in the Emergency Department, was found to be expired and therefore at risk of being less effective in the treatment of wounds. These failures had the potential for medication degradation, and the administration of a potentially expired or contaminated products which could lead to negative clinical outcomes. Findings: 1. During an inspection of the pharmacy on 1/9/24 at 11 am, two injectable vials of epinephrine 1 mg/1ml (milligram per milliliter, unit of measure) were observed outside of manufacture’s box in a clear storage bin on the shelf in the main pharmacy room. The storage bin did not have any “protect from light,” labels on the outside, and the two epinephrine vials were exposed to light. During an interview, on 1/9/24 at 11:05 am, with the Director of Pharmacy (DOP), the DOP stated, that the two vials should not be there, and they should be protected from light. During an inspection of the epinephrine box and manufacturer’s label in the pharmacy on 1/11/24 at 2:15 pm, the manufacture label on the box indicated, “Protect from Light.” During a review of the facility’s policy and procedure titled, “Storage of Medications,” dated 8/17, indicated, light sensitive medications will be kept in the closed manufacturer’s package... medication trays and bins in the pharmacy that hold light sensitive medications will be labeled with “protect from light,” to assure proper handling after removal from the manufacture’s package. 2. During a concurrent observation, and interview, made 1/10/24 at 12:35 pm, with Licensed Vocational Nurse (LVN) 2, a 1,000 mL (milliliter, a unit of measure) bag of 10% dextrose with an expiration date of 12/23, was found in the Emergency Department’s patient supply closet. LVN 2 stated, that the product was most likely set aside to be used for training purposes once it had expired, but confirmed that it was still in the patient supply closet, and could have been inadvertently used on a patient by staff. 3. During a concurrent observation, and interview, on 1/10/24 at 12:40 pm, with LVN 2, two bottles of 3% hydrogen peroxide, with an expiration date of 10/23, were found in the wound supply cart in the Emergency Department. LVN 2 removed the expired products, and stated that they should not be used on patients because they were expired, and would be disposed of. During an interview, on 1/11/24 at 1:40 pm, these findings were discussed and photographs shared with the temporary Director of Nurses, and ED Manager, who confirmed that these issues posed contamination risks to patients, and staff.”

“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: 40204 Based on observation, interview, and record review, the facility did not follow their policy when staff did not label the opened date on two reagent strips (patient monitoring device testing strip) bottles. This failure to enter the date of the opening of the container can lead to using out of date testing strips, resulting in incorrect test results, and improper treatment based on incorrect results, and potential negative clinical outcomes. Findings: During a concurrent interview, and observation, of the Cardiac Clinic on 1/10/24 at 10:30 am, with the Clinic Manager (CM) one bottle of “Stat Strip,” blood glucose (sugar) monitoring test strips was found opened. The bottle had no opened date filled in on the “Date Opened,” manufacturers label. The CM observed the label, and no date entered by staff and stated, that they should have written that on it when it was opened. The CM then provided a facility policy titled, “Nova Strip Glucometer,” The CM confirmed that per this policy the staff should have documented on the bottle the date the bottle was opened. The CM confirmed that failure to write the date could lead to using expired strips. During a concurrent interview, and observation, of the Cardiac Clinic on 1/10/24 at 11 am, with the CM one bottle of “Multi Stix Urine Reagent Strips,” were found opened without the required opened date. The CM confirmed the same process is required, and staff did not comply. The CM states, that it was the same process, if opened, it must have the opened date written on the bottle.”

“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: 41567 47884 Based on observation, interview, and record review, the facility did not ensure that staff were adequately oriented to the Medical, and Emergency Room units when: 1. One Registered Nurse (RN) 10 was floated from the Medical Unit into the Emergency Room, without unit specific orientation or training. 2. 14 of 16 employee files reviewed did not contain documented unit specific orientation, or other mandatory trainings. These failures resulted in an increased risk to patient safety, and had the potential to lead to negative clinical outcomes. Findings: During a review, of the facility’s policy titled, “Education and Training,” reviewed 12/14/18, and in effect, indicated that all employees would complete unit specific education to maintain a competent safe environment of care. And that all orientation and training records, would be maintained and stored in each employee’s personnel file. A review, of the facility’s policy titled, “Orientation of Emergency Department Personnel,” reviewed 9/26/19, and in effect, indicated that Emergency Room staff would be provided an orientation, and that the orientation would be completed under the supervision of an assigned preceptor. And that completion of orientation would assure each employee was familiar, and competent with unit policies, procedures, protocols, equipment, and able to provide safe competent care to the Emergency Room patient population. Additionally, the policy indicated that orientation checklists would be placed into each personnel file, after successful completion of orientation. A review, of the facility’s policy titled, “Nursing Services,” reviewed 10/27/21, and in effect, indicated that care of each patient would be provided by competent and qualified nursing staff. And that to provide safe competent patient care each patient’s specific needs, along with the qualification and competency of staff would be considered when making shift assignments. During an interview, and concurrent record reviews, on 1/11/23, at 11:30 am, with Human Resources Manager (HRM), it was noted that there were no unit specific orientation checklists in 3 of 5 personnel files reviewed. HRM indicated that unit specific orientation checklists, and other mandatory training records should be in each employee’s personnel file, and confirmed that 3 of 5 employee records reviewed were missing unit specific orientation checklists. During a concurrent observation, and interview, in the Emergency Department (ED) on 1/11/24 at 8:30 am, the sole Registered Nurse (RN) on duty was RN 10. RN 10 confirmed, that they were the sole RN on duty. During an interview, on 1/11/24 at 1:25 pm, RN 10 confirmed, that she was hired in 2023, and soon after her hire she was floated to the Emergency Department to cover lunch breaks, and then began being floated to cover entire shifts. RN 10 confirmed, that she has not had any specific ED unit training by the facility. During a concurrent two-part interview, and record reviews, on 1/10/24, and 1/11/24, employee competencies were reviewed with the HRM, of eleven sampled employees (seven RNs, three Licensed Vocational Nurses [LVNs], and one ER Technologist [ERT]) who either worked in the Emergency Department or floated there from the Medical/Surgical units, eight employees were found to have incomplete unit-specific training, or cross-training (RN 6, RN 8, RN 9, RN 10, LVN 1, LVN 2, LVN 3, ERT 1) to the Emergency Department. On 1/11/24 at 8:45 am, HRM confirmed, that the competencies were either not completed, or missing. On 1/11/24 at 9:15 am, HRM confirmed, that RN 10 had been hired in 2023 to work in the Medical/Surgical unit, and was working in the ED, and had no ED-specific cross training. A schedule of the day’s nursing assignments was printed, which indicated that the sole designated RN on duty 1/11/24 in the ED was RN 10. During an interview, on 1/11/24 at 1:40 pm, the temporary Director of Nurses/ER Manager stated, that she would expect staff to have cross training for the different units that they work in.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 47884 Based on interview, and record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the nursing care of patients on the medical unit when: 1. There was no documented RN assessment for every patient on the unit for each shift. 2. When assessments performed by Licensed Vocational Nurses (LVNs) were not reviewed, and co-signed by the supervising RN for each shift. This failure risked patient safety, and had the potential to lead to possible negative clinical outcomes. Findings: A review, of the facility’s policy titled, “Patient Care Planning,” reviewed 11/16/23, and in effect, indicated that all patients will have an individualized plan of care developed by an RN. The RN assessments would determine the specific needs and goals of each patient. Additionally, the policy indicated that LVN’s would be under the supervision of an RN, when performing patient assessments, evaluations, or care plan activities. A review, of the facility’s policy titled, “Nursing Services,” dated 10/27/21, indicated that an RN must supervise, and evaluate the nursing care for each patient 24-hours a day, on all shifts. During a review, of Patient 22’s medical record, a document titled, “Patient Progress Notes,” indicated that, from 2:07 am on 1/10, through 7:05 am, on 1/11/24, (over a span greater than 24-hours, and two shifts) that there was no RN assessment. During an interview, on 1/11/24 at 10:59 am, LVN 5 reported, that patient assessment and reassessment was a task delegated to LVNs on the medical unit, and that an RN did not regularly review, or co-sign those assessments. During an interview, on 1/11/24 at 11:02 am, LVN 4 reported, that patient assessment and reassessment was a task delegated to LVNs on the medical unit, and that an RN did not review or co-sign those assessments. LVN 4 stated, that they never have an RN co-sign their patient assessments. During an interview, on 1/11/24 at 11:10 am, with an RN 2, and temporary Director of Nursing (TDON), they reported that LVN’s had performed patient assessments without RN supervision, and that there was no process for RN review, and co-signing of patient assessments completed and documented by the LVNs. RN 2, and TDON confirmed that all patient assessments performed by LVNs should have been reviewed, and co-signed by an RN, and were not.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 41600 Based on observation, interview, and record review, the hospital failed to ensure a medication was administered in accordance to physician orders, facility policy, and accepted standards of practice for one of 29 sampled patients (Patients 5) when: A licensed nurse crushed a delayed release pantoprazole (medication to treat acid reflux, and heal stomach ulcers), 40 mg (milligrams) for Patient 5. This failure had the potential for Patient 5 to have an inconsistent drug concentration in the body, or experience unwanted side effects which could lead to negative clinical outcomes. Findings: During a medication administration observation on 1/10/24 at 8:45 am, Registered Nurse (RN) 1 was observed to crush, and administer one pantoprazole 40 mg delayed release tablet by mouth to Patient 5, along with other morning medications. During a review, and reconciliation of the medication administration observation with Patient 5’s electronic orders on 1/10/24 at 9:15 am, a physician order (dated 1/3/24) indicated, pantoprazole 40 mg tablet, 40 mg orally daily. During an interview, on 1/10/24 at 9:20 am, with RN 1, they stated there was no specific orders for crushing Patient 5’s medications, and that they didn’t know pantoprazole delayed release could not be crushed, since it is usually administered intravenously (into the vein). During an interview, on 1/10/24 at 12:40 pm, with the facility’s Registered Pharmacist (RPh), the RPh stated, that pantoprazole 40 mg tablet could not be crushed. In case of difficulties swallowing, the nurse could have asked the pharmacy for a recommendation. During an inspection of the pantoprazole box in the pharmacy on 1/11/24 at 2:10 pm, the manufacture label on the box indicated, tablets must not be split, chewed, or crushed before administration. During a review, of the facility’s policy and procedure titled, “Administration of Medications,” revised 12/22, it indicated, that the Registered Nurse, or Licensed Vocational Nurse will be knowledgeable regarding the dosage, therapeutic actions, indications, contraindications and sensitivity reactions of medications prior to administration. During a review, of the facility’s policy titled, “Drugs That May Not Be Crushed, or Divided,” dated 9/16, it indicated, that nurses should consult with a pharmacist, or the, “Do Not Crush,” list before altering drug forms for administration... Oral Dosage Form That Should Not Be Crushed... pantoprazole tablet.”

“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: 41567 Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary environment for its patient population. This failure had the potential for poor health outcomes through the transmission of infectious pathogens which could lead to negative clinical outcomes. Findings: A review, of the facility’s policy titled, “Infection Prevention Plan,” dated 1/30/23, indicated that the facility’s infection control program maintained a culture of zero tolerance for noncompliance with established infection prevention and control practices. During an observation, on 1/9/24 at 9:33 am, in the Medical/Surgical Unit Dirty Utility Room. The following items were observed. In a cupboard was a DonJoy Iceman ice therapy unit with tubing and wrap-on pad, and a dirty metal object with cobwebs in it, and a box of sani-bags (a urinary and fecal collection device). This and adjoining cupboards were filled with peeling paint, and the shelves were dirty, and littered with paint chips. During an observation, on 1/9/24 at 9:52 am, in the Medical/Surgical Medication Room, the following was observed. The under-sink pipe connection was thick with dark debris which overflowed onto the bottom of the cabinet. There was black, rusty red and yellow-brown material and stains on the bottom of the cabinet. A glass partition separated the sink from other items on the counter, the glass being supported by two gray brackets. Both brackets were rusting with small flecks of paint and rust, and the area around the edges of the sink and the glass, and the sink faucets were dirty with white built-up scale and soiling. During an observation, on 1/9/24 at 9:55 am, of the Medical/Surgical Unit patient supply closet the following was observed. Patient supplies were found to be scattered on the floor in the right corner including a package of tubing, a specimen collection container, an ace wrap roll, and plastic bags. During concurrent observation, and interview, on 1/9/24 10 am, with the Medical/Surgical RN on duty, Registered Nurse (RN) 2 who, when observing the patient supplies on the floor stated, that they posed an infection risk, and that she would dispose of them to prevent them from being used on patients. During concurrent observation, and interview, on 1/10/24 at 12:25 pm, with Licensed Vocational Nurse (LVN) 2, in the Emergency Department patient supply room the following was observed. On the floor were supplies which included specimen collection cups, a bedpan, a urine strainer, a urinary catheter kit, and disposable briefs. LVN 2 retrieved the supplies off the floor to dispose of them, stating that the items posed an infection risk to patients. During an interview, on 1/11/24 at 1:40 pm, these findings were discussed and photographs shared with the temporary Director of Nurses/ER Manager, who stated that these issues posed a contamination risks to patients, and staff.”