Modoc Medical Center

“K3 BUILDING: 01 - HOSPITAL Main Campus Building 100 (1111 N Nagles St., Alturas-since 2020) K6 PLAN APPROVAL: 7/1/1966 K7 SURVEY UNDER: 2012 EXISTING K12 TYPE OF STRUCTURE: One Story, Type II (111), Fully Sprinklered. The following reflects the findings of the California Department of Public Health, during a recertification Life Safety Code Survey. The findings are in accordance with 42 Code of Federal Regulations (CFR) §482.41(b)(c)(e), National Fire Protection Association (NFPA) 101 - Life Safety Code, 2012 Edition, and NFPA 99 - Health Care Facilities Code, 2012 Edition. CENSUS: 3”

“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: 43379 Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations in the wall. This affected three of eight smoke compartments and could result in the spread of fire and smoke in the event of a fire. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the walls were observed. 1. At 10:07 a.m., three separate one by one inch wall penetrations with conduits were observed in the Environmental Services closet of the Medical-Surgical area, lacking proper fire stopping. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetrations. 2. At 10:11 a.m., the storage room (DS101) in the kitchen area was observed with a one by one inch penetration with a conduit running through the wall. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetration. 3. At 10:23 a.m., four separate one by one inch penetrations were observed in the sterilizer room (RD107) with data cables running through the wall. Upon interview, the Maintenance Staff stated that he was not aware of the unsealed penetrations.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 43379 Based on observation and interview, the facility failed to maintain emergency lighting in the Operating Room (OR). This was evidenced by the failure to have battery-powered emergency lighting in the OR. This affected one of eight smoke compartments and could result in potentially hazardous conditions during a power outage, compromising patient safety and staff ability to effectively manage surgical procedures in low-visibility situations. NFPA 99, Health Facilities Code, 2012 edition. 6.3.2.2.11 Battery-Powered Lighting Units. 6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. 6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room. 6.3.2.2.11.4 Units shall be capable of providing lighting for 1 1/2 hours. 6.3.2.2.11.5 Units shall be tested monthly for 30 seconds, and annually for 30 minutes. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the lighting fixtures in the OR were observed. At 2:36 p.m., the OR was observed without battery-powered lighting units. Upon interview, the Maintenance Staff confirmed that the OR did not have battery-powered lighting units and stated that they were unaware of the requirement.”

“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: 43379 Based on observation and interview, the facility failed to maintain a hazardous enclosure. This was evidenced by the failure to have a self-closing device on the exit door to a storage room. This could result in the passage of smoke in the event of a fire, and affected one of eight smoke compartments. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the storage rooms were observed. At 11:51 a.m., the dry food storage room (DS107) located in the kitchen area failed to have a self-closing device on the exit door. The room was approximately 119 square feet and contained dry food storage. Upon interview, the Maintenance Staff stated that he was not aware that a self-closing device was required on the exit door.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 43379 Based on document review and interview, the facility failed to maintain the facility’s Smoke Detectors. This was evidenced by missing records of biennial smoke detector sensitivity testing. This affected three of three patients and eight of eight smoke compartments, and could result in a non-detected system malfunction in the event of a fire. NFPA 101, Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6 9.6.1* General. 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition. Chapter 14 Inspection, Testing, and Maintenance 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. Findings: During document review and interview with Maintenance Staff on 4/29/25, the smoke detectors were observed and records were requested. At 12:36 p.m., the facility failed to provide upon request the smoke detector sensitivity test records. The last test was unknown. Upon interview, the Maintenance stated that no documentation was available for review.”

“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: 43379 Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to maintain the pressure gauge on the facility’s wet system riser. This affected eight of eight smoke compartments and three of three patients, and could result in a delay of extinguishment in the event of a fire. NFPA 101 Life Safety Code, 2012 edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7.5 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 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the sprinkler system was observed. At 9:57 a.m., the wet sprinkler system riser was observed with a pressure gauge that was dated 2019. The wet sprinkler system riser was located in the mechanical room that was only accessible from the exterior of the facility. There was no indication the pressure gauge had been tested by comparison with a calibrated gauge. Upon interview, Maintenance Staff admitted they were unaware the gauge was over five years old or whether the vendor had tested its viability.”

“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: 43379 Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced a fire extinguisher that was obscured from view. This affected one of eight smoke compartments, and could result in delayed use of the fire extinguishers in the event of a fire. 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 Manual Extinguishing Equipment. 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 6.1.3.3 Visual Obstructions. 6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the facility’s fire extinguishers were observed. At 10:20 a.m., the telecom equipment room was observed with an ABC fire extinguisher that was obstructed from view. Two cardboard boxes were placed directly in front of the extinguisher. Upon interview, the Maintenance Staff confirmed that the ABC extinguisher was obstructed from view.”

“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: 43379 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a corridor door that failed to latch and by corridor doors that were obstructed. This affected two of eight smoke compartments and could result in the inability to contain smoke and/or fire to a room. NFPA 101, Life Safety Code, 2012 Edition. 19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the corridor doors were observed and tested. 1. At 10:02 a.m., the corridor door to room 102/103 in the medical-surgical area failed to latch when tested. The door latch did not line up with the strike plate. Upon interview, the Maintenance Staff confirmed that the door latching hardware was not lining up with the strike plate. 2. At 10:59 a.m., the corridor door for room CL206 was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door. 3. At 11:01 a.m., the Administrator area corridor door was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door. 4. At 11:06 a.m., the Nursing Supervisor corridor door was observed obstructed by a door wedge that held the door wide open. Upon interview, the Maintenance Staff stated that staff placed the door wedge on the door.”

“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: 43379 Based on record review and interview, the facility failed to maintain the Fire Dampers. This was evidenced by the failure to perform the initial Fire damper inspection after installation. This affected three of three patients and eight of eight smoke compartments, and could result in malfunction of the Fire dampers. 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. NFPA90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. 5.4.7 Installation. 5.4.7.1* Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer ’ s installation instructions and the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives. 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, for inspection and maintenance of fire dampers, ceiling dampers, and combination fire/smoke dampers. 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. 19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment. 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-in place if so equipped. Findings: During record review and interview with Maintenance Staff on 4/29/25, the Fire Damper documentation was requested. At 2:34 p.m., the facility failed to provide upon request the fire damper test documentation that was required to be performed on the facility’s fire dampers one year after installation. The facility was built in 2020. Upon interview, the Maintenance Staff stated that they were unaware of the initial testing requirement for the fire dampers and confimed that the facility had not performed the required initial fire damper test.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 43379 Based on record review and interview, the facility failed to maintain the hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia was administered. This was evidenced by the failure perform the initial electrical receptacle tension and polarity testing on the hospital grade receptacles at patient bed locations and the Operating Room (OR). This affected three of three patients and two of eight smoke compartments and could cause a malfunction. NFPA 99, 2012 edition. 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations here deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. Findings: During record review and interview with Maintenance Staff on 4/29/25, the electrical wiring and equipment documentation was requested. At 12:50 p.m., the facility was unable to provide requested records of electrical receptacle tension and polarity testing for hospital-grade receptacles in patient bed locations and the OR. During an interview, Maintenance Staff confirmed that testing had not been conducted since the facility’s move into the building in 2020.”

“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: 43379 Based on observation and interview, the facility failed to maintain the electrical wiring and equipment . This was evidenced by an electrical panel that was obstructed and a power switch that failed to have a cover plate. This affected two of eight smoke compartments and could result in potential electrical hazard. NFPA 101, Life Safety Code, 2012 Edition 19.5 Building Services. 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 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. 314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B). (A) Nonmetallic or Metal Covers and Plates. Nonmetallic or metal covers and plates shall be permitted. Where metal covers or plates are used, they shall comply with the grounding requirements of 250.110. Findings: During a tour of the facility and interview with Maintenance Staff on 4/29/25, the electrical wiring and equipment were observed. 1. At 10:57 a.m., the electrical panel located in the CT scan room CAT1 was observed with a rolling cart that was parked approximately three inches in front of the panel. Upon interview, the Maintenance Staff confirmed that the electrical panel was obstructed. 2. At 11:09 a.m., the dry sprinkler riser located by the front lobby area closet was observed without a cover faceplate for the air compressor power switch. Upon interview, the Maintenance Staff stated that he was not aware that the face plate was missing.”

“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: 43379 Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of a relocatable power tap. This affected one of eight smoke compartments,and could result in an electrical fire. NFPA 101, Life Safety Code, 2012 Edition 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. Chapter 9 Building Service and Fire Protection Equipment 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 (7) Where subject to physical damage Findings: During a facility tour and interview with Maintenance Staff 4/29/25, the electrical equipment and wiring was observed. At 11:04 a.m., the Administrator area was observed with a relocatable power tap that was connected to another relocatable power tap underneath the executive assistant desk. Upon interview, the Maintenance Staff stated that he was not aware that the relocatable power taps were connected.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 40204 Based on interview, and record review, the Critical Access Hospital (CAH) failed to provide written notice to all inpatients at the beginning of a planned, or unplanned inpatient stay, of not having a doctor of medicine or osteopathy present in the CAH 24-hours per day, seven days per week as required by Federal law. The purpose of this requirement is to assist the patient in making an informed decision about his/her care in deciding where to seek treatment. This failure to provide coverage information can result in patient care that is not known to be inconsistent with the patient’s treatment goals having the potential for less than desired clinical outcomes. Findings: On 4/22/25 at 7:30 am, during a concurrent interview, and record review, with the Chief Nursing Officer (CNO), the CNO was unable to provide evidence of patients being given written notice of the facility not having a Medical Doctor (MD), or Doctor of Osteopathy (DO) on site 24-hours a day, 7-days per week, 365-days per year as required by Federal law. When asked about the required written notice the CNO stated, “It is outside on the sign. That is all we have on that.” On 4/22/25 at 11:45 am, during a concurrent interview, and record review, with the Nurse Manager (NM), the NM was asked about the facility providing evidence of patients being given the written notice as described above. The NM provided a document that was for Swing Bed (beds for patients staying in the facility longer than 96-hours), not for the standard in patient admissions. The NM stated, “This is all we have that we could find.” On 4/22/25 at 5 pm, during a concurrent interview, and record review, with the CNO, the regulations regarding giving patients’ information of MD/DO presence were discussed. The CNO confirmed, that there is no notice provided to pre-admit patients and for ER patients the notice is provided only by “the sign out front.” The CNO confirmed, that that patients coming in for pre-admit screening (patient preparatory services such as x-ray, lab etc.) should be provided the information to comply with this regulatory requirement.”

“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: 41600 Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and monitored properly according to the facility’s policies and procedures, or manufactures’ specifications and requirements for a census of 3, when: 1. Twenty-three injectable vials of methylprednisolone, a medication to treat many different inflammatory conditions, were not protected from light in accordance with the manufacturer’s storage requirements. 2. A crash cart supplied with emergency drugs and equipment for resuscitation located in the Post-Anesthesia Care Unit (PACU), did not have a supply list posted outside of the cart with the shortest outdate listed for each medication. These failures had the potential for medication degradation and administration of potentially ineffective or expired medications, which could lead to negative clinical outcomes. Findings: 1. During an inspection of the facility’s pharmacy on 4/22/25 at 12:25 pm, twenty-three injectable vials of methylprednisolone 40 mg, and 125 mg (milligram, unit of measure) per vial were observed outside of manufacture’s box in two clear storage bins on the shelf in the main pharmacy room. The storage bins did not have any “protect from light,” labels on the outside and the twenty-three vials were exposed to light. During an interview, on 4/22/25 at 12:30 pm, with the Director of Pharmacy (DOP), the DOP stated, “the vials should not be there, and they should be protected from light to prevent drug degradation.” During an inspection of the methylprednisolone box and manufacturer’s label in the pharmacy on 4/22/25 at 12:35 pm, the manufacture label on the box indicated, “Protect from light.” During a review, of the facility’s policy and procedure (P&P) titled, “Inspection, Storage and Inventory of Medications,” dated 2/2018, the P&P indicated, that medications shall be maintained under all appropriate storage requirements (e.g. temperature and light condition) recommended by the drug manufactures. 2. During an inspection of the PACU medication storage area on 4/22/25 at 12:40 pm, a crash cart was observed to be in the unit without having a content list posted on the outside. During an interview, on 4/22/25 at 12:40 pm, with the DOP, the DOP was able to confirm the content list was not posted on the outside. The DOP stated, the staff can break the seal and gain access to the medications to see what medications are inside of each drawer. During a review, of the facility’s P&P titled, “Crash Cart content,” revised 2012, the P&P indicated, that all licensed staff will be oriented to cart contents during orientation, and shall be re oriented on a regular basis. These carts are sealed with plastic numbered locks which are checked and documented by nursing staff daily. Each locked drawer will have a contents list with shortest outdate listed for each medication. Assure correct outdate dates are on written on label outside of each drawer. During an interview. on 4/24/25 at 9 am, with the Surgery Director (SD), the SD acknowledge the pharmacy policy stated to list the content on the outside.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 42448 Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of patients were being met in accordance with recognized dietary practices when: 1. The facility diet manual contained multiple types of similar diets with different names, that did not meet professional standards of practice, and did not consistently match the diets ordered or provided to patients. 2. The diets available to be ordered in the electronic medical record by providers did not match the diets as described in the facility diet manual. 3. Dietary staff received minimal training regarding therapeutic diets and preparation of therapeutic diets. These failures had the potential to result in non-compliance with physician’s orders, and increased risk regarding patient safety and patient satisfaction in terms of their diets which could lead to negative clinical outcomes. Findings: During a review, of the facility’s policy titled Therapeutic Diets, effective 6/20, it indicated, that a therapeutic diet is a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substance in the diet (e.g., sodium or potassium) or to provide mechanically altered food when appropriate. Diets will be offered as ordered by the physician. During an interview, with the Food Services Manager/Certified Dietary Manager (CDM) on 4/21/25 at 9:50 am, he stated, that they had a 4-week menu cycle at their facility. He stated they had eight beds, and an average census of four patients, with average length of stay three-to-five days. During an interview, with the CDM on 4/22/25 at 9:56 am, he stated, that he worked Monday through Friday, and occasionally popped in on the weekend to check up on staff. He stated the kitchen closed at 8:30 pm, and the Cook was the person in charge when he wasn’t there. During an interview, with the Director of Nursing (DON) on 4/22/25 at 7:50 am, he stated the Registered Dietitian (RD) had a significant role in developing the current patient menus, and she approved the menus and diet manual for both the acute care, and long-term care facilities. During an interview, with a provider (MD) 1 on 4/22/25 at 9:10 am, he was asked if the diet orders available in the electronic medical record (EMR) met his patient’s needs. He stated there were too many options. “If I had a better indication of what the orders meant it would be helpful.” He stated he would like more details instead of a one-page summary. When asked what he thought a Cardiac Diet was he stated, “I could hazard a guess.” He stated he had received no education about diets from the RD. He was unaware of any diet manual available, or its location at the facility. During an interview, with the RD on 4/22/25 at 10:50 am, she stated she no longer did much with the kitchen and mostly went to the kitchen if there was a reason. She stated, she hadn’t been spot-checking patient meal trays much lately to know if the meals, as provided, were correct for the diet order. She stated she provided one “paper” in-service to kitchen staff on the IDDSI (International Dysphagia Diet Standardization Initiative - texture modified diets for patients with chewing or swallowing difficulty) about a year ago. During an observation, of breakfast tray line (assembly process for patient meal trays) on 4/24/25 at 7:26 am, Food Service Worker 3 (FSW 3), and FSW 4 prepared two patient meal trays. The meal card on Patient 6’s tray indicated he was on a 75 gram CCHO (consistent carbohydrate diet - a diet ordered to help control blood sugar levels for patients with diabetes), and also a Cardiac diet (a diet often ordered for patients with heart or blood pressure issues). The condiments on the tray included butter, salt-free seasoning, and pepper. FSW 4 stated the patient didn’t want the sugar substitute. In an additional breakfast meal tray observation, Patient 7’s meal card indicated she was on a Renal Diet (a diet often ordered for patients with kidney disease). Her tray condiments included a butter pat, pepper, and a salt packet. When asked if the salt packet was appropriate for a renal diet order, FSW 4 stated she wasn’t sure if that was correct, but she removed the salt packet, added salt-free seasoning, and stated she would look it up in the diet manual after tray line. On 4/24/25 at 7:30 am, an undated document posted for staff reference was reviewed. It was titled “Diets & Condiments,” and listed the condiments to be provided with assorted diet orders. It did not include whether butter should be provided or not. The renal diet was not included in the list of diets. The document indicated: Regular Diet - Salt, Pepper, and Sugar. No Added Salt (NAS) Diet - Mrs. Dash, Pepper, and Sugar. 2 gram NAS Diet - Mrs. Dash, Pepper, and Sugar. Heart Healthy/Cardiac Diet - Mrs. Dash, Pepper, and Sugar. NCS/Diabetic Diet - Splenda, Salt, and Pepper. CCHO 45 gram, 60 gram, 75 gram - Splenda, Salt, and Pepper. During further observation, and concurrent interviews, with FSW 4 on 4/24/25 at 7:30 am, she stated she was looking at the diet manual to see the condiments allowed for the renal diet. It did not include salt, and FSW 4 concluded she should not have put salt on the renal tray. She added she would be sure to share about that with the other staff. FSW 4 stated, that the diets of the two patients that morning were odd/unusual for them. One was for renal and the other for 75 gram CCHO Cardiac. She pulled down a clipboard containing the Cook’s diet spreadsheets staff used for reference, and showed staff only had the 60 gram CCHO spreadsheets available to refer to. When asked what they did for the 75 gram CCHO diet ordered that morning, she stated they just sent the regular 60 gram CCHO menu. They didn’t know what else to do and they didn’t add any additional carbohydrate to the tray. A review, of Cook’s diet spreadsheet documents provided by the CDM, titled “Edited 24/25 Version 2 - Week 1,” indicated the various foods and portions to be served on each meal tray, each meal, each day for each diet order. The spreadsheets directed butter to be provided for Consistent Carbohydrate (CHO 45 gram, 60 gram, and 75 gram) and Regular diets, but should NOT be provided to Heart Healthy (Cardiac) and Pureed diets. When FSW 4 was asked how she knew if butter should be included on the various meal trays, she stated she looked on the Cook’s spreadsheets to see if the diet included butter. Yet she had placed butter on Patient 7’s meal tray that had a 75-gram carbohydrate, cardiac (no butter included) combined diet order. A review, of a facility’s job description titled, “Acute Dietary, Dietary Manager,” (effective 11/22), did not indicate any requirements for knowledge, or responsibility regarding therapeutic diet compliance. A review, of a facility’s job description titled, “Dietary/Acute/SNF - Cook,” (effective date 8/4/20), indicated Specific Competencies Consults with Dietary Manager, and/or Clinical Dietitian on modified diets, as necessary. Follows therapeutic diet orders/spreadsheets/alternate meal requests. No job description for Acute Dietary Department Dietary Aides was provided. During an interview, on 4/22/25 at 9:56 am, the CDM stated, that the department had a general training checklist, staff had to initial off on it, but there was no position-specific training checklist. He stated, that he knew staff were competent in their duties because he kept an eye on them, and corrected them as needed. During an interview, with the CDM on 4/23/25 at 9:50 am, he stated that all employee education, training and competency was in their Human Resources (HR) files. He didn’t have any of their files in his office. A review, of employee files regarding education, training, and competency documentation for CDM, FSW 1, FSW 2, FSW 3, and FSW4 was conducted in HR on 4/23/25 at 1:55 pm. HealthStream (electronic training and competency software) Transcripts for each employee with transcript range 4/24/23 through 4/23/25, did not show any education or competency regarding therapeutic diets. An additional document titled, “Dietary Department Orientation Checklist,” was present in four out of five staff files reviewed (none for FSW 2), and included the Diet/Nutrition care manual, basic therapeutic diets offered, menus and recipes, and menu extensions for therapeutic diets (cooks spreadsheets). The orientation checklists each contained 145 topics and per the dates, were completed in one day. No evidence was provided to show that any further staff education or competency verification regarding therapeutic diets. A review, of an undated electronic medical record (EMR) report provided by the Nurse Manager (NM) on 4/21/25, titled “Order sentences for: Diet Order,” indicated diet orders available in the EMR for providers to select. It included approximately forty diet order choices. The list included but was not limited to: *Two “Cardiac” diet choices, and one “Healthy Heart” diet choice without further explanation as to the differences. *Four Carbohydrate-controlled diet choices - (Consistent Carbohydrate [CCHO] diets are ordered for patients with diabetes to help control their blood sugar levels): 45 gram Consistent CHO (grams of carbohydrate provided each meal); 60 gram Consistent CHO; 75 gram Consistent CHO; No Concentrated Sweets *Seven texture modified diet choices (ordered for patients with chewing or swallowing issues): Honey Thick; Mechanical Soft; NDD3 (chopped); (NDD = National Dysphagia Diets. Dysphagia means difficulty swallowing); NDD3 (chopped), Soft; Nectar Thick; Pureed; Soft Mechanical A review, of the facility’s diet manual created by Nutrition Therapy Essentials, Inc., titled, “Diet Manual for Rehabilitation, Residential and Long Term Care Facilities,” dated 2023, was last approved by the Administrator, Medical Director, Director of Nursing, Food & Nutrition Services Director, and Registered Dietitian Nutritionist on 1/1/24. A review, of the diet manual table of contents showed it did not list, explain or define a “Cardiac” diet, yet Cardiac diet was in the list of diets twice as orders available in the EMR. A review of the “Heart Healthy” diet in the diet manual described a diet lower in saturated animal fats and sodium. The diet order available in the EMR was “Healthy Heart (Cardiac).” During an interview, with the CDM on 4/22/25 at 9:56 am, he stated a cardiac (Heart Healthy) diet at their facility meant less fat, less salt (but not a 2 gram sodium restriction), and the cardiac diet did not get butter on the tray. He stated there was a condiment list posted in the kitchen for staff to use, to help them know what to put on meal trays for various diets. A review, of diet manual pages titled, “Consistent Carbohydrates/Reduced Concentrated Sweets Diet,” described it as the diet prescribed for diabetes management, with provision of 2200 - 2600 kcals (calories/a measurement of energy) daily, 70-110 grams protein, 100 grams fat. It showed approximate carbohydrate amounts provided per meal as “Breakfast: 75-90 grams; Lunch 75-105 grams; Dinner: 70-100 grams; Snack (if ordered): 15-30 grams.” A concurrent review of diets orderable by providers in the EMR showed consistent carbohydrate diet orders with 45, 60 or 75 grams of carbohydrate each meal. In an additional review of the Nutrition Care Manual of the Academy of Nutrition and Dietetics, the Reduced (or No) Concentrated Sweets Diet was listed as obsolete, yet remained as a stand-alone diet that could be ordered in the EMR. A review, of the diet manual regarding texture modified diets revealed many choices including Mechanical Soft or Dental Soft; Finely Chopped; Puree; Dysphagia & Thickened Liquids - Traditional System; and International Dysphagia Diet Standardization Initiative (IDDSI). The International Dysphagia Diet Standardization Initiative (IDDSI) Framework is a set of descriptors describing texture modified foods and thickened liquids for people with eating, drinking and swallowing problems across the lifespan. IDDSI is the only diet framework professionally recognized and supported by the Academy of Nutrition and Dietetics (AND) as of October 2021. While IDDSI is briefly described in the diet manual, none of the eight levels of IDDSI diets are available in the EMR for providers to order. NDD - National Dysphagia diets are listed in the EMR order choices, yet they are not described in the diet manual, and they are no longer recognized by AND. During an interview, with the Food Services Manager/ Certified Dietary Manager (CDM) on 4/21/25 at 9:50 am, he stated they rarely had texture modified diets, and it was usually for patients with no teeth (rather than swallowing difficulties). During an interview, with FSW 3 on 4/22/25 at 9:25 am, he stated he never received any training at this facility regarding texture modified diets, and they were rarely ordered there. He stated that when the orders came through, he asked the CDM for help and the CDM checked the consistency. He stated he never heard of IDDSI. During an interview, with the CDM on 4/23/25 at 4:05 pm, he stated the PU4 Pureed 4 (on tray tickets) was “similar to/ almost like the IDDSI diets.” Pureed should be smooth, lump free, moist consistency. He stated the department did all their pureed foods this way unless otherwise specified. During an interview, with the RD on 4/22/25 at 10:50 am, she stated she was unaware the diet manual described CCHO diets as a CCHO “or Reduced Concentrated Sweets” diet when they were not the same. She was unaware the diet manual did not describe what a cardiac diet was. She stated they used the Heart Healthy Diet instead of cardiac diet. She stated she was unaware the IDDSI diets were not possible to order in the EMR software. A review, of the facility’s policy titled, “Available Diets,” effective 8/20, indicated that the purpose was to inform the physicians and nursing staff of available diets the facility is able to provide and accommodate. It defined “diet” as “a type of food prescribed for a person to either meet their nutritional needs and/or treat a medical condition.” “It is the policy of Modoc Medical Center (MMC) Acute Dietary Department to provide a diet/nutrition care manual that outlines diets available for use in our facility.” “The following diets are offered at our facility and may be found in the diet/nutrition care manual.” The list included chopped, mechanical soft, pureed and thickened liquid diet, but did not include IDDSI diets that are the current professional standard of practice. It included Heart Healthy (Cardiac) diets but not Cardiac diet orders. It included “Diabetic/No concentrated sweets/controlled carbohydrate (CCHO)/calorie controlled diabetic diets i.e.; 1200, 1500, 1600, 1800, 2000, 2200, 2400.” Review of the Academy; of Nutrition and Dietetics Nutrition Care Manual listed no concentrated sweets, and calorie specific diabetic diets as obsolete diets, stating they were not evidence-based and were also not supported by the American Diabetes Association.”

“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: 47442 Based on observation, interview, and record review, the facility failed to ensure nursing services developed, maintained and followed facility policies when: 1. The facility did not develop a policy for monitoring and logging air flow checks on the isolation (quarantine) room on the Medical/Surgical Unit. 2. The nursing staff did not label two Nova (a brand name) StatStrip® glucose control solution (a solution with a specific known concentration of sugar used to check the accuracy of a blood glucose meter and test strips) vials and two Nova StatStrip® test strip (strips used with the meter to hold a drop of solution and the patient’s blood) containers did not have an open date or an expiration date on them. 3. The facility failed to remove expired Cidex (a brand name for a disinfecting solution) strips (strips dipped into the solution to make sure it had the minimum concentration level for disinfection to kill germs) from the sterile processing area. These failures had the potential to cause the spread of germs to patients and produce inaccurate patient blood glucose test results which could have led to negative clinical outcomes. Findings: 1. During an observation, of the Medical/Surgical (Med/Surg) Unit, on 4/21/25 at 11 am, Room 7 near the end of the hall was used for patients requiring isolation due to various infections. The isolation room was a negative pressure room (air pressure inside the room was lower than the air pressure outside the room so contaminated air would not flow out of the isolation room when the door was open). An ante room (area used for preparing to enter the isolation room) was located next to Room 7. During an interview, on 4/21/25 at 11:35 am, Nurse Manager (NM), stated the facility did not have a policy for maintaining or documenting air flow checks for the isolation room on the Med/Surg Unit. During an interview, on 4/21/25, at 11:40 am, Director of Maintenance (DM), stated the facility did not have a maintenance log indicating air flow checks were completed on the isolation room on the Med/Surg Unit. 2. During a concurrent observation, and interview, on 4/22/25 at 8:35 am, on the Med/Surg Unit, with Registered Nurse (RN) 2, two Nova StatStrip® glucose control solution bottles and two Nova StatStrip® test strip containers were not dated by the nursing staff when they were opened and when they expired. RN 2 confirmed there were no dates, and the containers should have been labeled with the dates indicating when they were opened and when they expired. During a review, of Nova StatStrip® Glucose Control Solution manufacturer’s guidelines, dated 1/2022, it indicated that the solution could only be used for three months after being opened. Upon opening a new vial of solution, the user should count forward three months and write that date on the label of the control solution vial. The user should discard any remaining solution after the date written on the vial. During a review, of Nova StatStrip® glucose meter test strips manufacturer’s guidelines, dated 1/202, it indicated that the expiration date was printed on the vial but once opened they were stable for up to six months or until the expiration date, whichever came first. The user was directed to not use the test strips if the expiration date had passed, for this may have caused inaccurate results. During a review, of the facility policy, titled, “Nova StatStrip® Glucose Meter,” dated 6/1/14, the policy indicated if a quality control test did not fall within the specified range, the user should have verified that the Nova StatStrips® and the control solutions were not past their expiration dates. During a review, of the facility’s record, titled, “Glucometer Competency Assessment,” dated 7/17/24 and used for staff training, it indicated that the first thing staff must do when opening a new set of controls or a new vial of strips was to date them. 3. During a concurrent observation, and interview, on 4/22/25 at 2:15 pm, with Nurse Manager (NM), in the sterile processing area, NM confirmed a bottle of Cidex strips stored in the area had an expiration date of 10/31/24. NM confirmed the bottle of Cidex strips was expired and should have been removed from the sterile processing area by the expiration date. A review, of a facility’s policy, titled, “Equipment and Supplies,” dated 2024, indicated that outdates should be checked in the supply room, soiled decontamination room, medication room, sterile processing, operating room, anesthesia office, and the procedure room with the adjacent cleaning and reprocessing area every month. Outdated instruments and supplies should be removed and replaced as needed.”

“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 insulin, medication to lower blood sugar levels, orders were administered in accordance with the facility policy, and accepted standards of practice for a census of 3, when: Three different types of insulin vials were kept together in a basket outside of the automated dispensing machine. The Registered Nurses (RN)s did not have a standardized process in place to administer patients’ insulin. This failure had the potential for medication errors to occur which could lead to negative clinical outcomes. Findings: During an inspection, of the medication storage room near the Emergency Department (ED) on 4/22/25 at 12:50 pm, with the Director of Pharmacy (DOP), 3 vials of insulin were observed to be sitting on the counter in a plastic basket which included insulin lispro, a rapid-acting insulin, 3 ml (milliliter, unit of measure), insulin novolin-R, a short acting insulin, 10 ml, and insulin glargine, a long-acting insulin, 10 ml. During an interview, on 4/22/25 at 12:50 pm, with the DOP, the DOP stated, the insulin vials were not stored in the refrigerator since the refrigerator was out of order for the past few days. The DOP also stated insulin vials were kept together in the basket and scanned by the nurses outside of patients’ rooms. During an interview, on 4/22/25 at 12:56 pm, with Registered Nurse (RN) 1, RN 1 stated the insulin goes through a double check process when the medication is being taking out of the vials. Since the medication is verified with two nurses, one nurse can go into patient’s room to administer the insulin. During an interview, on 4/22/25 at 3 pm, with the Nurse Manager (NM), NM stated, insulin should be scanned twice with the use of the insulin bottle inside the patient’s room. During an interview, on 4/22/25 at 3 pm, with RN 3, RN 3 stated she would take the vial and a witness to patients’ room in order to administer insulin. During an interview, on 4/22/25 at 3:05 pm, with the DOP, the DOP acknowledged there will be increased risk of infection if insulin bottles were carried into patients’ rooms for insulin administration. During an interview, on 4/23/25 at 10:05 am, with RN 1, RN 1 stated, the scanning is done in the hallway using the computer software, but not in the patients’ rooms. The RNs did not have a standardized process in place for insulin administration. During a review, of the facility’s policy and procedure (P&P) titled, “Insulin Preparation and Administration,” revised 7/2017, the P&P indicated, that it was the policy of Modoc Medical Center that all licensed staff shall be knowledgeable regarding the facility protocol on insulin and shall abide by the protocol...storage: store in refrigerator. Remove 30-60 minutes prior to use to facilitate absorption and prevent pain with injection. Administration: check insulin dose by another licensed staff person prior to administration to ensure accuracy.” During a review, of the facility’s P&P titled, “Omnicell Automated Dispensing Machines - Removing Medications,” revised 7/2017, the P&P it indicated, that it was the policy of Modoc Medical Center that medications will be removed from the automated dispensing machine for only one patient at a time when using multi-dose bottles, remove the dose prescribed and place the bottle back in the correct bin before closing the drawer or door. Any medication removed from the automated dispensing machine that is not administer must be returned to the external return bin. The pharmacist or the pharmacy technician will follow prompts on the Omnicell screen to place the correct medication into correct bin. The prompts shall include bar-code scanning of the specific medication, immediately followed by bar-code scanning of the Omnicell bin. Process only one individual medication and strength at a time. According to an online publication by the Institute for Safe Medication Practices (ISMP), an organization focusing on the prevention of medication errors and promoting safe medication practices, the guidelines for Optimizing Safe Subcutaneous insulin Use in Adults, published in 2017, stated, “Confusion between rapid-acting, short-acting, intermediate-acting, and long-acting insulin products have been known to contribute to medication errors...If an institution has different types or multiple concentrations of insulin on their formulary, risk-reduction strategies such as storage in separate, labeled (and possibly lidded) bins should be implemented to prevent inadvertent mix-ups of the various strengths and types ...Auxiliary warning labels can be useful to differentiate products, and barcode technology can assist pharmacy personnel in drug selection and validation.””

“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: 42448 Based on observation, interview, and record review, the facility failed to ensure infection prevention strategies and staff behaviors in food safety and sanitation processes met professional standards of practice when: 1. There was no evidence the kitchen was regularly surveyed by the Infection Prevention Nurse (IP), the Registered Dietitian (RD), or the Food Services Manager (CDM) to ensure compliance to food safety and sanitation regulations. 2. The kitchen was not sanitary,with kitchen equipment not being clean, and three pieces of equipment were in poor condition. 3. Staff did not follow professional standards of practice, facility policies and procedures, or chemical manufacturer’s instructions when cleaning fixed equipment (fixed equipment is equipment that cannot go through the dishwasher and cannot be washed in the three-compartment sink, such as counters, cabinets and drawers, refrigerators and small appliances). 4. The facility served unpasteurized eggs, and food was not consistently stored in a manner to ensure food safety and food quality. 5. Staff did not consistently perform behaviors to avoid cross contamination including hand washing, glove use, apron use, and use of beard nets. These failures had the potential to result in foodborne illness for patients, staff and hospital guests who consumed food from the facility’s Food and Nutrition Services, which could lead to negative clinical outcomes. Findings: 1. There was no evidence the kitchen was regularly surveyed by the Infection Prevention Nurse (IP), the Registered Dietitian (RD), or the Food Services Manager (CDM) to ensure compliance to food safety and sanitation regulations. During an interview, with the Director of Nursing (DON) on 4/22/25 at 7:50 am, he stated the RD reported to him, and her contract was for provision of nutrition care at the acute care facility, DP SNF (skilled nursing facility), and Clinic where she did outpatient counseling. She works 3 days per week. He stated in addition to patient care, the RD approved menus and the diet manual for both acute care, and the SNF. He stated the RD had some interaction with both kitchens, and did some “evaluations.” During an interview, with the Food Services Manager/Certified Dietary Manager (CDM) on 4/21/25 at 12:10 pm, he stated their Registered Dietitian (RD) lived locally and also provided services for the facility’s skilled nursing facility (SNF). He stated he understood the RD was supposed to physically be at the acute care facility at least once monthly, but he didn’t know. He stated she rarely came to the kitchen. He estimated she came to the kitchen maybe once every 6 months. During an interview, with the RD on 4/22/25 at 10:50 am, she was asked what her relationship was with the acute care kitchen. The RD replied, earlier in her employment she did kitchen inspections and staff training, but then she needed to spend more of her time in patient care and no longer did much with the kitchen. She stated she went into the kitchen more often if there was a reason. She stated, “All the kitchen staff know me.” She added she hadn’t been spot-checking patient meal trays much lately to know if the meals were correct for the diet order. The RD stated people told her about it when things (from the kitchen) weren’t right. The RD shared she had a difficult relationship with the CDM, and she stopped going to Dietary staff meetings. During an interview, with the Infection Prevention Nurse (IP) on 4/22/25 at 11:05 am, she stated she did walk-through’s of the kitchen during Environment of Care Rounds (EOC rounds) where where she followed food, temperatures, staff handwashing, and glove use, and the department had improved. IP stated they used to the inspections quarterly, but now do them about every 6 months, and she had not done an inspection for at least 3 months. She stated “If there is anything that comes up (in the kitchen), someone tells me.” During an interview, with the CDM on 4/22/25 at 2:05 pm, he stated he did intermittent inspections of the kitchen but had no documentation to show they were done, how frequently they were done, what was found, or what was done to resolve it. A review, of a document titled, “Dietitian Consulting Agreement,” signed by the Chief Executive Officer (CEO), and RD on 3/23/22, indicated that the consultant agrees to provide guidance to the Dietary Services Supervisor, and dietetic staff as needed, approves menus and participate in the revision of policies, and provide training to staff as needed and requested. A review, of the facility’s document titled, “Job Description, Acute Dietary Department, Dietary Supervisor,” revised 12/20, indicated their Position Responsibilities: Ensures cleaning and sanitation requirements are maintained. Inspects all work areas to ensure cleanliness. Ensures infection control practices are always maintained. Maintains regulatory requirements including all state, federal and county regulations. 2. The kitchen was not sanitary, kitchen equipment was not clean, and three pieces of equipment were in poor condition. A review, of the 2022 FDA (Food and Drug Administration) Food Code §3-304.14 showed: (B) Cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; and (2) Laundered daily as specified under 4-802.11(D). A review, of the facility’s policy titled, “Cleaning Instructions for Cloths, Pads, Mops and Buckets,” effective 9/20, indicated that cleaning cloths will be kept in container of clean sanitizing solution between uses. The sanitizing solution will be tested periodically to ensure that it maintains the correct concentration. A review, of the facility’s policy titled, “Kitchen Towels/Cloths,” effective 8/20, indicated that towels/cloths that are used for cleaning counter tops and other surfaces will be stored in a sanitizing solution between uses. During observations, in the kitchen throughout the survey, from 4/21/25 at 9:30 am, through 4/24/25 at 8:30 am, sanitizer cloths used for cleaning work areas were consistently left unattended on counters in the cook’s prep area and the cook’s cooking and serving area. Unattended sanitizer cloths are a potential source of cross contamination. Observations, of unattended rags were observed on 4/21/25 at 9:51 am in cook’s prep area, 10:40 am in the cook’s prep area, 10:45 am on the serving line, 10:50 am in the cook’s prep area, 10:57 am in the cook’s serving area with thermometer left on it, 11:06 am same rag with thermometer in cook’s serving area, and two rags on counter in cook’s prep area. Unattended rags were observed on 4/22/25 at 9:35 am - 9:51 am in the cook’s prep area. Items in the kitchen area were observed as not being cleaned. A review, of the 2022 FDA (Food and Drug Administration) Food Code 4-601.11 showed (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During an observation, of the Storage Room on 4/21/25 at 9:35 am, ten out of ten black milk crates used to store packaged food items were visibly soiled with a brown/gray substance resembling dirt and dust. During an observation, in the walk-in refrigerator on 4/21/25 at 10:15 am, the condenser fans had a thick coating of a gray fuzzy substance resembling dust. During a follow-up observation, and concurrent interview, with Hospital Maintenance Staff 1 (HMS 1) on 4/21/25 at 2:30 pm, he stated his team cleaned the refrigeration coils monthly, but they had no preventive maintenance (PM) for the walk-in refrigerator, or freezer condenser fans. He stated they only cleaned the condenser fans on the exterior of the building. He stated they did no regular walk through’s or inspections of the kitchen to ensure it was maintained. During an additional follow up interviews, with the Facilities Director (FD) on 4/22/25 at 11:30 am, he stated EOC Rounds were done in the kitchen in May, and November each year.. He agreed the walk-in refrigerator/freezer condenser fans were not on his department’s PMs, or on the EOC rounds list to look at and stated he would add them. During observations, in the cook’s food prep area on 4/21/25 at 10:36, a 24-cup muffin tin had burned on black debris on both top and bottom surfaces. In a concurrent interview, the CDM agreed it was not clean. He stated “Nobody ever looks at the undersides of pans.” During further observations, on 4/21/25 at 10:40 am, the blender and Robo Coup (food processor) bases had a buildup of grime. In a concurrent interview, FSW 3 agreed they were not clean. The edges of the base of the can opener had an accumulation of black grime. In a concurrent interview, the CDM stated they didn’t have a screwdriver to remove the base for cleaning and had to ask Maintenance to come and remove it when needed. During an observation, on 4/21/25 at 11:04 am, three drawers located under the microwave oven stored utensils and had a thick coating of dust/soil in the bottom. FSW 3 and the CDM agreed, that the drawers were not clean. The CDM directed staff to empty the drawers, clean them, and clean all contents. During an observation, of the cook’s cooking and serving area on 4/21/25, the oven interior had built up grime. During an interview, with the CDM on 4/21/25 at 12:10 pm, he stated they had a cleaning schedule with daily, weekly, and monthly cleaning assignments. They also had a special staff person come in twice each month to do deep cleaning. A review, of documents titled, “Dietary Acute Cleaning Schedule,” dated March 2025, and April 2025, showed position specific daily and weekly cleaning assignments. While some Daily Cleaning assignments directed staff to clean or wash, rinse and sanitize equipment, others only directed staff to wipe it down: “Small refrigerators wipe out bottom & polish outside,” “Prep area wipe down & sanitize all work surfaces,” “Wipe down toaster,” “Wipe down & clean inside of microwave,” “Wipe down front & side of stove, fryer & oven,” “Wipe down inside of oven alternate ovens,” “Wipe down & polish stand up freezer,” “Nourishment station at nursing station ...Wipe down inside of refrigerator & shelving.” While weekly cleaning included “Empty utensil drawers, wash utensils & drawers through dish machine,” (Saturday #4 position), it was signed off as completed during two weeks in March, zero completion in April, and the interior of the drawers was not clean. With the exception of the wiping down the toaster, small appliances (blender, Robo Coupe) were not included in the daily cleaning assignments. During an observation, and concurrent interview, in the cook’s food prep area on 4/21/25 at 10:36, the CDM agreed, that three out of eight cutting boards had deep cut grooves that could harbor bacteria. During an observation, in the cook’s food prep area on 4/21/25 at 10:40, the white mixing paddle of the KitchenAid mixer had multiple areas of chipped paint. In concurrent interviews, FSW ,3 and the CDM agreed, that the chipping paint could be a food contaminant. During an observation, in the kitchen on 4/21/25 at 11:04 am, a rubber spatula in a drawer under the microwave oven had deteriorating edges with chunks of rubber missing. FSW 3, and the CDM agreed, that the missing pieces of the spatula could be a food contaminant. 3. Staff did not follow professional standards of practice, facility policies and procedures, or chemical manufacturer’s instructions when cleaning fixed equipment (fixed equipment is equipment that cannot go through the dishwasher and cannot be washed in the three-compartment sink, such as counters, cabinets and drawers, refrigerators and small appliances). A review, of the 2022 FDA Food Code 4-603.15, 4-603.16, 4-701.10, and 4-701.11 showed that fixed equipment shall be disassembled and washed with a detergent solution, receive a distinct rinse with potable water to remove abrasives and cleaning chemicals, and then shall be sanitized. A review, of multiple facility’s polices (Cleaning instructions for Cabinets and Drawers, effective 9/2020; Cleaning Instructions for Can Opener, effective 9/2020; Cleaning Instructions for Food Carts, effective 9/2020; Cleaning Instructions for Freezers, effective 9/2020; Cleaning of Refrigerators, effective 9/2020) directed staff to use the following process to clean fixed equipment: Clean with a clean cloth soaked in hot soapy water; Rinse with clear water; Sanitize; Air dry. During an observation, and concurrent interview, with the CDM on 4/21/25 at 10:37 am, the blender base had a buildup of grime. The CDM agreed it was not clean. He stated his expectation was for staff to clean equipment with soap and sanitizer after each use. He did not include rinsing with water in his description of the process. During an observation, in the dish room on 4/22/25 at 9:25 am, FSW 1 sprayed down a patient meal cart with what she stated was water. In a concurrent interview, FSW 1 explained the process to clean the meal carts. She stated she first rinsed the cart down with water, then rinsed it down with sanitizer, then drained and air dried it. During an interview, with FSW 1 on 4/22/25 at 9:35 am, she described the process used to clean the cabinets, counters and refrigerator in the med/surg nursing unit patient food area. She stated she emptied the refrigerator, wiped it with a sanitizer rag, then allowed it to air dry. She stated she never used anything else to clean it. During an interview, with the CDM on 4/22/25 at 9:56 am, the labeled Directions for Use for the Ecolab Sink and Surface Cleaner were reviewed. The CDM stated kitchen counters and equipment were food contact, hard, non-porous surfaces. He stated that when staff cleaned after working with any kind of meat product, they should wash the area with soap (pot and pan detergent), then sanitize and air dry. He did not include any rinse process after the soap process. The CDM stated when staff cleaned after working with produce, they could just use sanitizer to wipe down their area as they went. Further review, of the manufacturer’s label for Ecolab Smartpower Sink & Surface Cleaner Sanitizer showed (at specified chemical concentration) DIRECTIONS FOR USE ...GENERAL CLEANING ...2. Apply use solution ...to wet the surfaces ...3. Wipe or rinse with potable water or allow to air dry ...4. For heavily soiled surfaces, pre-clean with this product prior to sanitizing ...TO SANITIZE HARD, NON-POROUS FOOD CONTACT SURFACES ...2. Surfaces must be pre-cleaned with this product prior to sanitizing ...no rinse is required prior to sanitizing ...3. To sanitize, apply this product to the surface ...wetting the surface ...4. Allow surface to remain wet for not less than 1 minute ...5. Allow to air dry. No water rinse required. TO CLEAN AND SANITIZE STATIONARY KITCHEN AND FOOD PROCESSING EQUIPMENT ...2. Surfaces must be pre-cleaned with this product prior to sanitizing ...no rinse is required prior to sanitizing ...3. To sanitize, apply this product to the surface ...wetting the surface ...4. Allow surface to remain wet for 1 minute ...5. Allow to drain and air dry. No water rinse required. Throughout the survey, staff were observed wiping their fixed equipment with a sanitizer rags. Staff were not observed washing fixed equipment with soap and rinsing any soap off, then sanitizing as per policy and professional standards of practice. There was no pre-cleaning step observed, and equipment did not remain wet with sanitizer for one minute as per manufacturer’s cleaner/sanitizer directions for use. 4. The facility served unpasteurized eggs, and food was not consistently stored in a manner to ensure food safety and food quality. A review, of the facility’s policy titled, “Food Safety and Sanitation,” effective 8/20, showed a purpose and policy for the facility’s Acute Dietary Department to follow all local, state and federal standards and regulations in order to ensure a safe and sanitary Dietary Department. It indicated: Food purchasing: “Eggs must be clean with shells intact. Pasteurized fresh, liquid or frozen eggs are preferred. Only pasteurized eggs will be used in preparation of foods such as Caesar salads, hollandaise or bearnaise sauce, mayonnaise, eggnog, ice cream and egg-fortified beverages, sunny side up, over easy, soft fried and poached eggs. A review, of the facility’s policy titled, “General Food Preparation and Handling,” effective 8/20, indicated that no raw eggs will be served, eggs must be cooked completely until all parts are firm. Pasteurized eggs are the exception (these may be served soft cooked). During an observation, in the walk-in refrigerator on 4/21/25 at 10:15 am, it contained a small unlabeled, undated pan of shell eggs. Behind it was a case of “Wholesome Farms Fresh Shell Eggs”. The egg packaging stated it was United Egg Producers Certified, www.uepcertified.com, and had a cautionary statement: “SAFE HANDLING INSTRUCTIONS: To prevent illness from bacteria: keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs thoroughly.” During an interview, with FSW 3 on 4/22/25 at 8:20 am, he was asked if cafeteria customers could have over-medium eggs if they asked for them. He stated he wasn’t sure and added, “Patients can’t have them.” When asked about the poached eggs on the patient menu, he stated they hard-poached them, same with fried eggs. During an interview, with the CDM on 4/22/25 at 2:05 pm, the CDM stated pasteurized eggs were too expensive to buy, so they had been hard-cooking poached and fried eggs for their patients (no undercooked eggs. The CDM went into his primary vendor’s ordering website and demonstrated it had no pasteurized shell eggs available to order. During an observation, of breakfast meal preparation and concurrent interview, with FSW 3 on 4/24/25 at 7:00 am, FSW 3 stated, that he was preparing poached eggs for the patients, and medical staff breakfast. FSW 3 stated, that he cooked eggs to internal temperature 160°F to 165°F (degrees Fahrenheit). FSW 3 temped the internal egg temperature at 165°F. 5. An effective system was not in place regarding disposal of dented cans. A review, of the facility’s policy titled, “Dry Storage Areas,” effective 8/20, indicated that its purpose was to keep food safe and free of infestation or contamination. Leaking, or severely dented cans and spoiled food will be disposed of promptly to prevent contamination of other foods. During an observation, of the Dry Storage Room on 4/21/25 at 9:43 am, a can of mandarin oranges was severely dented on the sides and on the top seams of the can, dated received 1/22/25, use by 1/22/26. It remained on the shelf with the other canned mandarins, ready for use. During follow-up observations, of the dented can, and concurrent interviews, on 4/21/25 at 10:21 am, Food Service Worker 2 (FSW 2) stated, that if cans came in dented, they sent them back to the manufacturer, or threw them away. He stated they had no specific location to put dented cans when they were found. During an additional concurrent interviews, FSW 4 stated it looked like someone dropped that can over the weekend because it wasn’t dented when the delivery was checked in. 6. Food was not labeled, dated or stored in a sanitary manner. A review, of the facility’s policy titled, “Food Safety and Sanitation,” effective 8/20, indicated that the the facility’s dietary department will follow all local, state and federal standards and regulations in order to ensure a safe and sanitary Dietary Department. All time and temperature control for safety (TCS) foods (including leftovers) will be labeled, covered and dated when stored. When a food package is opened, the food item will be marked to indicate the open date. This date is used to determine when to discard the food. A review, of the facility’s policy titled, “Food Storage,” effective 8/20, indicated that all food will be covered, properly labeled and dated. During an observation, of the dry storage room on 4/21/25 at 9:44 am, two out of two plastic trays containing “cookie ingredients,” were soiled with food debris and dust. During an observation, of the two reach-in kitchen freezers and the walk-in freezer on 4/21/25 at 9:53 am, a plastic bag with unidentified contents was, unlabeled, undated and was left open to the air. In a concurrent interview, with FSW 2, he stated the bag contained grilled chicken. When asked when it was opened, FSW 2 stated, it was “opened on the weekend sometime.” He labeled the bag as grilled chicken and added the current day’s date 4/21/25. He went into the walk-in freezer and came back, stating the box had a manufacturer’s expiration date 8/18/25. During an additional interviews, with the CDM on 4/21/25 at 9:55 am, he stated all bags in the freezer should be sealed up, labeled, and dated. He said the bag of grilled chicken should be thrown away since it wasn’t labeled and dated, and he threw it away. The CDM further stated that anything without an opened-on date should be thrown away because it was unknown. In a concurrent observation, with the CDM, beef patties, fish patties, chicken tenderloins, and chicken patties were labeled and dated but were left open to the air. The CDM agreed this food storage practice of unsealed food bags was a pattern and a problem. During an observation, of the walk-in refrigerator on 4/21/25 at 10:15 am, bottles of condiments (balsamic vinaigrette and Franks Red Hot Wings sauce) had drips of food particles around the lid and down the sides. This was a potential source of cross contamination. During an observation, of the med/surg nursing unit patient food supplies on 4/22/25 at 8:35, a bottle of Pedialyte was dated opened on 3/26, with manufacturer’s use-by date 9/1/26. A review, of the manufacturer’s instructions on the bottle showed to use or discard the Pedialyte within 48-hours of opening. In a concurrent interview, Registered Nurse (RN) 2 agreed the opened-on date was 3/26/25. She read the label, and agreed the Pedialyte should have been discarded on 3/28/25. 7. Staff did not consistently perform behaviors to avoid cross contamination including hand washing, glove use, apron use, and use of beard nets. A review, of the facility’s policy titled, “Employee Sanitation Practices,” effective 8/20, indicated that the facility’s dietary department employees will practice good personal hygiene and safe food handling procedures. It directed staff to wear hair and beard restraints to prevent hair from contacting exposed food; to wash hands before handling foods; and hands must be washed prior to using gloves, and after removing gloves. A review, of the facility’s policy titled, “Food Safety and Sanitation,” effective 8/20, indicated that facility’s dietary department will follow all local, state and federal standards and regulations in order to ensure a safe and sanitary conditions. It directed, all staff to use safe food handling practices. During an observation, on the med/surg nursing unit on 4/22/25 at 8:35 am, FSW 1 restocked the nursing unit food supplies for patients. She dropped a container of applesauce on the floor. She picked it up and discarded it, but did not wash her hands before continuing to stock the food supplies. During an observation, in the dish room on 4/22/25 at 8:55 am, FSW 1 worked the dirty side of the dish machine, wearing a brown vinyl apron and gloves. She removed her gloves, moved to the clean side of the dish machine, and put away the clean dishes. She did not wash her hands after removing her gloves, or before putting away clean equipment, or donning new gloves. During an observation, in the dish room on 4/22/25 at 9:25 am, FSW 1 cleaned a patient meal cart. She did not wash her hands before pulling a rack of clean dishes out of the dish machine. During an interview, with IP on 4/22/25 at 11:05 am, she stated her expectations for handwashing in the kitchen is that staff should change gloves, and wash their hands every time they changed tasks. During an interview, with the CDM on 4/23/25 at 9:50 am, he stated staff should change their gloves and wash their hands every time they leave a workstation or change tasks, or touch something like a refrigerator handle. During an observation, in the dish room on 4/22/25 at 8:55 am, FSW 1 worked on dirty side of dish machine wearing a brown vinyl apron and gloves. She removed her gloves, did not wash hands, did not remove apron, and put away clean dishes. She went back to the dirty side, put on clean gloves without any hand washing. This was a potential source of cross contamination. During an interview, with the CDM on 4/23/25 at 9:50 am, he stated he provided three cloth aprons to each staff. They wore clean aprons daily. He stated he provided plastic disposable aprons to be worn in the dish room. He state staff should be changing aprons between dirty and clean tasks, and should change gloves/wash hands when moving from dirty to clean. He explained, that FSW 1 wore a vinyl apron because she was getting wet when she wore the disposable aprons, but the vinyl apron should be removed before moving from dirty to clean tasks due to potential cross contamination. A review, of the facility’s policy titled, “Personal Hygiene and Health Reporting,” effective 8/20, indicated that beards and mustaches will be closely cropped and neatly trimmed. When around exposed foods, beards must be restrained using beard covers. A review, of the facility’s policy titled, “Food Safety and Sanitation,” effective 8/20, indicated that beard nets (coverings) are required when facial hair is visible. During an observation, in the cooks area on 4/21/25 at 9:50 am, FSW 2 had a beard and mustache and wore a beard net, but it did not fully cover his beard. In addition, FSW 3 had a beard and mustache, wore a beard net, but it hung down and did not cover his mustache. During observations, throughout the survey, from 4/21/25 at 9:35 am through 4/24/25 at 11: 30 am, the CDM had a mustache and goatee and did not wear a beard net in the kitchen. During an interview, with the IP on 4/22/25 at 11:05 am, she stated her expectations for hair covering were that staff should wear hairnets or surgical caps to cover their hair. If there were beards or mustaches, they should be covered with a beard net. She stated the CDM should wear a beard net if he was in the kitchen since he had a mustache and goatee. During an interview, with FSW 2 on 4/23/25 at 4:05 pm, he stated they were trained that beard nets had to be worn at all times, before entering, and when in the kitchen. He stated, “You’re supposed to have them on at all times unless you are in the bathroom, or on break.” During an interview, with the CDM on 4/23/25 at 4:07 pm, he stated if staff had a full beard they must wear beard nets. When asked if he should be wearing a beard net, the CDM stated he had a closely trimmed goatee, so he did not have to wear a beard net.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 42448 Based on observation, interview, and attempted record review, the facility failed to ensure the Food and Nutrition Services Department participated in quality assurance activities that evaluated their contributions patient care services and reported it up through the organization’s quality processes. This failure had the potential to result in patient satisfaction and patient safety issues, and decreased quality of care related to unidentified and unresolved food safety and sanitation practices and diet order compliance issues. Findings: During the facility’s recertification survey from 4/21/25 at 9:15 am through 4/24/25 at 11:30 am, food safety and sanitation concerns identified in the Food and Nutrition Services Department by the surveyor included but were not limited to soiled and damaged equipment, staff work practices having potential to result in cross contamination, serving unpasteurized eggs, patient meal trays not matching doctor’s orders or diet manual, and staff not following facility policies and procedures (Cross reference C-1208, and C-1020). During an interview, with the Registered Dietitian (RD) on 4/22/25 at 10:50 am, she was asked about her provision of oversight for the kitchen. She stated she no longer did much with the kitchen, she did not do kitchen food safety and sanitation inspections, and she hadn’t spot-checked patient meal trays for accuracy much lately to know if they were correct for the diet order. The RD stated she did not do any Quality Assurance/ Performance Improvement (QAPI) activities in relation to acute care clinical nutrition acute care or food services. During an interview, with the Food Services Manager/ Certified Dietary Manager (CDM) on 4/21/25 at 12:10 pm, he estimated the RD came to the kitchen maybe once every 6 months. During an interview, with the Infection Prevention Nurse (IP) on 4/22/25 at 11:05 am, she stated she did walk-throughs of the kitchen during Environment of Care Rounds (EOC rounds) where she followed food, temperatures, staff handwashing and glove use, and the department had improved. IP stated they used to do the inspections quarterly, but now do them about every 6 months, and she had not done an inspection for at least 3 months. She stated, “If there is anything that comes up (in the kitchen), someone tells me.” During an interview, with the CDM on 4/22/25 at 2:05 pm, he stated he did not have any documentation of kitchen food safety and sanitation inspections he performed, and his department had no QAPI activities in progress. During an interview, with the Quality-Risk Compliance Director (QRD) on 4/23/25 at 3:30 pm, she stated all departments were supposed to participate in QAPI, and each picked their own QAPI topics. She stated it had been a very long time since she’d received any QAPI data from the Food and Nutrition Services Department. She added QAPI data should be reported at least quarterly, but some departments provided it monthly. QRD searched her computer files for several minutes and then reported she had received no QAPI data from the CDM in at least the past 2 years. The QRD stated there had also been no QAPI submitted from the RD. The QRD confirmed that HCAPS (a set of nationally standardized patient experience surveys) no longer included food services-related questions in its surveys, so they also didn’t have that to provide any indicators for the Food and Nutrition Services Department.”