Jerold Phelps Community Hospital

“K3 BUILDING: 01 K6 PLAN APPROVAL: 1966 K7 SURVEY UNDER: 2012 EXISTING STRUCTURE TYPE: ONE STORY, CONSTRUCTION TYPE V, FULLY SPRINKLERED. Resident Certified Beds: 9 Resident Census: 10 The following reflects the findings of the California Department of Public Health, during an annual Life Safety Code recertification survey. The findings are in accordance with 42 Code of Federal Regulations (CFR) §483.90(a)(b)(c)(j), National Fire Protection Association (NFPA) 101 - Life Safety Code, 2012 Edition, and NFPA 99 - Health Care Facilities Code, 2012 Edition. The facility is not in substantial compliance with 42 CFR §483.90 for Long Term Care Facilities.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the facility’s emergency exit signs. This was evidenced by a malfunctioning exit sign. This could result in a delay in egress in the event of an emergency evacuation. This affected ten of ten patients and one of one smoke compartments. Findings: During a tour of the facility and interview with the staff on 6/8/26, the emergency exit signs were observed. At 1:56 p.m., the combination exit sign and emergency lighting component above the Emergency Department Entrance failed to remain illuminated when tested. During an interview, Staff 1 stated that the exit signs were inspected every month and was unsure why it had failed to illuminate.”

“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: 46858 Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to maintain the sprinkler system components. This could result in a malfunction to the automatic sprinkler system in the event of a fire. This affected ten of ten patients and one of one smoke compartments. 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. 9.7.1.1* 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 8.5.6 Clearance to storage. 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of the storage shall be 18 in. (457 mm) or greater. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Gauges (dry, preaction, and deluge systems) - Weekly/monthly 5.2.4.2, 5.2.4.3, 5.2.4.4 Control valves Table 13.1 Waterflow alarm devices - Quarterly 5.2.5 Valve supervisory alarm devices - Quarterly 5.2.5 Supervisory signal devices (except valve supervisory switches) - Quarterly 5.2.5 Gauges (wet pipe systems) - Monthly 5.2.4.1 Hydraulic nameplate - Quarterly 5.2.6 Buildings - Annually (prior to freezing weather) 4.1.1.1 Hanger/seismic bracing - Annually 5.2.3 Pipe and fittings - Annually 5.2.2 Sprinklers - Annually 5.2.1 Spare sprinklers - Annually 5.2.1.4 Information sign - Annually 5.2.6.1 Fire department connections Table 13.1 Valves (all types) Table 13.1 Obstruction, internal inspection of piping -5 years 14.2 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). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer 13.3.2 Inspection. 13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. 13.3.2.2 * The valve inspection shall verify that the valves are in the following condition: (1) In the normal open or closed position (2) *Sealed, locked, or supervised (3) Accessible (4) Provided with correct wrenches (5) Free from external leaks (6) Provided with applicable identification Findings: During a tour of the facility and interview with the staff on 6/8/26, the sprinkler system components were observed. 1.At 1:42 p.m., the sprinkler protecting the north wall of the Utility Room across the Nurse Station was observed obstructed by a seat cushion being stored too close. The seat cushion was observed being stored approximately nine inches away from the sprinkler pendant. During a concurrent interview, Staff 1 confirmed the finding and stated that the cushion should have been stored in a different location. 2. At 2 p.m., the sprinkler protecting the Clean Linen Closet was observed obstructed by a pile of clean towels. The towels were observed being stored approximately four inches away from the sprinkler pendant. During a concurrent interview, Staff 1 confirmed the finding and stated that the cushion should have been stored in a different location.”

“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: 46858 Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by an obstructed fire extinguisher. This could result in a delay of fire protection in the event of a fire. This affected ten of ten patients and one of one smoke compartments. 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 6.1.2 Extinguisher Readiness. Portable fire extinguishers shall be maintained in a fully charged and operable condition and shall be kept in their designated places at all times when they are not being used. 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. 6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view. 7.2.1.2 * Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals 7.2.1.2.1 Where electronic monitoring is used and the specific extinguisher cannot be verified electronically, the extinguisher shall be continuously monitored for location. 7.2.1.3 *Fire extinguishers shall be inspected at more frequent intervals when circumstances require. 7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items: (1) Location in designated place (2) No obstruction to access or visibility (3) Pressure gauge reading or indicator in the operable range or position (4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks (5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers (6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators Findings: During a tour of the facility and interview with the staff on 6/8/26, the portable fire extinguishers were observed. At 1:30 p.m., the K-class fire extinguisher mounted along the northeast corner of the Kitchen was observed obstructed from access. A wheeled metal cart containing food supplies was placed directly in front of the mounted fire extinguisher, obstructing it from view. During an interview, Staff 1 stated that the cart was in the process of being moved.”

“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: 46858 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a non-latching corridor door. This can increase the passage of smoke through smoke compartments. This affected ten of ten patients and one of one smoke compartments. Findings: During a tour of the facility and interview with the staff on 6/8/26, the corridor doors were observed. At 1:40 p.m., the corridor door to Room 108 was observed with a self-closing mechanism. The corridor door failed to latch when tested for closure. The door was tested for closure approximately three times. During an interview, Staff 1 stated that the doorframe likely warped during an earthquake, preventing it from closure.”

“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: 46858 Based on document review and interview, the facility failed to maintain the Heating, Ventilating, and Air-Conditioning (HVAC) system. This was evidenced by the failure to conduct the required test and inspection for the facility’s smoke dampers. This could result in the spread of smoke throughout smoke compartments in the event of a fire. This affected ten of ten patients and one of one smoke compartments. 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. 9.2.1 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 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 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. 19.4.3 Full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required. 19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-inplace if so equipped. 19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. 19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. 19.4.7 The damper shall not be blocked from closure in any way. 19.4.8 The fusible link shall be reinstalled after testing is complete. 19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/ smoke damper, date of inspection, name of inspector, and deficiencies discovered. 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. 19.4.10 All documentation shall be maintained and made available for review by the AHJ. Findings: During document review and interview with staff on 6/8/26, the smoke damper inspection and testing records were requested. At 3:45 p.m., the facility failed to conduct the four-year smoke damper testing. The date of the last smoke damper testing was 2/8/13. During a concurrent interview, Staff 1 stated that the facility had conducted another damper test after the one conducted in 2013 but was unable to find the records. Staff 1 stated that the facility has had difficulty getting a vendor to travel to the facility to conduct damper testing.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 46858 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by an exposed opening in an electrical panel. This could result in an electrical fire. This affected ten of ten patients and one of one smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 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 408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure. Findings: During a tour of the facility and interview with the staff on 6/8/26, the electrical equipment was observed. At 12:16 p.m., the electrical panel along the south wall of the Registration Office was observed with an exposed opening in one of 14 breaker spaces. The breaker space in the electrical panel was observed missing a cap. During an interview, Staff 1 confirmed the finding and stated he was not aware the panel contained an exposed opening.”

“ROUTINE STORAGE AND DISPOSAL OF TRASH CFR(s): (2) There is proper routine storage and prompt disposal of trash; This Standard is not met as evidenced by: 40830 Based on observation, interview and record review, the facility was unable to provide a clean environment for a census of three patients when one of one dumpster bin, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential to create an unsafe environment for the patients and visitors due to possible pest infestation and spread of disease in the facility. Findings: During a concurrent observation and interview on 6/1/26 at 2:57 p.m., observed one out of one outside dumpster bin was covered with its two lids. The dumpster lids were bowed away from the midline where they converged and leaving approximately two-inch gap in between. The lids also bowed away from both sides and left approximately two-inch gap in between for each side of the bin. The deformed lids lacked the integrity to securely cover the bin. Observed there were few bags of trash inside the dumpster bin. Dietary Service Manager (DSM) confirmed and stated the lids were bent and could not cover well to prevent the pest from going in and out of the trash. During a concurrent observation and interview on 6/2/26 at 2:14 p.m., Engineer/EVS Manager (EEM) observed and confirmed the deformed lids of the dumpster bin. EEM stated Engineer Department was responsible for the dumpster and trash bin. He stated the waste management picked up the trash twice a week, usually Monday and Friday. He stated he would check on the bin if someone reported issue. EEM further stated there was no specific time for the department to monitor the condition of the dumpster. He agreed and stated the lids were deformed and may create gaps for the rodents or pest from going in and out. He stated they did not have any policy and procedure for the trash bin maintenance and monitoring. A review of departmental policy and procedure titled, “Garbage and Rubbish Disposal,” revised 3/30/26, indicated, “All garbage and rubbish containing food wastes shall be kept in containers with tight fitting lids ...Garbage and rubbish containing food waste shall be stored so it is inaccessible to vermin ...Outside dumpsters must be kept closed ...” According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, indicated, “(A) Receptacles and waste handling units for refuse ...used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.””

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 27194 Based on observation, interview, and policy review, the facility failed to ensure safe medication storage practice when one of four single dose bottles of the oral contrast was open and available for reuse for another patient. This failure had the potential to result in patients receiving expired and ineffective treatment. Findings: During a concurrent observation and interview on 6/2/26, at 9:14 a.m., with Pharmacy Manager (PHM), in the hospital’s Computed Tomography (CT- a type of imaging that uses X-ray techniques to create detailed images of the body) unit, a medication cabinet inspection revealed a partially used 100 ml (milliliter- a metric unit of volume) bottle of Omnipaque (contrast for injection or oral use) 350 mg (milligram - a unit of measure) per ml. The Radiology Manager (RM) confirmed the bottle had been opened. During a concurrent observation and interview on 6/2/26, at 9:14 a.m., with PHM, the contrast bottle label was reviewed. It specified “Single-Dose Bottle” and “Each bottle for one procedure only. If used with an automated contrast management system, maximum use time is 4 hours after initial puncture. Discard unused portion.” The PHM confirmed that the unused contrast should not be saved for another use. During a review of the hospital’s policy and procedure (P&P) titled, “Disposition of Medications” dated 2/27/26, the P&P indicated, “...medications shall not be kept in stock after the expiration or Beyond-Use date on the label and no contaminated or deteriorated drugs shall be available for use.” It further states “Single Dose Vials - a vial of liquid medication that contains one dose of a drug to be used one time for a single patient.””

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 46237 Based on interview and document review, the Governing Body (GB) of the hospital failed to ensure the accuracy of its physician privileging process (the specific authorization granted by the GB to a physician allowing them to treat patients based on their training and competence) when one of seven physicians (Medical Doctor, [MD 1]) provided patient care at the facility without privileges to do so. This failure had the potential for patients to receive care from a provider who was not legally or professionally qualified to do so. Findings: During a concurrent interview and document review with the Compliance Lead (CL) on 6/2/26 at 2 p.m., seven physician credential files (CF - a file that confirms qualifications, education, licensure, training, and experience, which are verified through a formal process) were reviewed. During the review of MD 1’s CF it was noted MD 1 did not have privileges granted for a period from 5/1/25 through 8/6/25. The CL confirmed MD 1 did not have privileges to provide care at the facility during this time and stated physicians should not practice at the facility without privileges. A review of an untitled facility document indicated that MD 1 provided care to 482 patients from 5/1/25-8/6/25 and did not have privileges granted to do so. A review of the facility’s document titled, “The Medical Staff Rules and Regulations,” dated 6/6/24, indicated, “The responsibility for admitting and providing medical care or supervising the care of all patients seeking services in District programs shall be limited to appropriately privileged physicians who are members of the [name of hospital] Medical Staff.” A review of the facility’s document title, “Bylaws”, dated 6/23, indicated, “The Board is the governing body of the District ...To that end, the Board will oversee the development of policies, processes, and procedures that enable the District to fulfill its mission and vision and in an effective and ethical manner ...The Board shall approve appointment of all members of the Medical Staff.””

“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: 27194 Based on observation, interview, and document review, the hospital failed to ensure concentrated potassium injectable vials were not accessible in two of two medication automated dispensing cabinets (ADC) in one patient care area of the hospital (emergency department). This failure may cause undiluted potassium chloride to be injected directly from the vial, leading to potentially severe and life-threatening heart arrhythmias or sudden heart stoppage. Findings: During a hospital emergency department (ED) tour on 6/1/26 starting at 2:30 p.m., with the Pharmacy Manager (PHM), two small countertop ADCs were discovered. During a concurrent observation and interview with the PHM in the ED on 6/1/26 at 2:33 p.m., both ADC machines were audited for high-risk medications (medications that have an inherent narrow therapeutic index and/or have the potential to cause serious adverse events when administered incorrectly). Four 20 ml (milliliter- a metric unit of volume) vials of 40 mEq (miliequivalent - measurement of concentration in a solution) potassium chloride (concentrated electrolyte solution) for injection were found. The manufacturer labeled these vials with a prominent bold red warning stating, “Concentrate Must Be Diluted Before Use.” The PHM stated these vials would be removed immediately since the physician who prepared his own intravenous potassium bags no longer worked at this hospital. He also acknowledged and expressed the safety concerns of having the concentrated potassium injectable vials accessible in the patient care area to the nursing staff as well. During a review of the hospital’s policy and procedure (P&P) titled, “High-Risk Medication,” dated 12/12/25, the P&P indicated, “The following medications and medication classes have been identified as being high alert: ...Concentrated electrolyte solutions.” During an interview with the ED Nurse Manager (EDNM) on 6/1/26 at 3:12 p.m., she confirmed that the ED physician who used to prepare his own intravenous potassium bags was no longer employed at the hospital. She also stated that it would be appropriate to remove all the injectable potassium vials from the ADC out of an abundance of caution. The National Institutes of Health (NIH) is the primary agency of the United States federal government responsible for biomedical and public health research and policy. In the original published recommendations in May 2011 titled, “Potassium Chloride Injection Still Poses Threats to Patients,” and under “Safe Practice Recommendations,” it states, “3. Dispensing of vials should be prohibited. Vials of KCl (potassium chloride) should not be dispensed to prepare infusions by nurses on the patient’s floor. Instead, the pharmacy should dispense premixed solutions or should prepare admixtures for patients as needed. Vials should not be provided as floor stock.””

“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: 46237 Based on observation, interview and record review, the facility failed to: 1. Complete nutritional screenings on admission for three of three patients (Patient 1, Patient 2, and Patient 3), 2. Monitor patients’ weights according to policy for three of seven patients (Patient 1, Patient 2, and Patient 3) and, 3. Assess and document competencies for the use of patient restraints for three of three Emergency Department staff members (EDRN, SG 1, and SG 2). These failures had the potential to delay recovery of medically and nutritionally compromised patients and to result in harm to patients through improper restraint usage. Findings: 1. During a concurrent interview and record review on 6/4/26 at 9:16 a.m. with Registered Nurse (RN) 3, Patient 1’s medical record was reviewed. RN 3 stated nursing staff performed nutritional screening as part of the admission assessment using the Malnutrition Screening Tool (MST) to identify if patient was at nutrition risk. RN 3 confirmed the nutritional screening was not documented for Patient 1. RN 3 stated she was not aware she needed to fill the screening tool. Chief Nursing Officer (CNO) joined the interview and stated the nutrition screening should be completed to identify who was at high risk for malnutrition and then notify the Registered Dietitian for consultation. During a review of the medical records of Patient 2 and Patient 3 on 6/4/26 at 9:47 a.m., the malnutrition screening tools were not completed for Patient 2 and Patient 3. A review of facility policy and procedure (P &P) titled, “Admission of the Patient to IP (inpatient), SWG (Swing) or SNF (Skilled Nursing Facility),” dated 8/4/25, indicated, “All charting must be done through Electronic Health Record ...Begin with the Acute Admission Assessment ...located in the Assessment tab ...” A review of the job description of a Registered Nurse indicated, “Organizes interventions based on clinical priorities ...Coordinates all aspects of admission, transfer, and discharge ...Effectively evaluates patient to recognize change in condition and intervenes appropriately ...Organizes, prioritizes and completes activities and assignments in an efficient and timely manner ...” 2. During a concurrent patients’ chart review and interview on 6/3/26 at 10:46 a.m. and 2:11 p.m., with Registered Dietitian (RD) 2, seven patient records were reviewed. RD 2 confirmed three out of seven patients had inconsistent or missing documentation of weekly weight from the admission dates. Patient 1’s medical record indicated Patient 1 was admitted on 5/21/26 with a diagnosis of Stage 4 pressure ulcer at sacral region (the area at the base of the spine, situated above the tailbone and between buttocks). Review of admission history and physical also noted Patient 1 had a diagnosis of diabetes, hypertension, HIV (Human Immunodeficiency virus, a virus that targets and destroys specific cells in the immune system), prostate cancer, and sacral osteomyelitis (inflammation or infection of the bone) and was admitted for continued antibiotic therapy and wound care. Review of the weight record for Patient 1 was noted as follows: -5/21/26: 153 lbs. -6/2/26: 142 lbs. RD 2 confirmed and stated there was one weekly weight missing between 5/21/26 and 6/2/26, and there was an 11 lbs. weight loss in two weeks. She stated she was not sure why there was a missing weekly weight. RD 2 further stated usually nurses were responsible for weighing the patients. She stated Patient 1 had a pressure ulcer and weight should be closely monitored. She stated missing weekly weight might delay further interventions. Patient 2’s medical record indicated Patient 2 was admitted on 4/30/26 with a diagnosis of right gangrenous (body tissue that has died due to a severe loss of blood supply or a bacterial infection) toe needing treatment. Review of admission history and physical also noted Patient 2 had a diagnosis of left BKA (Below Knee Amputation), CAD (coronary artery disease, a type of heart disease), hypertension and depression. Review of the weight record for Patient 2 was noted as follows: -5/2/26: 186 lbs. -5/26/26: 200 lbs. -6/1/26: 203 lbs. RD 2 confirmed and stated there was a 14 lbs. gain, 7% in two weeks from 5/2/26 to 5/26/26, and there were two weekly weights missing. She stated the nurses missed two weekly weights between 5/2/26 and 5/26/26. Patient 3’s medical record indicated Patient 3 was admitted on 4/20/26 and discharged on 5/16/26 with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease, a group of progressive, long -term lung conditions that cause irreversible damage to the airways and obstructs airflow in and out of the lungs, making it increasingly difficult to breathe) with exacerbation (an acute worsening or flare-up of a disease). Patient 3’s height was 5 feet 9 inches, admission weight was 109 lbs. Of note, Patient 3 was admitted with a low Body Mass Index, (BMI, a screening tool used to estimate total body fat based on an individual’s height and weight. BMI acts as an indicator to help identify potential weight-related health risks with a BMI less than 18.5 Kilogram per meter [unit of measurement]indicating the individual is underweight.) Review of the weight record for Patient 3 was noted as follows: -4/20/26: 109 lbs. -5/15/26: 106 lbs. RD 2 confirmed and stated there were two weekly weights missing from 4/20/26 to 5/15/26. She confirmed and stated Patient 3 had a three pound weight loss in three weeks and Patient 3’s food intake was less than 50% of the meals. RD 2 stated nurses were responsible for weighing the patients weekly. RD 2 further stated Patient 3’s weight should be closely monitored because Patient 3 was underweight with a low BMI and low meal intake. A concurrent interview and chart review on 6/3/26 at 3:13 p.m. with Registered Nurse (RN) 1, Patient 1’s and Patient 2’s medical records were reviewed. RN 1 confirmed there were missing weekly weights for Patient 1 and Patient 2. RN 1 stated the nurses were responsible for weighing patients weekly and documenting in the electronic medical record system. RN 1 stated it was difficult to view all the weights for each patient to compare weight changes. RN 1 stated she was not sure about the policy and procedure regarding patients’ weights and only knew about weighing patients weekly. She further stated if there was weight gain or loss more or equal to five pounds in week, the nurses should re-weigh the patient and notify the physician and dietary department for the weight changes. During an interview with Chief Nursing Officer (CNO) on 6/4/26 at 8:52 a.m., CNO stated the nurses were responsible for weighing the patients and should follow the P&P regarding weights. She further stated the nurses should weigh the patients upon admission and weigh the patients weekly for four weeks and would weigh the patients monthly if 4-week weights were stable. CNO acknowledged and stated she was not aware that the computer charting system was not user friendly and that the nurses had a hard time navigating and reviewing patients’ weights. A review of an undated facility policy and procedure (P &P) titled, “Swing Bed and SNF (Skilled Nursing Facility) Weights,” indicated, “Purpose: The primary purpose of a policy for taking patient weights in hospital swing beds ...is to monitor nutritional status ...and ensure regulatory compliance. Standardized weighting ensures consistent, accurate data crucial for assessing rehabilitation progress and preventing adverse health events ...Standardized weights: is a consistent, uniform protocol for measuring a resident’s (patient’s) body weight to ensure accuracy, facilitate tracking of weight changes, and detect nutritional or health issues early ...Procedure: ...All patients/residents must have their weight assessed on admission and then WEEKLY for four weeks from date of admission. It is expected that no longer than seven days will pass before the next weekly weight is measured. If weight is stable after four weeks, patients/residents can be weighed monthly within the first seven days of each month. Weight assessments should be documented in the resident’s (patient’s) medical record and include the date and method of measurement ...Nursing will notify physician and registered dietitian if weight gain or loss is greater than or equal to 5lbs [pounds] in one week ...Nursing will notify physician and registered dietitian if weight gain or loss is greater than or equal to 5% in 30 days, 7.5% in 90 days or 10% in 180 days.” 3. During a concurrent interview and record review on 6/3/26, at 9:30 a.m., with the Human Resource Manager (HRM), the employee files for an Emergency Department Registered Nurse (EDRN) and Security Guard (SG) 1 assigned to the Emergency Department were reviewed. No competencies for use of patient restraints were located in the employees’ files. The HRM stated competencies were kept separately in the department where the employee worked. During an interview on 6/4/26 at 10:30 a.m. with the CNO, competency documentation for use of patient restraints was requested for EDRN and SG 1. A document titled, “Emergency Department Nursing Competency”, undated and unsigned was provided for EDRN and did not include the use of patient restraints. No competency documentation was provided for SG 1. During a review of the facility’s P&P titled, “Chemical or Physical Restraint,” undated, the P&P indicated, “It is the policy of [hospital name] to implement emergency intervention procedures for behavior control. The policy describes the techniques that may be used in the management of patients who exhibit severe aggressive or explosive behavior which pose an immediate threat of bodily harm to themselves or others ...the decision to use physical restraint should be made by the physician but may be initiated by the Registered Nurse in extenuating circumstances.” A review of the facility document titled, “Job Description: Security and Transportation Guard,” undated, indicated, “Competencies: Excellent De-Escalation Skills: Proficiency in managing aggressive, psychiatric or intoxicated patients without using force preferred.” During an interview on 6/4/26 at 9:30 a.m. with SG 2, SG 2 stated he has assisted to restrain a patient in the ED. SG 2’s use of patient restraints competencies was requested from the Chief Nursing Officer (CNO) but were not provided. A P&P for staff competencies addressing patient restraints was requested but not received.”

“NUTRITION CFR(s): Nutrition (§483.25(g)(1) and (g)(2) of this chapter). “ §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This Standard is not met as evidenced by: 40830 Based on interview, medical record and facility document review, the facility failed to address the nutritional needs of one of three patients (Patient 3) when the nutritional evaluation and recommendations for Patient 1 did not reflect standards of practice for a patient with a pressure ulcer (damage to the skin and underlying tissue caused by prolonged, unrelieved pressure that restricts blood flow to the area). This failure had the potential to delay Patient 1’s wound healing. During a concurrent interview and record review on 6/3/26 at 10:46 a.m. with registered dietician (RD) 2 , Patient 1’s medical record was reviewed. The record indicated Patient 1 was admitted on 5/21/26 with admitting diagnosis of Stage 4 Pressure ulcer at the sacral region (the area at the base of the spine, situated above the tailbone and between buttocks). The admission history and physical indicated Patient 1 had history of paraplegia (a medical condition characterized by partial or complete paralysis of the lower half of the body which typically affects both legs), diabetes, hypertension, HIV (Human Immunodeficiency Virus, a virus that targets and destroys specific cells in the immune system), prostate cancer, and sacral osteomyelitis (inflammation or infection of the bone) for continued antibiotic therapy and wound care. The record indicated Patient 1’s admission weight was 153 pounds (lbs.). The record indicated Patient 1 had a regular diet and nutrition consult ordered on admission. The record indicated the initial nutrition assessment was completed by RD 1 on 5/25/26, four days after the RD consultation was ordered. The initial nutrition assessment indicated Patient 1’s documented meal intake was 50 to 100%, and Patient 1 was receiving protein powder, and multivitamins with minerals. The initial assessment indicated Patient 1’s calculated estimated protein needs was 0.8 - 1.0 gram protein/kg (weight in kg). Patient 1’s initial assessment recommended RD follow-up in two to three months. RD 2 stated RD 1’s initial assessment did not accurately reflect the protein needed to promote wound healing and at least 1.3 g protein/kg would be needed for wound healing. RD 2 stated nutritional follow-up would be needed at closer intervals since Patient 1’s meal intake was variable. RD 2 she did the follow up notes on 6/2/26 and the weight was 142 lbs. She stated there was a 11 lbs., 7.2% weight loss from 5/21/26 to 6/2/26. The nutrition follow-up notes indicated if the wound did not improve, Patient 1 would need an increase in calorie and protein intake. RD 2 stated nutrition department did not have specific policy and procedure (P&P) outlining nutrition care for patients with pressure ulcers. During an interview on 6/3/26 at 12:50 p.m. with Wound Care Nurse/Director of Nursing (WCN/DON), WCN/DON stated she would inform the dietary department and request consultation from RD if the pressure ulcer got worse. A review of undated nursing P&P titled, “Pressure Injury Prevention,” noted there was a section related to nutrition care and indicated, “provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional cycle ...include: nutritional assessment; estimation of nutritional requirements; comparison of nutrient intake with estimated requirements, provide appropriate nutrition intervention; based on the appropriate feeding route; monitoring and evaluation of nutritional outcome, with a reassessment of status as frequent intervals while an individual at risk ...” Review of NIH article titled, “Clinical Impact of Nutritional Intervention on Pressure Injury Healing in Paraplegic Patient: A Case Report,” dated 10/31/2025, indicated, “Nutrition plays a critical role in both the prevention and management of pressure injuries. Adequate nutritional support promotes wound healing ...The 2019 NPIAP (National Pressure Injury Advisory Panel) guidelines ...recommend providing 1.25-1.5 g [gram] of protein per kilogram of body weight per days for adults with pressure injuries who are malnourish or at risk of malnutrition. For individuals with Category/Stage II or more severe pressure injuries, providing high-calorie, high protein oral nutritional supplements ...is advised ...””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 38970 Based on interview and record review, facility failed to maintain an accurate central log of patients seeking care for an emergency medical condition, including whether patients refused treatment, were admitted and treated, stabilized and transferred, or discharged (known collectively as patient disposition) when: 1. 22 of 75 log entries reviewed did not include patients’ disposition (Patients 23-44), 2. One of the ten patients (Patients 45) who received emergency care on 10/5/24 and two of eleven patients (Patient 46 and Patient 47) who received emergency care on 2/8/25 were not listed on the central log, 3. Two patients (Patient 48 and Patient 49) presenting for outpatient services (laboratory draws and prescribed on-going care) on 10/5/24 and one patient (Patient 50) presenting for outpatient services on 2/10/25 were listed in the central log. These failures resulted in the inability to accurately track the emergency care delivered. Findings: During a concurrent interview and record review of the Emergency Department (ED) Central Log (CL) with Emergency and Acute Care Nurse Manager (NM), on 3/5/25 at 10:50 a.m., NM confirmed the paper log book located in the ED was the CL and was missing disposition entries on log pages 24, 59, and 77. NM stated ED techs were responsible for completing log entries and had failed to do so. NM stated the disposition information would be in individual patient electronic records. NM stated the Quality and Compliance Lead (QCL) could create and provide an electronic record for the dates requested for review, which were 10/5/24 and 2/8/25. During a concurrent interview and record review of the CL and electronic health record report (eHRR) of ED visits, with Chief Nursing Officer (CNO), NM, and QCL on 3/6/25 at 2:05 p.m., QCL stated the eHRR was comleted on 3/6/25 at 11 a.m. (24 hours after surveyor request.) QCL stated eHRR had not been created prior to surveyors’ arrival and was not readily available on 3/5/25. In a continued interview and record review, the two records were compared. The eHRR indicated Patient 45 received emergency care on 10/5/24, and Patient 46 and Patient 47 received emergency care on 2/8/25. CNO stated the eHRR was the most accurate record of emergency care delivered. NM confirmed patients received emergency care on those dates and the CL did not record the visits, and stated, “The department must have been busy those days.” In a continued interview and record review of the CL and eHRR, NM and QCL confirmed Patient 48, Patient 49, and Patient 50 had been included in the CL but were not on the eHRR. QCL stated only patients who received emergency care would be included on the eHRR. NM stated patients who had physician orders for outpatient services such as recurrent intravenous infusions, laboratory blood draws, or wound care entered the facility for the outpatient services through the ED entrance but were not seeking emergency care and should not have been included on the CL. NM confirmed Patient 48, Patient 49, and Patient 50 had physician orders for outpatient services. In a review of a facility policy titled, “Emergency Medical Treatment and Labor Act (EMTALA)”, dated June 2023, the policy indicated, “Central log means a log maintained by the hospital recording the names who come...seeking emergency assistance and the disposition of each individual ... [and] does not apply to an outpatient.””