Louis A Weiss Memorial Hospital

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 32741 Based on document review, observation and interview, the hospital failed to comply with the Condition of Participation 42 CFR 482.55 Emergency Services. Findings include: 1. The hospital failed to ensure that patients presenting to the Emergency Department (ED) were able to receive appropriate monitoring based on their needs due to a lack of equipment and monitoring devices. See A-1116 The immediate jeopardy (IJ) was identified on 7/11/2025 at 42 CFR 482.55 Emergency Services, due to the hospital’s failure to ensure that the provisions were readily available to provide emergency care for 3 (Pt. #1, Pt. #2, and Pt. #3) of 10 patients that presented to the hospital’s Emergency Department seeking emergency care and ensuring appropriate monitoring was provided in accordance with acceptable standard of practice. The IJ was announced on 7/11/2025 at 2:30 PM during a meeting with Manager of ED, Director of Nursing and Clinical Coordinator of Nursing Services and was not removed by the survey exit date of 7/12/2025.”

“PROVISIONS CFR(s): Provisions include equipment, supplies, and medication used in treating emergency cases. Such provisions must be kept at the hospital and be readily available for treating emergency cases to meet the needs of patients. The available provisions must include the following: (i)Drugs, blood and blood products, and biologicals commonly used in life saving procedures; (ii) Equipment and supplies commonly used in life-saving procedures; and (iii) each emergency services treatment areas must have call in system for each patient. This Standard is not met as evidenced by: 32741 Based on document review, observation, and interview, for 3 of 10 (Pt. #1, Pt. #2 and Pt. #3) patients presenting to the emergency department (ED), the hospital failed to ensure that patients presenting to the ED were able to receive appropriate monitoring based on their needs due to a lack of equipment and monitoring devices. Subsequently, Pt. #1, Pt. #2 and Pt. #3 were not able to be monitored until transferred. Findings include: 1. On 7/10/2025, the hospital’s policy titled, “EMTALA” (Emergency Medical Treatment and Labor Act) (dated 1/2025) was reviewed and indicated, “The medical screening exam (MSE) is the examination of the patient by the Qualified Medical Person required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient’s complaint, and depending on the presenting symptoms, the MSE may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies and procedures. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred.” 2. On 7/10/2025, Pt. #1’s ED clinical record (dated 7/3/2025 from 12:16 AM to 5:20 AM) noted the following: “Pt. #1’s vital signs (time not documented) heart rate 69 (reference range 60-80), O2 (oxygen) saturation -100% (normal range 95% -100%), blood pressure 138/98 (reference range 90/60 -140/90), respiratory rate 18 (14-20), temperature 97.8 (97.4 -99) and pain score 8 (pain score reference range: 1-3 mild, 4-6 moderate, and severe 7-10). Problems - acute vaginitis, status epilepticus (serious neurological emergency that occurs when a seizures last a long time in close succession without recovery in between), acute pelvic inflammatory disease and right lower quadrant pain.” -Emergency Department Note: RN (Registered Nurse) received a call (at 2:49 PM) from CT (computed tomography- diagnostic test that obtain images of the body) that Pt. #1 reported feeling like Pt. #1 was going to have a seizure. On arrival to CT, Pt. #1 was actively seizing. Per CT tech, Pt. #1 seized for 1 minute. Pt. #1 still actively seizing upon arrival to ED. Vitals stable. Pt. #1 responding to verbal commands. Reports taking Keppra for seizures. 2 mg (milligrams) Versed (medication that helps relaxation) given at 2:46 AM, 3 mg Versed given at 3:02 AM and 5 mg Versed given at 3:05 AM. -MD #1’s “History of Present Illness” (dated 7/3/2025 at 3:53 AM) noted, “(Pt. #1) with past medical history of diabetes mellitus I and seizure disorder admitted secondary to PID (pelvic inflammatory disease) and multiple seizures. (Pt. #1) presented with RLQ (right lower quadrant) pain. (Pt. #1) said that (Pt. #1) has had this pain off and on for the last 15 days. (Pt. #1) says (Pt. #1) has been to multiple other hospitals and had CT’s and ultrasounds but never found anything wrong. (Pt. #1) has not gotten the pelvic exam for this because (Pt. #1) has always deferred due to pain. (Pt. #1) says that the last 3 to 4 days the pain, was worse. (Pt. #1) also says that over the last 5 to 6 days has been having some red, abnormal discharge. Last menstrual period was 1 week ago. (Pt. #1) did vomit today. Feels worse whenever (Pt. #1) moves. Denies fevers, chills, diarrhea. (Pt. #1) is sexually active right now and does not use barrier protection. (Pt. #1) is monogamous. (Pt. #1) has not taken (Pt. #1’s) home Keppra x 5 days secondary to nausea and pain. - 3:07 AM: Pt. #1 had a seizure while returning from CT imaging and subsequently had 4 more seizures requiring 3 doses of IV (intravenously) Midazolam (same as Versed -sedative used to treat seizures). Keppra Load given. - 3:45 AM: Pt #1 Vital signs -Pain score - 8 (abdomen, lower right quadrant), temperature 97.8, blood pressure 109/58, heart rate 75, respirations 18 and pulse oximetry 99 %. Assessment and Plan: - Seizures/epilepsy - seizures x 5 in ED. Status post Versed x 3 and 1 gram IV Keppra (anti-seizure medication) Plan -Keppra 500 mg IV BID (twice a day), Seizures Precautions, Neuro (neurology) Consult, PID, gyne (gynecologist) consult. Medical Necessity for Hospitalization - Pt. #1’s medically necessary hospital care was initiated. Treatment - oxygen supplementation, medications, continuous. -3:43 AM - MD #1 notes included, “Given (Pt. #1’s) recurrent seizures, MD #1 had extensive discussion with house supervisor, charge nurse, respiratory therapist (RT) on what to do if Pt #1 requires intubation (tube in airway for breathing). We are currently in an office building that does not have wall oxygen. RT states that we do have large capacity oxygen tank. That could theoretically run a ventilator at 20 % Fi02 for 5 to 6 hours as well as multiple other tanks. Other considerations included possibly moving Pt. #1 back over to the other ER (emergency room) for the wall oxygen. There were legitimate safety concerns as MD #1 would have to remain in the office building separate from Pt. #1 or leave the ER, both of which are unsafe. MD #1 spoke with house supervisor at Hospital B (outside hospital/OSH) and Hospital B accepted Pt. #1. -4:15 AM - Despite Dilantin (anti-seizure medication) load, Pt. #1 had 3 further seizures and was not returned to baseline. - 4:20 AM - Pt. #1 had 2 more active seizures. At 4:22 AM, 250 Dilantin given. At 4:23 AM, Pt. #1 continued to seize. At 4:30 AM, Dilantin 750 mg drip started. At 4:34 AM, etomidate (sedative used in emergency setting) 20 mg given, 4:35 AM rocuronium (used for endotracheal intubation) 100 mg given. - 4:45 AM - Procedures Performed: Endotracheal Intubation by MD #1. Intubation confirmed by colorimetric CO2 (method used to determine concentration of a substance), equal breath sounds, quiet over the stomach. -5:10 AM - Pt. #1 on the way to Hospital B. 3. On 7/10/2025, Pt. #2’s clinical record (dated 7/2/2025 from 9:43 PM to 10:47 PM) was reviewed and indicated: “(Pt. #2) here for fireworks injury. Firework was shot at (Pt. #2). (Pt. #2) came in largely missing (Pt. #2’s) left hand. Gross deformity with active pulsatile bleeding and significant exposed bone. Makeshift tourniquet placed in field by (Pt. #2’s) friend, tourniquet placed on arrival. Vital signs stable. Given ancef (antibiotic medication) fentanyl (pain medication), morphine (pain medication) and tdap (tetnus shot). Will attempt trauma transfer. At 10:36 PM, spoke with Hospital C (OSH) hand surgery. Accepted to the ER. At 10:45 PM, Pt. #2 out the door. Per interview with MD #1, (Pt. #2) required immediate transfer due to trauma to hand. The x-ray machine that is available at makeshift ED is too large and heavy to bring to patient. Pt. #2 was not stable enough to bring to the radiology department. 4. On 7/11/2025, Pt. #3’s clinical record (dated 6/24/2025 from 1:50 PM to 2:55 PM) was reviewed and indicated, “(Pt. #3) presented with reported hematemesis (vomiting of stomach contents mixed with blood, or the regurgitation of blood only). Arrived pale, diaphoretic, and was found lying on the waiting room floor. Denies chest pain or abdominal pain. Of note, the primary emergency department is not in normal operation due to a shutdown secondary to heat and non-functioning air conditioning. We are currently out of a separate office building with limited resources. Vital signs at 1:57 PM - blood pressure 145/78, temperature 98.6, heart rate 105, respirations 18 and O2 saturation 98%. Physical examination - Ill appearing, pale, clammy, diaphoretic. Concern for an upper GI (gastrointestinal) bleed. 80 mg PPI (proton pump inhibitors - medication commonly used to reduce stomach acid production), 4 mg Zofran (medication used to treat nausea and vomiting). Pt. #3 was placed on a portable monitor. Given the limited resources at this location, the plan is to transfer Pt. #3 immediately for definitive care. Pending labs (laboratory tests) to assess for anemia, will assess for electrolyte abnormalities, occult (hidden) signs of infection, renal dysfunction, hepatic (liver) dysfunction, and cardiac strain on laboratory studies. Pt. #3 sent to Hospital B. A transfer process complicated by the fact that the ER is currently operating out of a clinic due to technical issues with the facility. Pt. #3’s clinical record lacked documentation that Pt. #3 portable cardiac monitor was monitored by a staff member. Refer to MD #2’s (ED Medical Director) interview below for the reason why the transfer process was complicated. 5. On 7/10/2025 at 9:30 AM, an interview was conducted with MD #1. MD #1 stated that MD #1 cared for Pt. #1 on 7/3/2025. MD #1 stated that Pt. #1 had multiple seizures and had to be intubated. MD #1 stated that the concerns for Pt. #1 were the following: 1) there is no telemetry monitoring 2) there is no wall oxygen or ventilator hookups 3) there is no medication system (pyxis) and the nurses have to obtain the medication from pharmacy 4) there is no suction available 5) there was no portable x-ray (machine too bulky to bring to ED). MD #1 stated that Pt. #1 was able to be transferred to Hospital B but MD #1 stated that there was lack of adequate monitoring due to the concerns described above. MD #1 stated that MD #1 cared for Pt. #2 on 7/2/2025. MD #1 stated that Pt. #2 came to the ED for a traumatic bleeding hand injury from fireworks. MD #1 stated that there was no tourniquet in the ED to stop Pt. #2’s bleeding so MD #1 had to make a tourniquet out of dressings and ace wrap. MD #1 stated that Pt. #2 was transferred to Hospital C. MD #1 stated that the ER was not safe and continues not be safe due to lack of ability to monitor and treat appropriately. MD #1 stated that MD #1 verbalized MD #1’s concerns to the ED Medical Director (MD #2). MD #1 stated that MD #2 told MD #1 that the concerns were communicated to the CNO (Chief Nursing Officer/E #4). MD #1 stated that the CNO stated that 2 cases out of 200 isn’t too bad. 6. On 7/10/2025 at 10:00 AM, an interview was conducted with the ED Medical Director (MD #2). MD #2 stated that MD #2 has serious concerns regarding the patients in the ED receiving safe care. MD #2 stated that the ED is not able to safely intubate a patient. MD #2 stated that the ED does not have monitoring equipment for the patients. MD #2 stated that MD #2 has verbalized MD #2’s concerns to the CNO (E #4). MD #2 stated that the CNO told MD #2 that 2 cases out of 200 isn’t bad. MD #2 stated that the hospital leadership lacks the awareness of the capabilities of the ED. MD #2 stated that MD #2 has been locked out of the system to report adverse events. MD #2 stated that the ED is not safe for patients. 7. On 7/10/2025 at 3:00 PM, an interview was conducted with the Registered Nurse (E #5). E #5 stated that E #5 quit working at the hospital on 7/10/2025 due to unsafe conditions in the makeshift ER. E #5 stated that the patients coming to the ER are not receiving equivalent care as the main ER due to lack of medications, oxygen supplies and monitoring equipment. E #5 stated that even if a patient is on the portable cardiac monitor, there is no staff to monitor the patient’s heart rate or rhythm. E #5 stated that this is not safe for the patients. E #5 stated that Pt. #1 was in the CT and started having seizures. E #5 stated E #5 had to leave the makeshift ER, go to the pharmacy to get medication and then go to the CT area to administer the medication. E #5 stated there is no capability for a portable x-ray to go down the ramp for an x-ray in the makeshift ER. E #5 stated that when Pt. #1 was intubated, the placement could not be verified by x-ray. 8. On 7/11/2025 at 10:00 AM, an additional interview was conducted with the ED Medical Director (MD #2). MD #2 stated that MD #2 was told to transfer patients within the system (Hospital B). MD #2 stated that MD #2 was told this by either the COO (Chief Operating Officer - E #6 or the CNO (Chief Nursing Officer/E #4). MD #2 stated that the reason Pt. #3’s transfer was complicated was finding an ER that would accept Pt. #3. MD #3 stated that Pt. #3 was transferred to Hospital D (OSH). MD #3 stated that there is only one large oxygen tank that will last for 2 hours if the patient requires a high flow oxygen rate.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 27125 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Findings include: 1. The hospital failed to ensure there was adequate staff to care for the patients. See A-392. 2. The hospital failed to ensure emergency room patients were reassessed with vital signs every hour, per policy. See A-395 A. 3. The hospital failed to ensure a fall risk assessment was completed on admission. See A-395 B.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for the intensive care unit, the hospital failed to ensure that adequate staffing was determined based on acuity. Findings included: 1. The hospital ’ s document titled, “Staffing guidelines” was reviewed on 5/12/2025 and included, “Daily and shift staffing plans are developed and adjusted based on actual patient census, acuity and skills and abilities of available staff to meet the care ... Appropriate staffing coverage is required at all times.” 2. The ICU (intensive care unit) schedule/assignments for April 2025 to May 10th, 2025, was reviewed on 5/12/2025. The schedule included, “Ratio for ICU patients is 1 RN [registered nurse] for 2 patents.” The schedule/assignments did not include the acuity/level for each patient on census. 3. The staffing grid for ICU was reviewed on 5/13/2025 and included the following required staffing based on census: 1 - 8 patients: 3 nurses; 9 patients: 4 nurses; 10 - 11 patients - 5 nurses; 12 - 13 patients - 6 nurses; 14 - 15 patients - 7 nurses; and 16 patients - 8 nurses. The grid did not include acuity in the staffing requirements. 4. The following days/shifts are examples of shifts that did not have the required nurses, based on staffing grid only: - 5/12/2025 and 5/10/2025 on 7:00 AM to 7:00 PM had a census of 5 and had 2 nurses on shift (1 nurse short). - 5/5/2025 on 7:00 PM to 7:00 AM had a census of 5 and had 2 nurses on shift (1 nurse short). - 4/30/2025 on 7:00 PM to 7:00 AM had a census of 10 and had 3 nurses on shift (2 nurses short) - 4/18/2025 on 7:00 AM to 7:00 PM had a census of 12 and had 4 nurses on shift (2 nurses short) - 4/17/2025 on 7:00 AM to 7:00 PM had a census of 13 and had 4 nurses on shift (2 nurses short) - 4/16/2025 on 7:00 AM to 7:00 PM had a census of 11 and had 4 nurses on shift (1 nurse short). From 7:00 PM to 7:00 AM had a census of 12 and had 4 nurses on shift (2 nurses short) - 4/12/2025 on 7:00 AM to 7:00 PM had a census of 10 had 3 nurses on shift (2 nurses short) 5. E#7 stated, “Because of the different acuity levels and patient ratios, it is hard to really quantify our true staffing requirements from shift to shift. Currently there are 3 days shift openings and 1 night shift opening that I have been unable to fill.” E#7 stated that the ICU has several levels of acuity patients on the unit that all have a different nurse to patient ratio. E#7 stated, “We take ICU patients that are a 1:2 (nurse: patient) ratio; step down patients that are a 1:3 ratio; and telemetry patients that are a 1:5 ratio. The levels and acuity are looked at each shift, but not documented to ensure the right staff is available.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 27125 A. Based on document review and interview it was determined that for 5 of 22 emergency department (ED) patient records (Pt. #21, Pt. #s 28 - 31) reviewed, the hospital failed to ensure ED patients were reassessed with vital signs every hour, per policy. Findings included: 1. The Hospital’s policy titled, “Documentation of the Plan of Care for the Emergency Department (1/2025)” was reviewed on 5/14/2025 and required, “Reassessment of each patients general status shall be done at least every hour; including vital signs.” 2. The clinical record of Pt. #21 was reviewed on 5/14/2025. Pt. #21 presented to the ED via ambulance on 3/30/2025 at 5:57 PM with the complaint of ETOH (alcohol intoxication). - Vital signs at 6:12 PM in triage were within normal limits and included: Blood pressure 121/70 (normal 130/80), temperature 98.5 (93 - 98.6), pulse 80 (60-100), respirations 20 (12-20). - The nurse’s note (E#20), dated 3/31/2025 at 3:18 AM included, Vitals included blood pressure 147/69, pulse 98, temperature 98, respirations 14. - The clinical record lacked documentation of hourly reasessments and vital signs between admission on 3/30/2025 at 6:12 PM and discharge on 3/31/2025 at 3:18 AM (9 Hours). 3. The clinical of Pt. #28 was reviewed on 5/14/2025. Pt. #28 presented to the ED on 5/12/2025 at 6:00 PM with a diagnosis of seizure disorder. Documentation of hourly reassessments and vital signs were missings during the following timeframes: - 5/12/2025 - 8:03 PM and then 11:25 PM (3 hours, 22 minutes) - 5/13/2025 - 8:01 AM and then 12:50 PM (4 hours, 49 minutes) - 5/13/2025 - 9:24 PM and then 5/14/2025 5:16 AM (8 hours, 52 minutes) 4. The clinical record of Pt. #29 was reviewed on 5/15/2025. Pt. #29 presented to the ED on 5/12/2025 at 2:16 PM with the diagnosis of syncope (dizziness). Documentation of hourly reassessments and vital signs were missings during the following timeframes: - 5/12/2025 - 3:52 PM and then 7:01 PM (3 hours, 9 minutes) - 5/12/2025 - 8:51 PM and then 5/13/2025 12:57 AM (4 hours, 6 minutes) 5. The clinical record of Pt. #30 was reviewed on 5/15/2025. Pt. #30 presented to the ED on 5/13/2025 at 4:54 PM with the diagnosis of dizziness. Documentation of hourly reassessments and vital signs were missings during the following timeframe: - 5/13/2025 - 6:53 PM and then 11:35 PM (4 hours, 42 minutes) 6. The clinical record of Pt. #31 was reviewed on 5/15/2025. Pt. #31 presented to the ED on 5/13/2025 at 8:53 AM with the diagnosis of generalized weakness. Documentation of hourly reassessments and vital signs were missings during the following timeframe: - 5/13/2025 - 9:39 AM and then 1:13 PM (3 hours, 34 minutes) 7. During an interview on 5/14/2025 at approximately 10:30 AM, the Director of ED and Telemetry (E#1) stated that patients should be reassessed, including vital signs every hour. 8. The treating ED Physician (MD#2) was interviewed via telephone on 5/14/2025 at 11:15 AM. MD#2 stated, “I believe the ED staff are supposed to re-vital and assess patients every one to two hours. I only know of the assessment when there has been a change.” B. Based on document review and interview, it was determined that for 3 of 5 ED patient records reviewed (Pt.#21, Pt. #30 and Pt. #31) for fall risk assessments, the hospital failed to ensure a fall risk assessment was completed on arrival. Finding included: 1. The Hospital’s policy titled, “Fall Risk Reduction (1/2025)” was reviewed on 5/12/2025 and included, “All patients will be assessed for fall risk at the time of admission and reassessed once per shift. Fall prevention strategies will be implemented specific to the needs of the patient.” 2. The clinical record of Pt. #21 was reviewed on 5/14/2025. Pt. #21 presented to the ED via ambulance on 3/30/2025 at 5:57 PM with the complaint of ETOH (alcohol intoxication). The clinical record lacked documentation of a fall risk assessment being completed while in the ED. 3. The clinical record of Pt. #30 was reviewed on 5/15/2025. Pt. #30 presented to the ED on 5/13/2025 at 4:54 PM with the diagnosis of dizziness. The clinical record lacked documentation of a fall risk assessment on arrival. 4. The clinical record of Pt. #31 was reviewed on 5/15/2025. Pt. #31 presented to the ED on 5/13/2025 at 8:53 AM with the diagnosis of generalized weakness. The clinical record lacked documentation of a fall risk assessment being completed on arrival. 5. The nurse (E#2), who triaged Pt. #21, was interviewed via telephone on 5/14/2025 at 12:45 PM. E#2 stated that Pt. #21 was a fall risk, however E#2 did not recall documenting the fall risk. E#2 stated, “I endorsed to the next nurse that [Pt. #21] was a fall risk and needed assistance when out of bed.” E#2 stated that all patients are to have a fall assessment upon arrival. 6. On 5/14/2025 at approximately 12:37 PM, an interview was conducted with the ED Charge Nurse (E#12). E#12 stated that a fall risk assessment will be done for all patients who present in the ED.”

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 40079 Based on document review and staff interview, it was determined that the hospital failed to ensure that the weekly narcotic counts were completed in the Emergency Department, as required. Findings include 1. The hospital’s policy titled, “Controlled Substance Purchasing, Inventory Control, Diversion Prevention, and Detection” (reviewed 01/2025) was reviewed and required, “A. Controlled Substance Procurement and Inventory: 1. An inventory system that assures accuracy of controlled substances is required and must be maintained ... 3. ... Weekly controlled substance inventories must be completed by the department’s Manager ... The inventory must be completed for all controlled substances, including those that were not accessed during that time frame and the inventory documented.” 2. An interview was conducted with the Director of Pharmacy (E #9) on 05/13/2025 at 11:50 AM. E #9 stated that each department manager is responsible for conducting a weekly narcotic count for their department. The current MDS (Medication Dispensing System/Pyxis) keeps track of any medication including controlled substances that are dispensed. The system will record the name, dose of medication, to whom it was dispensed and name of the patient that was prescribed. 3. An interview was conducted with the ED Director/Interim ED Manager (E #1) on 05/13/2025 at approximately 1:30 PM. E #1 stated that E #1 has been the acting as ED Manager since approximately October 2024, when the previous ED Manager left the position. The Pyxis keeps track of any narcotic medication that is dispensed, which requires that the person removing the narcotic verify the count before they remove the medication from the locked cabinet and enter the number of medications present. E #1 stated that E #1 has not conducted the weekly narcotic count for the ED, since becoming Interim ED Manager.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to ensure the ED (emergency department) Log included the accurate disposition. See deficiency at A-2405. 2. The Hospital failed to ensure an appropriate MSE (medical screening examination) was completed, as required. See deficiency at A-2406.”

“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: 32741 Based on document review and interview, it was determined that for 1 of 20 records (Pt. #1) reviewed for individuals who presented to the emergency department (ED), the hospital (Hospital A) failed to ensure that the correct disposition was documented on the ED Centralized Log, as required. Findings include: 1. On 5/13/2025, Hospital A’s policy titled “EMTALA” (dated 1/2025) was reviewed and required, “Central Log - The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged...” 2. On 5/13/2025, Pt. #1’s ED clinical record (dated 2/5/2025) was reviewed. Pt. #1 presented by ambulance to Hospital A’s ED on 2/5/2025 at 5:22 PM, with a chief complaint of psychiatric evaluation. - MD #1’s (ED Medical Director) note, dated 2/5/2025 at 5:23 PM, included “Chief complaint - psych eval - History of Present Illness - Past medical history of schizophrenia (a mental disorder characterized variously by hallucinations [typically hearing voices], delusions, disorganized thinking and behavior and flat or inappropriate affect) presents to the emergency department for medical screening and route to Hospital B. Pt. #1 reportedly was supposed to go to Hospital B but was erroneously brought to Hospital A. Confirmed with local police department that they were supposed to go to Hospital B. Review of symptoms - constitutional: no fever, no chills, no fatigue; Eyes - no visual changes; ENT (ear, nose, throat); no ear pain, no sore throat; Cardiovascular - no chest pain, no palpitations; Respiratory - no cough, no SOB (shortness of breath); GI (gastrointestinal) - no abdominal pain, no nausea, no vomiting, no constipation; Genitourinary - no dysuria (painful urination), no frequency, no hematuria (blood in urine); Musculoskeletal - no back pain, no joint pain, no myalgias; Skin - no rash; Neuro - no headache, no confusion; All other systems negative except as per history of present illness. Medical Decision Making & ED Course - Initial Assessment & Plan - Medical Screening Exam - Pt. #1 no acute distress. No concern for emergency medical condition. Pt. #1 to be redirected to correct facility. Pt. #1 discharged with strict return precautions and anticipatory guidance. Pt. #1 expressed full understanding. Final disposition - Transferred to Outside Facility.” - Final Report (dated 2/5/2025 at 6:09 PM, by ED Nurse E #2) noted, “Pt. #1 came to Hospital A by fire department/police department from nursing home with petition for involuntary admission for violent behavior per caseworker at nursing home. Pt. #1 was accepted at Hospital B and there was a non-verbal agreement between the nursing home and police department to have Pt. #1 brought to Hospital B; police called their superior to confirm and the police will be taking Pt. #1 to Hospital B. Pt. #1 triaged and Pt. #1 is stable and able to be transferred.” 3. On 5/13/2025, the Hospital’s ED Log, dated 2/5/2025, was reviewed. Pt. #1’s disposition was listed on the ED Log for 2/5/2025 as discharge location - “Home.” Pt. #1’s ED clinical record (dated 2/5/2025) noted that Pt. #1 was transferred to Hospital B. 4. On 5/13/2025 at 10:00 AM, an interview was conducted with the ED Director (E #1). E #1 stated that the ED log should have noted that Pt. #1 was transferred to Hospital B.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) ED clinical records reviewed for MSE (medical screening exam), the Hospital failed to conduct an appropriate MSE, including a psychiatric assessment, to determine whether or not an emergency medical condition existed. Findings include: 1. On 5/12/2025, the Hospital’s policy titled, “EMTALA” (dated 1/2025) was reviewed and indicated, “Medical Screening Examination - 1. The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department. 2. The medical screening examination is the examination of the patient by Qualified Medical Person required to determine within reasonable confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient’s complaint, and depending on the presenting symptoms, the medical screening examination may represent a spectrum ranging from a single process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies and procedures.” 2. On 5/12/2025, Pt. #1’s ED clinical record (dated 2/5/2025 from 5:22 PM to 6:23 PM) was reviewed and indicated: - Fire Department Pt. #1’s Care Report (dated 2/5/2025 at 4:56 PM) noted, “Narrative - In summary, crew was sent to location (nursing home) for a psych emergency. Upon arrival, crew found Pt. #1 with police being verbally aggressive but cooperative. Police state they were called because Pt. #1 who has a history of schizophrenia (a mental disorder characterized variously by hallucinations [typically hearing voices], delusions, disorganized thinking and behavior, and flat or inappropriate affect). physically assaulted 3 fellow residents today, and [broke a few doors]. No SI (suicidal ideation)/ HI (homicidal ideation), signs of trauma, or drugs, ETOH (alcohol). Pt. #1 remained verbally aggressive but agreed to move into ambulance, preferring to ambulate. Pt. #1 secured to stretcher. Vitals and assessment done. Pt. #1 transported without incident to Hospital A, prenotification given. At Hospital A, Pt. #1 moved to hallway bed without incident. Care and report transferred to nurse. Arrived at scene - 2/5/2025 at 5:07 PM.” - E #3 (ED Triage Registered Nurse) notes dated 2/5/2025 at 5:34 PM indicated, “Chief complaint - psych eval. Mode of Arrival - ground ambulance fire department. Vital signs - blood pressure 114/76 [normal 90/60-120/90], pulse 76 [60-100] and respirations 16 [12-20], spO2 98% [94-100%]. No actual or suspected pain. ESI -2.” (Emergency Severity Index- level 2 patients are considered high-risk and require prompt, but not immediately lifesaving, interventions) - MD #1 (ED Medical Director) notes dated 2/5/2025 at 5:33 PM indicated, “Chief complaint - psych eval - History of Present Illness - Past medical history of schizophrenia (a mental disorder characterized variously by hallucinations [typically hearing voices], delusions, disorganized thinking and behavior and flat or inappropriate affect) presents to the emergency department for medical screening and route to Hospital B. Pt. #1 reportedly was supposed to go to Hospital B but was erroneously brought to Hospital A. Confirmed with local police department that they were supposed to go to Hospital B. Review of symptoms - constitutional: no fever, no chills, no fatigue; Eyes - no visual changes; ENT (ear, nose, throat); no ear pain, no sore throat; Cardiovascular - no chest pain, no palpitations; Respiratory - no cough, no SOB (shortness of breath); GI (gastrointestinal) - no abdominal pain, no nausea, no vomiting, no constipation; Genitourinary - no dysuria (painful urination), no frequency, no hematuria (blood in urine); Musculoskeletal - no back pain, no joint pain, no myalgias (muscle pain); Skin - no rash; Neuro - no headache, no confusion; All other systems negative except as per history of present illness. Medical Decision Making & ED Course - Initial Assessment & Plan - Medical Screening Exam - Pt. #1 no acute distress. No concern for emergency medical condition. Pt. #1 to be redirected to correct facility. Pt. #1 discharged with strict return precautions and anticipatory guidance. Pt. #1 expressed full understanding. Final disposition - Transferred to Outside Facility.” Pt. #1’s clinical record did not include an assessment of Pt #1’s behavior or psychiatric health in the medical screening exam. - Final Report (dated 2/5/2025 at 6:09 PM written by the Registered Nurse (E #2) noted, “Pt. #1 came to Hospital A by fire department/police department from nursing home with petition for involuntary admission for violent behavior per caseworker at nursing home. Pt. #1 was accepted at Hospital B and there was an agreement between the nursing home and police department to have Pt. #1 brought to Hospital B; police called their superior to confirm and the police will be taking Pt. #1 to Hospital B. Pt. #1 triaged and Pt. #1 is stable and able to be transferred.” 3. On 5/14/2025, Pt. #1’s clinical record from Hospital B (dated 2/5/2025 thru 2/24/2025) was reviewed. ED Physician note, dated 2/5/2025 at 10:19 PM, included “Hospital B ED Arrival time - 6:36 PM on 2/5/2025 - means of arrival -police, chief complaint - psychiatric evaluation, diagnosis - aggressive behavior, adult. Pt. #1 with a history of schizophrenia that was sent from a psych nursing home to the emergency room. It is worth noting that patient was diverted to another emergency room on the way to Hospital B because of violent behavior. Pt. #1 was taken to Hospital A. Unclear if Pt. #1 had an evaluation but Pt. #1was sent from Hospital A to Hospital B by police. The initial intent however was for Pt. #1 to directly transfer from Pt. #1’s nursing home to Hospital A. Pt. #1’s psychiatrist sees patients at Hospital A.” 4. On 5/12/2025 at 12:10 PM, an interview was conducted with the ED Registered Nurse (E #2). E #2 stated that E #2 left a voice message with the psychiatric department at Hospital B regarding Pt. #1’s transfer from Hospital A to Hospital B. E #2 stated that there were no medical records sent to Hospital B from Hospital A. E #2 stated that Pt. #1 was transported to Hospital B by the police department. E #2 stated that usually a patient is transferred by ambulance. E #2 stated that MD #1 examined Pt. #1 and then police transported Pt. #1 to Hospital B. 5. On 5/12/2025 at 1:00 PM, an interview was conducted with the ED Medical Director (MD #1). MD # 1 stated that MD #1 examined Pt. #1, and then Pt. #1 was transported by the police to Hospital B. MD #1 stated that there were no medical records sent to Hospital B. MD #1 stated that there was no report given to Hospital B.”

“The Life Safety Code portion of a Full Survey relating to Complaint survey #IL00175955/242951 and #IL00176258/242981(linked) and #IL00179797/2421338 and #IL00181571/2421488(linked) was conducted 2/25-2/26/2025. The requirements of 42 CFR Subpart 482.41 Physical Environment are NOT MET as evidenced by the deficiencies cited under the K-Tags. The surveyors were accompanied during the survey walk-through and document review by the following facility representatives: Executive Director of Operations & Chief Operating Officer (EDO/COO) Facility Engineer (FE) Facility Carpenter (FC) The facility was observed to consist of an original building and several additions. The following buildings were surveyed as Healthcare Buildings with mixed occupancies: Building 01 - Central Building Building 06 - Blum Building Building 07 - Northwest Building This Form 2567 is for the Central Building. This building was observed to be: The First through Fourth Floors, as well as the Ground Level and Lower Level, constructed in 1955. The Fifth through Eighth Floors, as well as a Mechanical Penthouse (Ninth Floor), constructed in 1957. The Central Building was observed to be of Type I (332) construction and fully covered by an automatic sprinkler system (See K351 for deficient areas). The Central Building was observed to be separated from non-health care occupancies by minimum 2-hour fire rated construction and was surveyed as an existing healthcare occupancy high-rise under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Unless otherwise noted, all locations for cited deficiencies for this survey are based upon the Life Safety Floor plans, dated March 29, 2019, as provided by the Facility Representatives. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 1999) are taken from the 2000 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited were found through observation during the survey walk-through, staff interview, or document review.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, the means of egress from occupied spaces is not maintained in accordance with Code requirements. Failure to maintain means of egress for all spaces can result in confinement of occupants in a building during required evacuation. Findings include: On 2/26/2025, while in the company of the FE, it was observed that the several Exit doors were blocked, broken and malfunctioning which do not comply with Section 7.5. Locations observed: A. At 11:08 am, Exit door near the revolving door at the Blum Building southwest corner main lobby at the first floor was observed blocked by a sofa. B. At 11:12 am, Exit door at the ED Entrance at the first floor was observed broken and malfunctioning. C. At 11:15 am, two Exit doors in series at the ED Ambulance Entrance at the first floor were observed broken and malfunctioning.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 42887 Based on observation egress doors are not maintained in a manner permitted by the code. Installation of egress doors which do not comply with code requirements can compromise the safety of occupants and staff during an emergency by not providing the safeguards afforded by the code for egress. The findings are: At 2:00pm on February 25, 2025, while accompanied by FC, two roof access doors serving the mechanical penthouse were observed with broken and/or missing hardware installed. The broken and missing hardware will prevent re-entry from the roof.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 42887 Based upon observation and staff interview, Exit Signage is not being inspected, tested, and maintained in accordance with code requirements. Failure to properly performing testing and maintenance activities can result in failure to correctly identify exit paths which can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency. Findings include: At 9:15am on February 26, 2025, while in the company of the FC it was observed that the exit sign in C878A was not illuminated to comply with 7.10.5”

“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: 45373 Based on document review and staff interview, testing and maintenance of the battery powered emergency lighting systems were not completed. Failure to perform periodic testing and maintenance activities can result in failure of the lighting systems affecting all occupants during an emergency event. Findings include: A. On 2/25/2025, at 10:55 am while in the company of the EDO/COO, it was observed that the documentation for the following Battery-Operated Emergency Light & Battery-Operated Emergency Exit Sign Light testing as required by Section 7.9.3.1.1, was not available for review. It was reported that Battery-Operated Emergency Light testing was not performed since October 2024. 1. Battery-Operated Emergency Light: Monthly 30-seconds functional test 2. Battery-Operated Emergency Light: Annual 90-minutes functional test 3. Battery-Operated Emergency Exit Sign Light: Monthly 30-seconds functional test 4. Battery-Operated Emergency Exit Sign Light: Annual 90-minutes functional test”

“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: 45373 Based on observation during the survey walk-through, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to compromise the use of the adjacent corridor for exiting. Finding includes: On 2/26/2025, at 2:14 pm while in the company of the FE, third floor hallway near the elevator bank B was observed being used for storage of combustible materials and was not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2, and 8.4.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 45373 Based on document review, the kitchen fire suppression system and kitchen hood are not being inspected and cleaned in accordance with Code requirements. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event. Findings include: On 2/25/2025, while in the company of the EDO/COO, it was observed that the following documentation was not available for review: A. At 11:50 am, it was observed that the documentation for the Semi-Annual Kitchen Fire Suppression System Inspections as required by 2011 Edition of NFPA 96, Section 11.2, was not available for review. B. At 11:55 am, it was observed that the documentation for the Semi-Annual Kitchen Hood Inspections and Cleaning as required by 2011 Edition of NFPA 96, Section 11.4, and 2009 Edition of NFPA 17A, Section 7.3.2, was not available for review.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in order to provide for prompt evacuation of an area or room. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility. Findings include: On 2/26/2025, while in the company of the FE, it was observed that smoke detectors were loose and falling from the ceiling. This condition does not comply with 2010 Edition of NFPA 72, Section 17.7. Locations observed: A. At 10:40 am, second floor corridor connection between Blum Building and Central Building. B. At 3:05 pm, eighth floor Conference Room A800. Based on observation during the survey walk-through, smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner. Findings include: On 2/25/2025, While in the company of the FE, it was observed at various locations that smoke detectors were located where airflow may prevent normal operation of the device as written in 2010 Edition of NFPA 72, Section 17.7.4.1. Locations observed: C. At 3:10 pm, several smoke detectors were observed within 3’-0” of an HVAC supply/return register at the eighth floor elevator A bank lobby. D. At 3:15 pm, a smoke detector was observed within 3’-0” of an HVAC supply/return register at the eighth floor middle hallway entrance.”

“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: 45373 Based on document review, the fire alarm system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event. Findings include: A. On 2/25/2025, at 11:00 am while in the company of the EDO/COO, it was observed that the documentation for the second Semi-annual Fire Alarm System Inspection of initiating and notifying Fire Alarm devices for 2024 as required by 2010 Edition of NFPA 72, Section 14.4.5, was not available for review. B. On 2/25/2025, at 11:05 am while in the company of the EDO/COO, it was observed that the documentation for the 2-Year Smoke Detector Sensitivity Test as required by 2010 Edition of NFPA 72, Section 14.4.5.3.2, was not available for review.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors. Finding includes, A. On 2/25/2025 & 2/26/2025, while in the company of the FC & FE, it was observed that the building’s traction elevator machine rooms lacked fire sprinkler protection to comply with 2010 Edition of NFPA 13, Section 8.1.1. B. On 2/26/2025, while in the company of the FE, it was observed that ceiling tiles were missing at several locations. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to bypass the sprinkler. This condition does not comply with 2010 Edition of NFPA 13, Section 8.6.4.1. Locations observed: 1. At 10:25 am, third floor Respiratory Care area ceiling. 2. At 10:50 am, second floor ICU hallway, spot cooler loose connection at the ceiling.”

“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: 42887 Based on document review and staff interview, the sprinkler system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event. The findings are: A. At 12:15pm February 26, 2025, while accompanied by the FC, ceiling tiles were observed removed in the H.R. Offfice which would allow heat and products of combustion to bypass the installed sprinkler heads. This installation is therefore not in compliance with NFPA 13-2010, 8.6.4.1.1. 45373 B. On 2/25/2025, while in the company of the EDO/COO, it was observed that the documentation for the following Sprinkler System Inspections was not available for review: 1. At 11:10 am, it was observed that the documentation for the Monthly Sprinkler System Pressure Gauges Inspection as required by 2011 Edition of NFPA 25, Table 5.1.1.2, was not available for review. 2. At 11:25 am, it was observed that the documentation for the 3-Year Dry Pipe System Gas Leakage Test as required by 2011 Edition of NFPA 25, Section 13.4.4.2.9, was not available for review. 3. At 11:30 am, it was observed that the documentation for the 5-Year Fire Sprinkler Pressure Gauges Calibration/ Replacement as required by 2011 Edition of NFPA 25, Section 13.2.4.2, was not available for review. 4. At 11:35 am, it was observed that the documentation for the Annual Backflow Prevention Inspection as required by 2011 Edition of NFPA 25, Section 13.6.2, was not available for review. 5. At 11:40 am, it was observed that the documentation for the 5-Year Check Valves Inspection (FDC check valve, fire pump discharge check valve, fire pump bypass check valve, jockey pump check valve) as required by 2011 Edition of NFPA 25, Section 13.4.2.1, was not available for review. 6. At 11:45 am, it was observed that the documentation for the 5-Year Fire Department Connection (FDC) Hydrostatic Piping Test as required by 2011 Edition of NFPA 25, Section 6.3.1, Section 6.3.2.1 and Table 13.8.1, was not available for review. C. On 2/25/2025, while in the company of the EDO/COO, it was observed that the documentation for the following Sprinkler System Inspections cited deficiencies. However, corrective actions were not available for review: 1. At 11:15 am, it was observed that the documentation for the Quarterly Inspections of the Waterflow Alarms and Supervisory Devices or Pressure Switches dated 9/3/2024 and 12/2/2024 cited few deficiencies. However, corrective actions were not available for review to comply with 2011 Edition of NFPA 25, Section 5.2.1. 2. At 11:20 am, it was observed that the documentation for the Annual Sprinkler System Inspection dated 9/3/2024 cited few deficiencies. However, corrective actions were not available for review to comply with 2011 Edition of NFPA 25, Section 5.2.1.”

“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: 45373 Based on observation during the survey walk-through, the facility failed to document inspection of all facility portable fire extinguishers. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: On 2/25/2025 & 2/26/2025, while in the company of the FC & FE, it was observed that the Monthly Visual Inspection for several Portable Fire Extinguishers throughout the building was not documented properly to comply with 2010 Edition of NFPA 10, Section 7.2.1.2. A. It was observed at certain areas of the building that the tags on the Portable Fire Extinguishers, which record the date and initials of the person conducting the Monthly Visual Inspection, were signed one month ahead of schedule. B. It was observed at certain areas of the building that the tags on the Portable Fire Extinguishers, which record the date and initials of the person conducting the Monthly Visual Inspection, were missing the record for last month’s inspection.”

“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: 45373 Based on observation during the survey walk-through, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other. Finding includes: On 2/26/2025, at 10:40 am while in the company of the FE, it was observed that the two fire doors in series at the second floor corridor connection between Blum Building and Central Building did not latch to a closed position to comply with Section 19.3.6.3.5.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services 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. This Standard is not met as evidenced by: 42887 Based on observation during the survey walk-through, the facility failed to maintain equipment inspections and maintenance to meet safety requirements. This deficient practice may detrimentally affect the ambient temperature of the building housing visitor’s staff and patients should a boiler become inoperable. Findings include: On 2/26/2025, while in the company of the FC, during the facility walk through, the surveyor observed the following which does not comply with Section 19.5.1 and 2011 Edition of NFPA 85: A. Housekeeping essentials for safe operation of the boiler do not comply with 2011 Edition of NFPA 85, Section 4.4.1.2 (8) flooring, horizontal ledges are not clean thereby providing visual evidence for any type of necessary repairs or equipment leakage due to the existence of standing water on the floor observed at 1:40pm within the Boiler room. B. Active leaks were observed in the main boiler room. Defects are not corrected to comply with 2011 Edition of NFPA 85, Section 4.4.1.4 bushings and connections were observed cracked and in disrepair. C. At 11:20am evidence of system leaks were observed in Bay 4 of Ambulatory Surgery in the form of water stains on the floor.”

“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: 45373 Based on observation and document review, the HVAC system is not being inspected, tested and maintained in accordance with Code requirements. This deficient practice may affect all patients, staff and visitors within the building should a component of an essential system fail during a fire event. Finding includes, On 2/25/2025, at 12:35 pm while in the company of the EDO/COO, it was observed that the documentation for 6-Year Maintenance and Inspection of Fusible Link Fire and Smoke Dampers as required by 2010 Edition of NFPA 80, Section 19.4 and 2010 Edition of NFPA 105, Section 6.5.2, was not available for review.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, the facility failed to install components for the fire fighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect visitors, staff and patients during a fire event. Finding includes, A. On 2/25/2025, at 12:55 pm while in the company of the EDO/COO, it was observed that the documentation for Monthly Elevator Fire Fighter’s Service Testing for elevators equipped with recall capabilities to comply with Section 19.5.3, 9.4.6.1 or 9.4.6.2, and 2007 Edition of ASME A17.1, was not available for review. B. On 2/25/2025 & 2/26/2025, while in the company of the FC & FE, it was observed that the Elevator Machine Rooms lacked a compliant means to automatically disconnect the main power supply to elevators prior to the application of water due to activation of the fire sprinkler system. The Elevator Machine Rooms lacked heat detectors (within 2 feet of the sprinkler head), and sprinkler heads for elevator shut down to comply with Section 19.5.3, 2007 Edition of ASME A17.1, Section 2.8.3.3.2 and 2010 Edition of NFPA 72, Section 21.4.2.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 45373 Based on document review and staff interview, the facility failed to conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills. Finding includes: On 2/25/2025, at 10:50 am while in the company of the EDO/COO, it was observed that the Fire drill documentation for the past 12 months was not available for review to confirm that fire drills are performed at least once per quarter on each shift. It was reported that fire drills were not performed since October 2024. This condition does not comply with Section 19.7.1.6.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 45373 Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency. Finding includes, On 2/25/2025, at 12:45 pm while in the company of the EDO/COO, documentation review for the Annual Fire and Smoke Door Inspections was not complete to comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2. The latest Annual Fire and Smoke Door Inspection report dated December 4, 2024, cited several fire and smoke door failure. Corrective actions for failed fire and smoke doors were not available for review.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained. Findings include: At 11:50am on February 26, 2025, while in the company of the FC it was observed on the first floor Mammography Department has medical gas outlets present, however gas zone valves serving these outlets could not be located. This in not in accordance with NFPA 99-2012, 5.1.4.8.4”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99) This Standard is not met as evidenced by: 45373 Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained. The finding is: On 02/26/25 at 1:40 pm while accompanied by the FE surveyor observed branch circuit panels located such that access is limited and does not comply with NFPA 70, 2011, 110-26 Location observed: seventh floor Mechanical room #A743 circuit panels located having one foot clearance between the panel and a server rack.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained. Findings include: At 11:55am on February 26, 2025, while in the company of the FC it was observed on the first floor Radiology Department has medical gas outlets present, however gas zone valves serving these outlets could not be located. This in not in accordance with NFPA 99-2012, 5.1.4.8.4”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 45373 Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors. Findings: On 02/25/25 while in the company of the FC, it was observed on the sixth floor receptacles are within 6’-0” of a sink fixture and are not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5). Locations observed: 1. At 9:10 am Room C675 near medical Records and bathroom C695 2.At 9:30 am Room C652F near Exam room and Offices”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 42887 The Type 1 Essential Electrical System (EES) is not arranged in compliance with Code requirements. Failure to distribute EES power in accordance with Code requirements can result in loss of emergency power to select functions designed to remain functional for evacuation puposes. Findings include: At 2:20pm on February 25, 2025, while in the company of the FC in the 8th floor electrical closet between Elevator Banks “C” & “D”, it was observed that the panel index within the critical branch panel identified smoke dampers in the panel circuits. This installation is therefore not in compliance with NFPA 99-2012, 6.4.2.2.3.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 45373 Based on document review and staff interview, required essential electrical equipment inspection and testing is not being conducted. This deficient practice could affect patients, staff and visitors during a utility outage or fire event. Findings include: On 2/25/2025, while in the company of the EDO/COO, it was observed that the following documentation was not available for review: A. At 12:15 pm, it was observed that the documentation for the Weekly Generator Visual Inspection as required by 2010 Edition of NFPA 110, Section 8.4.1, was not available for review. B. At 12:20 pm, it was observed that the documentation for the Monthly Automatic Transfer Switch Test as required by 2010 Edition of NFPA 110, Section 8.4.6, was not available for review. C. At 12:25 pm, it was observed that the documentation for the Annual Diesel Fuel Quality Test as required by 2010 Edition of NFPA 110, Section 8.3.8, was not available for review. D. At 12:30 pm, it was observed that the documentation for the 3-Year 4-Hour Generator Load Test as required by 2010 Edition of NFPA 110, Section 8.4.9, was not available for review.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation the facility is not storing medical gas cylinders in a compliant manner. Failure to properly store medical gas cylinders could result in an increased hazard in a fire event. This deficient practice could affect patients, staff, and visitors. The findings are: At 1:50pm on February 26, 2025, while accompanied by the FC, 13 medical gas cylinders were observed stored on the basement level floor in a room without ventilation. The room is located across the hall and due East of Soiled Linen. This is not in compliance with NFPA 99-2012, 9.3.7.5.3.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 39802 Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.28, Food and Dietetic Services. Findings include: 1. The hospital’s Director of Dietary Services failed to ensure that staff followed manufacturer’s directions for testing and use of sanitizing solutions. (A-620 A) 2. The Director of Dietary Services failed to ensure that times of each meal service were documented and taste/appearance/temperatures checks of each food item served were completed. (A-620 B)”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 1 (Pt. #20) of 2 psychiatric patient records reviewed, the hospital failed to ensure that allegations of abuse were reported and escalated up to leadership in order for a thorough investigation to be completed. Findings include: 1. The hospital’s policy titled, “Abuse and Neglect: Allegations, Reporting, Prevention and Management” (revision 4/2024), was reviewed and required, “...To provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred... Immediately report allegation to the Nursing Supervisor and/or Director... The Nursing Supervisor will contact the Administrator on Call (AOC), the Chief Human Resources Officer (CHRO), and the Risk Manager (RM) immediately... A thorough investigation will be conducted by leadership and documented... Complete an incident report in the electronic occurrence reporting system...” 2. The clinical record of Pt. #20 was reviewed on 02/24/2025, at approximately 2:30 PM. Pt. #20 was admitted on 02/08/2025 to the Geropsych Unit (behavioral health unit for patients 50 and above), with a diagnosis of schizoaffective disorder (mental health condition). The cognitive test completed by a nurse on 02/08/2025 at 1:31 PM indicated that Pt. #20 had none to no significant cognitive impairment. The Psychiatrist (MD#2) note, dated 02/09/2025 included, “...[Pt. #20] has been having recurrent psychotic episodes with VH+ [visual hallucinations] and AH+ [auditory hallucinations]... with commands/patient has been obviously in episodic distress due to the content of hallucinations... patient has been admitted after getting very agitated, unable to sleep, unable to relax...” MD#2’s note, dated 02/10/2025 at 8:49 PM, included “...[Pt. #20 stated] ’...There were these guys, on the unit trying to rape me. They asked me to remove my clothes and try to rape me. I didn’t let them do it. They took my phone from me. They will put naked pictures on all Internet and [social media]... didn’t point to any staff members or peers trying/being the ones trying to rape her...’ ...The patient was asked if [Pt. #20] will agree with trying to get a rape kit. [Pt. #20] started to be hesitant [and stated] ‘no I will not allow anybody to touch me.’... All staff were instructed to have only female staff helping with patient with all services... will have 1 to 1 sitter till dc [discharge] from the unit... patient didn’t make any specific people accusation, only mentioned 2 men...” The record indicated that a sitter was ordered for Pt. #20 on 02/11/2025 at 2:08 AM (after MD#2 signed the note indicating Pt. #20 reported attempted abuse). MD#2’s note on 02/13/2025 included, “...[Pt. #20 stated] ‘It is elderly abuse. They rape me 2 days ago! You don’t believe me!’ When I asked to describe the abuser, [Pt. #20] described a tall guy with pony tail...” MD#2’s note on 02/19/2025 included, “...Cont[inues] to focus on ‘rape’...[Pt. #20 stated] ‘don’t tell what happened... I know he tried to rape me!’ Patient is not able to f/u [follow-up] on the chronological events and time. I tried to educate [Pt. #20] we do not have any staff with long hair and pony tail/ and perhaps [Pt. #20] is a little ‘confused’ about the settings. [Pt. #20] continues to focus on the staff who get [Pt. #20] naked, took picture of [Pt. #20]...” 3. The Staffing Schedules for the Gero-Psych Unit were reviewed for February 2025 and indicated that there were male staff working on the unit between 02/08/2025 and 02/10/2025. 4. The hospital’s Complaints/Grievances/Occurrence Log for February 2025 was reviewed and did not include any complaints, grievances, or incidents filed for Pt. #20. Per the Executive Director of Quality (E#11) on 02/25/2025 at 12:10 PM, E#11 confirmed there were no reports filed for Pt. #20 and spoke with the Nursing Leadership (E#4) who was not made aware that Pt. #20 had made an allegation of abuse. E#11 stated that they were not made aware of the allegation and therefore have not completed an investigation in regards to Pt. #20’s allegation of abuse. 5. An interview was conducted with Registered Nurse (E#35) on 02/24/2025, at approximately 3:00 PM. E#35 stated that if a patient makes an allegation of abuse to E#35, E#35 would report it to the doctor and manager but would not file a report in Clarity (the hospital’s occurrence reporting system). 6. An interview was conducted with the Manager of the Behavioral Health Unit (E#7) on 02/25/2025, at approximately 1:55 PM. E#7 stated that E#7 was not made aware of the allegation until days after the patient made the allegation. E#7 stated that it should have been reported up the chain of command, all the way up to Risk Management. E#7 stated that the Psychiatrist who received the allegation of abuse never reported it. E#7 stated that they only found out about it, when they requested for a sitter and were told the reason for the sitter. E#7 stated that nobody filed a report in Clarity. 7. An interview was conducted with Pt. #20 on 02/25/2025, at approximately 3:55 PM. Pt. #20 stated that Pt. #20 has a sitter with Pt. #20 at all times but didn’t know why. Pt. #20 stated that it was always a female sitter “because something happened elsewhere and here with male staff.” Pt. #20 stated that Pt. #20 did not feel comfortable talking about what happened. Pt. #20 stated that some days Pt. #20 feels safe and some days not. Pt. #20 wouldn’t elaborate on when Pt. #20 didn’t feel safe. 8. An interview was conducted with Registered Nurse (E#36) on 02/25/2025, at approximately 4:10 PM. E#36 stated that E#36 would notify the supervisor if a patient made an allegation of abuse. When asked about filing a report in Clarity, E#36 did not affirm that E#36 would file a report in Clarity and stated in Pt. #20’s case, Pt. #20 was hallucinating and the male staff have worked over 30 years on the unit and are so dedicated to the patients that they would never do something like that. 9. An interview was conducted with Psychiatrist (MD#2) on 02/26/2025, at approximately 9:05 AM. MD#2 stated that most bipolar patients when manic are sexually preoccupied. MD#2 stated that when MD#2 first saw Pt. #20, Pt. #20 made the allegation that two men tried to rape Pt. #20. MD#2 stated that Pt. #20 did not give a description of the men at the time but continued to bring it up every day. MD#2 stated that MD#2 placed Pt. #20 with a female sitter and female staff only immediately after Pt. #20 made the allegation. MD#2 stated that MD#2 asked Pt. #20 if Pt. #20 was sure this happened here and the patient stated that it did happen here. MD#2 stated that Pt. #20 did not report any actual abuse, just attempted abuse. MD#2 stated that days later, Pt. #20 stated that one of the men had a ponytail but MD#2 stated that there were no male staff that had a ponytail. MD#2 stated that MD#2 investigated Pt. #20’s allegation of abuse and stated “it didn’t happen.” MD#2 stated that MD#2 did report it to administration because they knew why they needed a sitter.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that the hospital failed to ensure that for 1 of 3 (Pt.#21) clinical records reviewed for restraints that physical holds used to administer forced medications were considered as restraints. This has the potential to affect any patients forcibly placed in a physical hold. Finding includes: 1. The hospital’s policy titled, “Restraint Management Policy” (revised 04/2022), was reviewed and required, “...Physical Hold: 1. Considered a restraint when holding a patient in a manner that restricts the patient’s movement against his or her will... Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient’s ongoing care. The order shall include the type of restraint... In the event that the physician or authorized licensed practitioner does not place the order for restraint, he/she will be notified as soon as possible, and an ordered obtained within the appropriate timeframe... If the attending physician is not available, and emergency use of restraint and/or seclusion is required, a registered nurse may initiate its use. An order is obtained within one (1) hour of the initiation of the restraint and/or seclusion. Staff will document the rationale for the restraints and/or seclusion...” 2. The clinical record of Pt. #21 was reviewed on 02/24/2025. Pt. #21 was admitted on 02/18/2025 with a diagnosis of schizoaffective disorder (mental health condition). The record indicated that Pt. #21 received a dose of hydroxyzine (medication used to calm patient when agitated) intramuscularly on 02/23/2025 at 9:35 AM. The nurse’s (E#35) note, dated 02/23/2025 at 9:43 AM included “...Pt was destructive, pulled name sign off wall... Pt refused all medications, Pt threw medications at nurse. RN [registered nurse] attempted three times. Pt got a PRN [as needed medication] 0935 AM... Pt was agitated and not re-directable...” 3. An interview was conducted with Psychiatric Unit Registered Nurse (E#35) on 02/24/2025, at approximately 3:00 PM. E#35 stated that they do not use physical (mechanical) restraints on the psychiatric unit. E#35 stated that a patient becomes combative/aggressive, they try to redirect the patient and if they can’t be redirected, they will call a Code Gray (security alert) and security will come up to the unit. E#35 stated that security will come up and will hold the patient while the nurse administers as needed medications to calm the patient down. E#35 stated that they had to call security up for Pt. #21 just yesterday because Pt. #21 was becoming combative and threw the medications back at E#35. E#35 stated that security had to hold Pt. #21 for E#35 to give the medication because Pt. #35 was still being combative and refusing to take the medication. E#35 stated that they do not notify the doctor or get any order when a physical hold is used. E#35 stated that E#35 will document a shift note in the patient’s record and stated that the doctor can read their nurses notes. E#35 stated that there is no way to keep track of when a physical hold is used on their patients. 4. An interview with the Manager of Behavioral Health (E#7) on 2/25/2025, at approximately 2:25 PM . E#7 stated that there is no way in the system to put an order for a physical hold. E#7 stated that besides a shift note, they do not keep track of when physical holds are used.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 1 of 3 (Pt #28) clinical records reviewed for restraints, the hospital failed to ensure that restraints were applied in accordance with a physician’s order. Findings include: 1. The hospital’s policy titled, “Restraint Management” (dated 12/2024), was reviewed, and required, “ ...Procedure: Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient’s ongoing care. The order shall include the type of restraint ...Non-violent, Non-Self-Destructive: For the restraint applied for non-violent or non-self-behavior. Physician’s order ...” 2. The clinical record for Pt #28 reviewed on 2/25/2025. Pt #28 was admitted on 2/17/2025, with a diagnosis of sepsis (bloodstream infection). Pt #28’s physician orders were reviewed. The orders included an order for non-violent restraints (soft upper limbs), dated 2/19/25 and 2/20/25, “order valid for 1 calendar day.” The clinical record did not include any additional restraint orders. 3. On 2/24/2025 at 1:15 PM, an observational tour of 3 South/North Medical Surgical unit, was conducted. During the tour, observation of Pt #28, was conducted with the Registered Nurse (E #19/Pt #28’s assigned nurse). Pt #28 had bilateral wrist restraints applied. 4. On 2/24/2025 at 1:25 PM, an interview was conducted with E #19. E#19 stated that E #19 received report stating that Pt #28 no longer had restraints applied. E #19 stated that E #19 was not aware that Pt #28 had restraints on. Pt #28’s clinical record lacked a current restraint order. 5. On 2/24/2025 at 1:30 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that non -violent restraints should be renewed every 24 hours. E #22 acknowledged that Pt #28’s clinical record lacked a current restraint order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 3 (Pt #28) clinical records reviewed for restraints, the hospital failed to ensure that patient was monitored while in restraints, was done in accordance with policy. Findings include: 1. The hospital’s policy titled, “Restraint Management” (dated 12/2024), was reviewed and required, “ ...Non-violent, Non-Self-Destructive: The patient shall be monitored at regular intervals, not to exceed every 2 hours interval, to be determined consistent with physician orders and/or patient condition and will have documented assessments to assure patient is free from adverse events and to determine if restraint shall be continued ...” 2. The clinical record for Pt #28 reviewed on 2/25/2025. Pt #28 was admitted on 2/17/2025, with a diagnosis of sepsis (bloodstream infection). Pt #28’s physician orders were reviewed. The orders included an order for non-violent restraints (soft upper limbs), dated 2/19/25 and 2/20/25, “Restraint Monitoring Non-Violent Behavior, every 2 hr [hours]”. Pt #28’s flowsheet was reviewed for restraint monitoring. The most recent restraint assessment was dated 2/19/25 at 4:00 AM (5 days prior). 3. On 2/24/2025 at 1:25 PM, an interview was conducted with the Registered Nurse (E #19/Pt #28’s assigned nurse). E #19 acknowledged that there was no restraint monitoring documentation since E #19 was not aware that Pt #28 had restraints applied. E #19 was not able to verbalize the required time frame for restraint monitoring. 4. On 2/24/2025 at 1:30 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that non-violent restraints monitoring is required every 2 hours.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 1 Director of Nursing (E #4/Executive Director of Nursing) the hospital failed to ensure appropriate provision of hospital-wide nursing service under the direction of one registered nurse. Findings include: 1. On 2/25/2025, the personnel file for E #4 (Executive Director of Nursing) was reviewed. E #4’s personnel file included a document, dated 9/27/2024, that indicated, “(Signed by E #4)... Functional Name: Chief Nursing Officer/Executive Director... The Chief Nursing Officer practices within the scope of the Illinois Nurse Practice Act... Provides overall leadership, administration, and coordination of patient care and nursing services... Adheres to the mission, values, and philosophy of (Name of Another Hospital)...” 2. On 2/24/2025, the hospital’s meeting minutes for 2024 and 2025 discussing provision of hospital-wide nursing issues were requested. On 2/25/2025 at approximately 9:30 AM, E #4 stated that there has been no nursing minutes for 2024 and 2025. 3. On 2/25/2025, an interview was conducted with E #4. E #4 stated that E #4 was originally hired to be the Director of Nursing at (Name of Another Hospital). As of October 2024, E #4 stated that E #4 was delegated and also appointed to be the Director of Nursing at this hospital and (Name of Another Hospital). E #4 stated that it has been a challenge to lead and direct the nursing services for two hospitals. E #4 could not provide documentation regarding meetings held discussing appropriate provision of hospital-wide nursing services.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50411 A. Based on observation, document review, and interview, it was determined that for 5 of 5 patients (Pt. #2, Pt #29, Pt. #31, Pt.#32, and Pt. #34) observed receiving intravenous (IV) fluids or medications, the hospital failed to ensure that the IV tubing was labeled, as required. Findings include: 1. On 2/24/2025 between approximately 10:45 AM through 12:15 PM, during an observational tour of the intensive care unit (ICU), the following was observed: - Pt. #2 was receiving supplemental nutrition via feeding tube. The feeding tube was not labeled. 2. On 2/24/2025 between approximately 10:50 AM through 11:55 AM, an observational tour of the Medical Surgical Telemetry was conducted. The following were observed: - Pt.#29-Pt.#31, Pt.#32, Pt #34 had IV bags hanging in their rooms. The IV tubing lines lacked the date and time indicating when the bags were hung. 3. On 2/24/2025, the hospital’s policy titled, “Peripheral Intravenous Catheter Placement and Management (Revision Date - 01/2025) was reviewed and required “...Intravenous tubing: Tubing is labeled with date and time...” 4. On 2/24/2025 at approximately 11:18 AM, an interview was conducted with the Clinical Coordinator (E#7). E #7 stated that feeding tube bottles and lines should be labeled and dated and lines should be changed every 24 hours. B. Based on the observation, document review, and interview, it was determined that for 2 of 2 patients (Pt. #2 and Pt. #30), the hospital failed to label IV (intravenous) sites with insertion date and time as required. Findings include: 1. On 2/24/2025 at between 10:45 AM to 12:15 PM, a tour of the Intensive Care Unit (ICU) was conducted. During the tour, Pt. #2’s peripheral IV’s dressing on the right antecubital area (front of elbow and forearm) and right hand was not labeled with insertion date, time, and initial. 2. On 2/24/2025 between approximately 10:50 AM through 11:55 AM, an observational tour of the Medical Surgical Telemetry was conducted. Pt.#30’s peripheral IV site was not labeled with the insertion date and time. 3. The policy titled “Peripheral Intravenous Catheter Placement and Management (Revision Date - 1/2025) was reviewed and required “...Document date and time of insertion...” 4. On 2/24/2025 at 1:45 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that IV sites should be labeled with the date and time that it was inserted so that the nurses can know when to change them or how long they have been in.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that the hospital failed to ensure medical records were completed within 30 days after discharge. Findings include: 1. On 2/25/2025, the hospital’s Rules & Regulations (dated 6/9/2016) was reviewed and required, “Incomplete/Delinquent Medical Records - Records will be completed within 30 days of discharge.” 2. On 2/25/2025, the hospital’s letter dated 2/25/2025, from the Manager of Health Information Management (E #16) noted “ As of today, the total number of delinquent deficiencies for [the hospital] is 229. 3. On 2/25/2025 at approximately 11:20 AM, an interview was conducted with the E #16. E #16 stated, “Records are considered delinquent if not completed within 30 days, including history & physical and discharge summary.” E#16 was unsure of the exact amount of delinquent records, however, would check for the exact number. The above letter was presented later on 2/25/2025.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 39802 A. Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#37 and E#38) observed performing food service sanitization procedures, the Director of Dietary Services failed to ensure that staff followed manufacturer’s directions for testing and use of sanitizing solutions. This had the potential to affect all patients receiving dietary services at the hospital. Findings include: 1. The hospital’s policy titled, “Three Compartment Sink” (revised 09/2024), was reviewed and required, “...Make sure to test soap detergent & sanitization detergent for proper temperature degrees as well as QUAT [sanitizer concentration] reading...” 2. The testing strip manufacturer’s testing procedures posted on the wall by the dishwashing sink included, “...2. Testing must be done in sanitizer solution that is clean, fresh and at room temperature 65-85 degrees Fahrenheit... 4. Tear off a 1 1/2 - 2 inch strip of test paper. 5. Hold the test strip in the solution for 10 seconds. 6. Do not move the test strip around, as this will give a false high concentration....” 3. The sanitizing solution manufacturer’s label for instructions for use included, “...Allow surfaces to drain thoroughly and air dry...” 4. A tour of the kitchen was conducted on 02/24/2025 between approximately 11:00 AM and 1:00 PM. At approximately 12:03 PM, a Food Services Staff (E#37) was observed performing a demonstration of how to test the sanitizer solution. E#37 tore off a 1 centimeter (less than 1.5 inches) strip of testing paper and dipped it in the solution while counting to 10. E#37 did not use a timer or clock to accurately count 10 seconds. E#37 stated that they do not measure the temperature of the water when they test it. 5. During the tour on 02/24/2025 at approximately 12:50 PM, a Food Service Staff (E#38) was observed preparing a tub of sanitizing solution to clean the food trays. E#38 tore off a 1 centimeter piece of testing paper and swished it in the solution (not in accordance with manufacturer’s guidelines). E#38 held the test strip in the solution for over a minute until it changed color. E#38 did not measure the temperature of the solution. E#38 then used the solution to sanitize used food trays. After applying the solution to all the trays, E#38 then started to wipe the trays dry with a cloth instead of allowing them to air dry per manufacturer’s instructions. 6. An interview was conducted with E#38, at approximately 12:55 PM. E#38 stated that the strip is supposed to be in there for 10 seconds. E#38 stated that they don’t measure the temperature of the solution. B. Based on document review, observation, and interview, it was determined that for 2 of 2 months (January and February 2025) of food temperature logs reviewed, the Director of Dietary Services failed to ensure that times of each meal service were documented and taste/appearance/temperatures checks of each food item served were completed. Findings include: 1. The hospital’s policy titled, “Food Quality & Taste” (revised 09/2024), was reviewed and required, “To ensure that the food quality is held to the highest standards. This includes if the food looks visually appealing and that the food taste is appropriate... Procedure: Cooks are required to take temperatures & taste test before meal services is to be served.” 2. The hospital’s policy titled, “Food Temperatures for Trayline Service” (revised 09/2024), was reviewed and required, “...To ensure department HACCP [Hazard Analysis Critical Control Point] guidelines are followed as requested by Regulatory Agencies... Cooks are responsible for taking temperatures before Food tray line (B [breakfast], L [lunch], D [dinner] as well as after each meal period has finished. Food is to be discarded after one hour has passed since the tray line was completed for all meal services...” 3. The hospital’s Standard Operating Procedures for HACCP Plans (undated), was reviewed and required, “...All potentially hazardous foods must be cooked to... proper minimum internal temperature for 15 seconds.... Review cooking temperature logs... All food items are hot held at temperature of 135 degrees Fahrenheit or above... Internal product temperatures will be checked using a calibrated stem thermometer at regular intervals as specified in HACCP or at a minimum of every two hours... Monitor temperature logs, and/or observe temperature...” 4. The hospital’s policy titled, “Food Storage Temperatures” (revised 09/2024), was reviewed and required, “...Foods, which require cold storage will be held at a temperature below 41 degrees Fahrenheit...” 5. The Hospital’s Food Safety Quality Reports from 01/01/2025 to 02/24/2025 were reviewed as follows: - No food quality/temperatures logs were completed for 01/03/2025, 01/24/2025, 02/08/2025, 02/11/2025, 02/13/2025, and 02/23/2025. - Times of meal service start were missing for lunch and/or dinner on 47 days between 01/01/2025 to 02/24/2025. - Cook times and temperatures were not completed on 30 days between 01/01/2025 to 02/24/2025. - Trayline Start and End Temperatures were either missing or documented out of range (i.e. at greater than 40 degrees Fahrenheit for cold food items) on 01/02/2025, 01/10/2025, 01/11/2025, 01/12/2025, 01/15/2025, 01/23/2025, 01/27/2025, 01/28/2025, 01/29/2025, 01/31/2025-02/05/2025, 02/07/2025, 02/12/2025, 02/14/2025, and 02/18/2025-02/22/2025. - None of the logs indicated that appearance or taste quality were checked. 6. During a tour of the kitchen on 02/24/2025, the end meal (lunch) temperatures were documented on the log sheet at approximately 11:45 AM; however, the lunch trayline service had not yet been completed. The food remained in the warmers (available to serve) at least until 1:00 PM/end of tour.] 7. An interview was conducted with the Food Service Supervisor (E#27) on 02/24/2025, at approximately 11:30 AM. E#27 stated that the staff should be completing the temperature logs for each food item served and should document the times meal serve started and ended. E#27 stated that cold items should be kept at 40 degrees Fahrenheit or less. E#27 stated that the cook should be checking the taste and appearance of the food. 8. An interview was conducted with Cook (E#39) on 02/24/2025, at approximately 11:53 AM. E#39 stated that they are suppose to document the temperature of the food at the end of the trayline. E#39 stated that after the trayline is completed, they still hold the food in case of late trays. E#39 stated they can hold it for 2-3 hours. E#39 stated that E#39 takes the temperature of the food before preparing the late trays but does not document it. 9. An interview was conducted with the Director of Dietary Services (E#28) on 02/24/2025, at approximately 11:55 AM. E#28 stated that they do not keep the food more than 45 minutes to 1 hour after the trayline has ended. 51457 C. Based on document review, observation, and interview, it was determined that for dry and cold food stored in the kitchen, the Director of Dietary Services failed to ensure that expired/outdated food items were discarded and not available for use. This has the potential to affect all patients receiving oral diets. dry and cold food items that were stored in the kitchen were readily available for patient use Findings include: 1. The hospital’s policy titled “Outdated Supplies” (revised on 9/2024) was reviewed and required “... Regular inventory audits are to be conducted to ensure that no supplies that are expired are kept in rotation. If any supplies are to be found expired is to be discarded immediately.” 2. During a observational tour of the Dietary storage area, conducted 2/24/2025 at 11:57 AM, the following were observed in the coolers/refrigerators: 1 of 2 buckets of raw chicken expired on 02/16/2025, 1 small bag of tomatoes expired on 02/16/2025, 1 bag of diced potatoes expired on 02/19/2025, 11 packs of tortillas expired on 02/04/2025, 1 bag of cauflower expired on 02/19/2025, and 1 bucket of oranges expired on 02/16/2025. There was also green pepper, dated 2/24/2025 that was growing mold on it. 3. An interview was conducted with Food Store Room/Cook (E#34) on 02/24/2025 at approximately 12:05 PM. E#34 confirmed the food was expired and stated that the expired food should be discarded. D. Based on document review, observation, and interview, it was determined 2 of 3 food items observed, the Director of Dietary Services failed to labels open food items. Findings include: 1. The hospital’s policy titled, “ Shelf Life for Open and Closed Items” (revised on 09/2024) was reviewed and required, “Label and date all open items with proper opening date as well as expiration date if items require. Insure (sic. ensure) all the items are placed in proper storage area.” 2. During an observational tour of Dietary Services Unit, on 2/24/2024 at approximately 11:59 AM, 9 of 30 food items observed, including cucumbers, pineapples, lettuce, zucchini, bell peppers, cantaloupe, cauliflower, potatoes, and mushrooms, were not labeled with a use by date. 3. An interview was conducted with the Dietary Services Store Room/Cook (E#34), on 02/24/2025 at approximately 12:05 PM, E#34 stated that the food items should be dated and labeled with a use by date.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 36774 Based on document review, observation, and interview, it was determined that the hospital failed to ensure that documentation regarding incident, actions taken, follow-up, and resolution regarding the physical environment were maintained, as required. 1. On 2/24/2025 at approximately 1:30 PM, E #9 (Executive Director of Operations) provided an email, dated 12/8/2024. The email indicated, “From (E #10/Engineering), Sunday, December 8, 2024, 4:48 AM ... Made (boiler) rounds. #1 and #2 (boilers) online and #3. Made (building) rounds, got reports of water coming out of the nurses locker room (in) 3 South. Busted a coil and got another call, busted another coil in the room next door. Cleaned up space and talked to EVS (Enviromental Services) about sanitizing space. Put a pump in sump pit of C bank elevator. Cleaned up as much water as I could ...” 2. On 2/25/2025, the hospital’s policy titled, “Safety Management Plan” (4/2021) was reviewed and included, “Policy ... Th safety program is designed to monitor and evaluate non-clinical safety issues in order to ensure a safe environment for patients, visitors and personnel ... Procedure ... Report and investigate all incidents of property damage ... The Risk Manager reviews all incident reports and appropriate actions are taken as incidents occur. A summary of these incidents is reported at each Safety Committee meeting and reviewed for any possible patterns or trends, and actions taken as appropriate ...” 3. On 2/25/2025 between approximately 10:00 AM through 10:40 AM, an observational tour of the 3 South was conducted. During the tour, Elevators Bay A and B were observed. One of the three cars (Car 1) in Elevator Bay A, and one of the three elevators (B6) in Bay B used for patients were not working. A work order was requested from E #9, none was provided. 4. On 2/25/2025 at approximately 9:50 AM, an interview was conducted with E #9 (Executive Director of Operations). E #9 stated, “There were several issues with steam heat. The hospital is boiler heated. The problem is that everything is so old, when it gets cold, some of the pipes and coils gets so cold and freeze. For the December 2024 incident, we have heating units that need significant repair. In this incident, the coil broke (in a mechanical room adjacent) to locker room in 3 South. Since the incident, that has not happened. However, there were situations when coil in other areas of the hospital would freeze and cause flooding.” Requests were made from E #9 regarding the incident, actions taken, or resolution for the December 8, 2024, including logs regarding coils that caused flooding in the hospital were requested. However, none were provided. 5. On 2/25/2025 at 12:15, an interview was conducted with E #11 (Director of Quality). E #11 stated, “Risk reports to me. If there is a flooding incident in the hospital, there should be an incident report completed so we can follow-up.” Requested any incident report regarding flooding in the hospital from E #11, however, none were provided. 6. On 2/25/2025 at approximately 2:40 PM, an interview was conducted with E #10 (Engineering). E #10 stated, “There was a flooding when a coil busted on the third floor. There was no incident report. We would enter incident of leaking or flooding in the log. There was a recent occurrence last week. A coiler busted that cause flooding on the first floor between MRI and the ER. As far as I know, the issue has not been resolved.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on 2/25-2/26/2025, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 34411 A. Based on document review, observation, and interview, it was determined that for 1 of 2 (E #17), Patient Care Technician (PCT), observed performing blood glucose monitoring and disinfecting patient equipment, the hospital failed to ensure that isolation and infection control practices were adhered to, in accordance with policy. Findings include: 1. The hospital’s policy titled, “Blood Glucose Monitoring Point of Care Testing” (dated 1/2025), was reviewed and required, “ ...Blood Glucose Testing: Cleaning: Clean the exterior of the meter with a low-level disinfectant cleaning cloth ...” 2. The hospital’s policy titled, “Isolation Precautions: Contact or Contact Plus” (dated 1/21/2025), was reviewed and required, “ ...Contact Plus precautions is used only when the organism requires soap and water hand wash and a surface disinfection with a hospital approved bleach product ...” 3. The hospital’s “Contact Plus Isolation” signage, included, “ ...After leaving this room: Clean all equipment with bleach!” 4. On 2/24/2025 at 10:45 AM, an observational tour of the 3 South/North Medical Surgical unit was conducted. During the tour, the following was observed: -The PCT (E #17), was observed performing blood glucose monitoring on 3 patients (Pt #29, Pt #31, Pt #41), (Unit Manager/E#22) was present. E #17 was observed performing the blood glucose checks and failed to disinfect the glucose machines, following the testing. E #17 proceeded to the next patient’s room without cleaning the machine. - E #17 was observed leaving Pt #28’s room with vital signs monitoring equipment. E #17 wiped down the equipment with wipes from a purple container. Pt #28’s signage outside the room indicated that the patient was on Contact Plus Isolation precautions. Contact Plus Isolation requires disinfecting/cleaning with wipes from the blue container (contains bleach). E #17 did not use the proper wipes for cleaning equipment from Pt #28’s room. 5. On 2/24/2025 at 11:25 AM, an interview was conducted with the Medical Surgical Unit Manager (E #22). E #22 stated that the blood glucose monitors should be cleaned after testing on each patient. E #22 stated that if a patient is on Contact Plus Isolation precautions, the staff need to clean with the wipes that contain bleach. B. Based on document review, observation, and interview, it was determined that for 2 of 2 patients (Pt #27, Pt #28) reviewed for isolation, the hospital failed to ensure that isolation orders were properly placed, in accordance with policy. Findings include: 1. The hospital’s policy titled, “Isolation Precautions: Contact or Contact Plus” (dated 1/21/2025), was reviewed and required, “ ...This policy defines situations in which contact or Contact Plus isolation would be implemented ...Order Contact or Contact Plus isolation. Isolation may be initiated by physician order or nursing order ...Contact or Contact Plus precautions are used for specified patients known or suspected to be infected or colonized ...Contact Plus precautions is used only when the organism requires soap and water hand wash and a surface disinfection with a hospital approved bleach product ...” 2. On 2/24/2025 at 10:45 AM, an observational tour of 3 South/North Medical Surgical unit was conducted. During the tour, 5 patient rooms were noted with isolation signs outside their doors. 3. The clinical records for 2 of 5 (Pt #27, Pt #28) patients on isolation were reviewed. - Pt #27’s isolation sign indicated that the patient was on Contact isolation. The physician orders included a “Standard Precautions” order, dated 2/22/25 (not Contact Precautions). Pt #27’s lab results indicated that Pt #27, had a positive MRSA (bacterial infection), requiring a Contact Isolation order. - Pt #28’s isolation sign indicated that the patient was on Contact Plus isolation. The physician’s orders included a “Contact Precaution” order, dated 2/17/25 (not Contact Plus). Pt #28 had a lab drawn to rule out C-difficile (bacteria in the colon), which requires Contact Plus isolation. According to the Infection Preventionist (E #6), Pt #28 has a history of Candida Auris (which also requires Contact Plus isolation). 4. On 2/25/2025 at 1:30 PM, an interview was conducted with the Infection Preventionist (E #6). E #6 stated that after review of Pt #27 and Pt #28’s orders, E #6 acknowledged that the isolation orders were not entered as required for those particular organisms that the patients had. E #6 stated that in particular with Pt #28, the order for Contact Plus would require that the staff take additional precautions with cleaning equipment using bleach wipes. C. Based on document review, observation, and interview, it was determined that for 1 of 1 Medical Surgical unit observed, the hospital failed to ensure that sharps were disposed of safely and secured, as required to prevent cross contamination and potential harm from needle sticks. Finding include: 1. The hospital’s policy titled, “Sharps Securement and Disposal Procedures” (dated 1/25), was reviewed, and required, “Purpose: To outline nursing responsibilities in the safe disposal and securing of sterile and contaminated sharp instruments ...Assess sharps containers for replacement daily. Sharps containers are replaced weekly. If container becomes full sooner, call EVS [Enviromental Services] department to replace. No contaminated sharps should be extended beyond the window of the container housing ...” 2. On 2/24/2025 at 10:45 AM, an observational tour of the 3 South/North Medical Surgical unit was conducted. During the tour, 5 of 5 occupied patient rooms were observed with the Unit Manager (E #22). The rooms contained puncture resistant containers used to secure sharp items (needles, sharp instruments, scalpels, etc.). All 5 of 5 containers, were full above the “fill line” and had needled exposed that extended out of the top of the container. 3. On 2/25/2025 at 1:35 PM, an interview was conducted with the Infection Preventionist (E #6). E #6 stated that sharp containers that have sharps past the “fill Line”, pose an infection control risk. E #6 stated that when the sharps container is full beyond the “fill line” and more than 3/4 full, then the environmental services department should be called to replace the containers.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that the hospital failed to demonstrate periodic assessment of the discharge planning process, including an internal audit of closed medical records and review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the hospital. Findings include: 1. On 2/25/2025, the hospital’s policy titled, ‘Case Management Discharge Planning’ (revised 1/27/2025) was reviewed and included, “ ...V. Procedure: ...Assessment of Discharge Planning Process: Discharge planning process will be re-evaluated, minimally annually, by internal audit of closed medical records to review effectiveness of discharge plans for responsiveness to identified discharge needs, preventable readmission and other quality indicators ...Readmissions will be reviewed on a 30 day readmission interval ...”. 2. On 2/25/2025, the hospital’s ‘2024 Case Management Dashboard’ document was reviewed and indicated that readmissions measures were provided per the Quality Department which included ‘Medicare Readmission Rate’ and Medicare #30 day Readmissions’, however, no data was presented between September - December 2024. 3. On 2/25/2025, any documentation or data collected to indicate that the hospital conducted an internal audit of closed medical records and patients admitted within 30 days of previous admission was requested. No available documentation was provided. 4. On 2/25/2025 at approximately 9:55 AM, an interview with the Director of Social Work (E #12) was conducted. E #12 stated that monthly department and utilization meetings should be conducted and include metrics including readmissions, however, with the leadership turnover in the department, the review has not been conducted as it should. 5. On 2/25/2025 at approximately 10:50 AM, an interview with the Utilization Review Registered Nurse Case Manager (E #15) was conducted. E #15 stated that utilization review meetings had not focused on readmissions.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that for 3 of 3 patients’ (Pt. #27, Pt. #39, and Pt. #40) clinical records reviewed for discharge planning, the hospital failed to ensure that the discharge planning evaluation and plan was documented and discussed with the patient and or a patient representative. Findings include: 1. On 2/26/2025, the hospital’s policy titled, “Case Management Discharge Planning” (reviewed 11/2023) was reviewed and included, “ ...I. Scope: Discharge Planning ...V. Procedure: ...Patient Rights & Responsibilities in Discharge Planning Process ...patient has the right to participate in the development and implementation of his/her plan of care ...patients or their representatives are actively involved in the discharge planning process ...the patient or his/her representative will be afforded the right to make informed decisions regarding his/her care and being involved in care planning and treatment ...”. 2. On 2/26/2025, the clinical record for Pt. #27 was reviewed. On 1/07/2025, Pt. #27 was admitted due to shortness of breath and altered mental status. The clinical record indicated that Pt. #27 came from home (skilled nursing facility) and on 1/12/2025, Pt. #27 was discharged back home. The clinical record did not include notification and follow-up with the patient and or patient’s representative regarding the plan and results of discharge planning evaluation. 3. On 2/26/2025, the clinical record for Pt. #39 was reviewed. On 10/27/2024, Pt. #39 was admitted due to a seizure. The clinical record indicated that Pt. #39’s initial discharge post facility need was a skilled nursing facility; however, on 11/01/2024, Pt. #39 was discharged home with home health. The clinical record did not include notification and follow-up with the patient and or representative regarding the plan and results of discharge planning re-evaluation. 4. On 2/26/2025, the clinical record for Pt. #40 was reviewed. On 11/03/2024, Pt. #40 was admitted due to altered mental status. The clinical record indicated that Pt. #40 came from home (skilled nursing facility) and initially would require a higher level of care facility prior to returning home. On 11/21/2024, Pt. #40 was discharged home. The clinical record did not include notification and follow-up with the patient’s representative regarding the plan and results of discharge planning evaluation. 5. On 2/26/2025 at approximately 1:59 PM, an interview with the Registered Nurse Lead Case Manager (E #13) was conducted. E #13 reviewed patient’s (Pt. #27, Pt. #39, and Pt. #40) clinical records and confirmed that the records did not include documentation that the patient and or representative were included throughout the discharge planning process as they should have been.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 50411 Based on document review, observation, and interview, it was determined that for 1 of 2 Registered Nurses (RN) (E #29), 1 of 1 CRNA (Certified Registered Nurse Anesthetist/E#31), and 1 of 2 Surgical Technicians (E #30) in Operating Room (OR) #5, the hospital failed to ensure adherence to the acceptable operating room attire while in the operating room, as required. Findings include: 1. On 2/25/2025, the hospital’s policy titled, “Proper Operating Room Attire” (Revised 8/2024) was reviewed and required, “...Head Covering - I.3.1 All head and facial hair should be covered within the Department of Surgery...I.6. Accessories...I.6.2. No jewelry will be worn in the OR...” 2. On 2/25/2025 between 9:10 AM and 10:40 AM, an observational tour of OR #5 was conducted. E #29, E #30, and E#31 had hair that was not confined in the surgical head covering and E#30 was observed wearing a necklace. 3. On 2/25/2025 at 1:28 PM, an interview was conducted with the Director of Surgical Services (E #5). E#5 stated that head covering should cover all head and facial hair. E#5 also stated that absolutely no jewelry of any kind is allowed to be worn within the surgery department.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 36774 Based on observation, document review, and interview, it was determined that for 1 of 1 ED (Emergency Department), the hospital failed to ensure the ED met the required registered nursing personnel. Findings include: 1. On 2/24/2025 between 10:45 AM and 11:15 AM, an observational tour was conducted in the ED (Emergency Department). The staffing included one charge nurse, two additional nurses, one patient care technician, one unit secretary, and one ED physician. The staffing was short of one RN based on the staffing grid. 2. On 2/25/2025, the ED RN (Registered Nurse) staffing guideline (undated), provided by E #4 (Executive Director of Nursing) was reviewed. The guideline included the following staffing requirements: Day Shift (7:00 AM through 7:00 PM): Three RNs with one ED technician and one unit secretary; Mid-Day Shift (10:00 AM through 10:00 PM): Additional One RN; Night Shift (7:00 PM through 7:00 PM): Three RNs with one ED technician and one unit secretary. 3. On 2/25/2025, the ED staffing was reviewed with E #7 (ICU Manager/Clinical Coordinator). The review indicated the following: - From 2/18/2025 through 2/24/2025: Short one RN from 7 PM through 7 AM on 2/23/2025, and one RN from 7 AM through 7 PM (2 of 21 12-hour shifts). 4. On 2/25/2025 at approximately 9:30 AM, E #4 (Executive Nursing Director) stated that appropriateness of staffing can be reviewed and validated with E #7 (Clinical Coordinator/ICU Manager). E #7 validated that the ED did not meet the staffing grid on the above dates.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 32741 Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.21 Quality Assessment and Performance Improvement Program. Findings include: 1. The Hospital failed to have a quality assessment performance improvement program. (A-273).”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 27125 Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services. Findings include: 1. The Hospital failed to ensure the Emergency Services Medical Director coordinated services with the Chief Executive Officer (CEO), per job description. See deficiency at A-1102 2. The Hospital failed to ensure the carts and cabinets were locked to prevent unauthorized access to unsafe equipment. See deficiency at A - 1104 3. The Hospital failed to ensure the emergency department had adequate staffing, per staffing grid. See deficiency at A-1112.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 2 of 5 clinical records reviewed for restraints (Pt. #1 and Pt. #2), the Hospital failed to ensure a physician order was obtained for restraint application, as required. Findings include: 1. On 11/19/2024, the Hospital’s policy titled, “”Restraint and Seclusion” (dated 2/2022) was reviewed and required, “Procedure - the physician will place the order for restraints in the EMR (electronic medical record). Once the restraints are applied, begin documentation in the EMR. RN (Registered Nurse) assessments are documented in the EMR ...” 2. On 11/19/2024, Pt. #1’s clinical record dated 10/3/2024 thru 10/11/2024 was reviewed and indicated: -Pt. #1 was admitted to the hospital on 10/3/2024 with the diagnosis of hyperkalemia (increased potassium level) and metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain). -Pt. #1 was placed in non-violent restraints (bilateral soft wrist restraints) on 10/9/2024 for attempting to bite a nurse. -Pt. #1’s clinical record lacked a physician’s order for non-violent restraint application on 10/9/2024. 3. On 11/19/2024, Pt. #2’s clinical record dated 7/26/2024 was reviewed and indicated: -Pt. #2 was seen in the ED (Emergency Department) on 7/26/2024 with a diagnosis of breakthrough seizure, noncompliance with medications and epilepsy. -Pt. #2 was placed in non-violent restraints (bilateral soft upper limb restraints on 7/26/2024 from 8:10 AM to 10:30 AM. -Pt. #2’s clinical record dated 7/26/2024 lacked documentation of a physician order for the bilateral soft upper limb non-violent restraints. 4. On 11/19/2024 at 9:00 AM, an interview was conducted with the ED Clinical Coordinator (E #3). E #3 stated that there should be a physician’s order for when a patient is placed on restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt. #2) reviewed for restraints, the Hospital failed to ensure the patient’s response to the restraint application. Findings include: 1. On 11/19/2024, the Hospital’s policy titled, “”Restraint and Seclusion” (dated 2/2022) was reviewed and required, “Procedure - the physician will place the order for restraints in the EMR (electronic medical record). Once the restraints are applied, begin documentation in the EMR. RN (Registered Nurse) assessments are documented in the EMR...Monitoring determines the following: patient’s physical and emotional well-being; maintenance of patient’s right, dignity, and safety; assessment of patient’s condition to determine if the current restraint should be continued or if less restrictive methods could be used or restraints could be discontinued. Assessment and reassessment must include, but are no limited to -circulation, sensation, level of distress and agitation, behavior, mental status, cognitive functioning, elimination needs, patient safety and comfort, during and after restraint is removed...Results of patient monitoring will occur at regular intervals according to the individual’s assessed needs but not to exceed 2 hours between intervals...Monitoring is accomplished by observation, direct face-to-face interaction with the patient...Real time documentation of assessment of restrained patient status at a minimum of every 2 hours for non-violent restraints...” 2. On 11/19/2024, Pt. #2’s clinical record dated 7/26/2024 was reviewed and indicated: -Pt. #2 was seen in the ED (Emergency Department) on 7/26/2024 with a diagnosis of breakthrough seizure, noncompliance with medications and epilepsy. -Pt. #2 was placed in non-violent restraints on 7/26/2024 from 8:10 AM to 10:30 AM. -Pt. #2’s clinical record dated 7/26/2024 did not include Pt. #2 restraint assessment after the application of restaints.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that the Hospital did not have a Quality Assessment and Performance Improvement (QAPI) plan or program. 1. On 11/21/2024, a request was made for the hospital to provide a QAPI program/plan. The hospital did not have any plan or program. QAPI meeting minutes were requested, and the hospital did not have any. There was no documentation of any information about QAPI since 2022. 2. On 11/25/2024, Medical Executive Meeting minutes were reviewed for 2024 and included no QAPI reference or review of QAPI. 3. On 11/20/2024 at 9:00 AM, an interview was conducted with the ED (Emergency Department) Director (E #6). E #6 stated that the ED (Emergency Department) collects date but E #6 does not know where it goes. E #6 stated that there are no quality indicators and does not know the frequency of indicators. 4. On 11/20/2024 at 2:15 PM, an interview was conducted with the CEO (Chief Executive Officer) (MD #5). MD #5 stated that the Hospital not having Quality Program might be an oversight. MD #5 stated that MD #5 bought 2 hospitals this year and is working on other hospital first, then will get to this hospital after. MD #5 stated that the Medical Executive/Governing Body has not set performance improvement or quality indicators, nor does it monitor the effectiveness and safety of services provided by the Hospital. 5. On 11/21/2024 at 11:15 AM, an interview was conducted with the Executive Director of Nursing (E #7). E #7 stated that the hospital does not have a quality improvement plan or program. E #7 stated that this a priority and E #7 is going to begin working on it.”

“ORGANIZATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(1) [If emergency services are provided at the hospital --] (1) The services must be organized under the direction of a qualified member of the medical staff. This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for 1 of 1 Medical Director of Emergency Services (MD#2), the hospital failed to ensure the Medical Director of Emergency Services coordinated services with the Chief Executive Officer (CEO), per job description. Findings included: 1. The “Job Description of the Medical Director of Emergency Services” was reviewed on 11/20/2024 and included, “Coordination of Services. CEO and Medical Director shall coordinate their activities. ... Duties of Medical Director Emergency Services: Medical Director Reports to CEO - Monthly - informal meeting, Quarterly - formal meeting, Annual evaluation. 2. The hospital’s medical executive committee meeting minutes for 2024 were reviewed on 11/21/2024. The following was the ED (Emergency Department) activity at medical executive committee: - January, February, March, and April 2024 - ED Medical Director did not attend - no report. - May, June 2024 - ED Medical Director attended - no report. - July and August 2024 - no meeting. - September 2024 - ED Medical Director attended - thanked team for support with joint commission. - October 2024 - ED Medical Director attended - ED working on new patient flow to avoid patients leaving without being seen. 3. The ED Medical Director (MD#2) was interviewed via telephone on 11/20/2024 at 2:15 PM. MD#2 stated that the ED physicians are a contracted service and are independent contractors. MD#2 stated “I was appointed medical director of the ED service in June 2022. No evaluation of my duties has occurred. I am only responsible for the ED physician and physician assistant team. We have monthly provider meetings among our team. This information is private and not shared with the hospital administration. 4. The Chief Executive Officer (MD#3) was interviewed via telephone on 11/21/2024 at 9:30 AM. MD#3 stated that there are regular informal meetings with the ED physicians. MD#3 stated, “I know the ED physicians have their own meetings, but I do not receive the minutes. I get involved with all budgeting needs or financial expenditures.” MD#3 stated that the ED Medical Director attends medical executive meetings and reports when there is something to report. There is no regular schedule for required reporting.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 27125 Based on document review, observation and interview, it was determined that for 12 of 12 emergency room supply carts and 2 of 2 trauma room supply cabinets, the hospital failed to ensure the carts and cabinets were locked to prevent unauthorized access to unsafe equipment. This potentially affected the average daily census of 12 patients. Findings included: 1. The Hospital’s policy titled, “Supply Carts/Boxes (5/2022)” was reviewed on 11/20/2024 and included, “Maintain various types of supply and emergency carts for use by clinical departments throughout the hospital.” 2. The Hospital did not have a policy related to locked storage of sharps or unsafe equipment. 3. A tour of the emergency department (ED) was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the clinical coordinator of the ED (E#3). During the tour the following was observed: - There was one trauma room (divided into 2 trauma bays) by the ambulance entrance. The room contained two large metal storage cabinets that contained needles and trocars (sharp pointed surgical instrument) used for trauma cases. The storage cabinets were not locked. - A bedside table contained IV (intravenous) start kits, including needles available in the room. Directly outside the room was a hallway bed that had a patient assigned. The patient was walking around and was stopped as they were entering the trauma room where unlocked supplies/equipment were present. - Each ED room had rolling supply carts containing syringes and individual needles. The supply carts were not locked and accessible to anybody walking by the room. 4. During an interview on 11/20/2024 at 12:45 PM , the ED Clinical Coordinator/Director (E#3) stated that no one knows where the keys for the trauma room storage cabinets or the supply carts are. Everything is left unlocked. E#3 stated, “All supplies should be locked to prevent unauthorized access to the equipment.””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 27125 Based on document review, observation and interview, it was determined for 7 of 7 days (11/13/2024 - 11/19/2024), the hospital failed to ensure the emergency department had adequate staffing, per staffing grid. This potentially affected the average of 12 patients present in the ED (Emergency Department) daily. Findings included: 1. The list of emergency department (ED) staff was reviewed on 11/19/2024. The list included that the ED had 3 full-time registered nurses, 11 registry nurses (no set hours required), 5 agency contract nurses, and 2 agency nurses available for staffing. 2. The “Emergency Room Staffing Guidelines” were reviewed on 11/19/20204. The guidelines included that staffing was the same from 7:00 AM - 7:00 PM (days) and 7:00 PM to 7:00 AM (nights). The staffing grid required: 1 charge/triage nurse, 2 registered nurses, 1 additional RN (Registered Nurse) from 10:00 AM to 10:00 PM, 2 technicians, 1 secretary and 1 constant observer. 3. The ED Daily staffing sheets for 11/13/2024 to 11/19/2024 were reviewed on 11/19/2024. The following shifts were short based on guidelines: 11/13/2024 - days - short one 7 AM to 12:00 PM triage/charge nurse, 1 technician and 1 constant observer. 11/14/2024 - days - short 1 constant observer 11/14/224 - nights - short 1 technician and 1 constant observer 11/15/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer 11/15/2024 - nights - short 1 technician and 1 constant observer 11/16/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer 11/16/2024 - nights - short 1 charge/triage nurse, 2 technicians and 1 constant observer 11/17/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer 11/17/2024 - nights - short 1 RN, 1 charge/triage nurse, 2 technicians and 1 constant observer 11/18/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer 11/18/2024 - nights - short 1 technician, 1 technician from 1 AM to 7 AM and 1 constant observer 11/19/2024 - days - short 1charge/triage nurse and 1 RN 4. A tour of the ED was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the Clinical Coordinator of the ED (E#3). The ED had 12 bays with an additional 6 hallway beds available. The current staffing was 2 registered nurses, 1 technician, 2 externs (students), 1 secretary and 1 constant observer. The staffing was 3 nurses and 1 technician below staffing guidelines. 5. During the tour, the charge nurse (E#1) was interviewed. E#1 stated, “Unfortunately we are short nurses most days. We do what we can. When a patient comes into the ED, whatever nurse is available, we go do the triage and keep the patient for their stay in the ED. Patient triage is alternated between whatever nurses are here. The registration desk notifies us of any patient arrival.” E#1 stated that most nurses are either registry or agency.” 6. During the tour, the ED Clinical Coordinator (E#3) was interviewed. E#3 stated, “We have been struggling to get ED staff. We have agency contracts and registry to pull from. We have a lot of call ins and have difficulty replacing staff at the last minute.” E#3 stated that staffing is not based on census and a set number of staff has been determined to have available at all times to deal with the fluctuating needs of the ED (i.e.: emergencies and fluctuating census).”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 50702 Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department, the Hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA-Emergency Medical Treatment and Labor Act) that was visible to patients as they enter the hospital. This potentially affected all patients that enter the hospital through the ambulance bay. Findings include: 1. The Hospital’s policy titled, “EMTALA” (revised February 2022), was reviewed and required, “Posting Signs ... The hospital must post conspicuously, in the dedicated Emergency Departments (ED) and all areas in which individuals routinely present for treatment of emergency medical condition and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.” 2. A tour of the ED was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the Clinical Coordinator of the ED (E#3). There was EMTALA signage in both English and Spanish posted on the wall at the registration desk in the waiting area of the ED. However, the entrance to the hospital’s ED through the ambulance bay lacked posting of the required EMTALA signage. 3. An interview was conducted with E#3 at approximately 10:45 AM. E#3 stated that [E#3] did not know why EMTALA signage was not posted in that ED area. E#3 stated that there should be EMTALA signage posted in the entrance to the hospital through the ambulance bay area, as it was at the registration desk in the waiting area.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 50411 A. Based on document review and interview, it was determined that for 2 of 3 emergency room clinical records (Pt #3 and Pt.#10) reviewed for transfers, the Hospital failed to ensure the transfer forms were completed, as required. Findings include: 1. On 11/19/2024, the Hospital’s policy titled, “EMTALA” (Revision Date 2/2022) was reviewed and indicated, “...1. A decision regarding patient transfer may be made by either patient request or physician certification...b. With certification...The individual may be transferred if a physician ...has certified that the medical benefits expected from transfer outweigh the risks...” 2. On 11/19/2024, the clinical record for Pt #3 was reviewed. Pt #3 was seen in Hospital A’s (this hospital) emergency department on 7/20/2024 with a diagnosis of sublingual abscess. Pt #3 was transferred to Hospital B (outside hospital) for ENT (Ear, Nose, Throat) specialty. Pt.#3 clinical record lacked the required transfer consent form and physician certification. 3. On 11/20/2024, the clinical record for Pt.#10 was reviewed. Pt.#10 was seen in Hospital A’s emergency department on 4/16/2024 with a diagnosis of Bipolar Disorder, Paranoia, Acute Psychosis, Agitation. Pt.#10 was transferred to Hospital C (outside hospital) for inpatient psychiatric treatment. Pt.#10’s clinical record lacked the required transfer consent form and physician certification. 4. On 11/19/2024 at approximately 10:30 AM, an interview was conducted with ED (Emergency Department )-RN (Registerd Nurse) (E#1). E#1 stated that a transfer form should be completed for all patient transfers. 5. On 11/19/2024 at 10:45 AM, an interview was conducted with the ED Physician (MD#1). MD#1 stated that the transfer consent forms should be filled out completely for all transfers. B. Based on document review and interview, it was determined that for 1 of 3 emergency room clinical records (Pt #2) reviewed for transfers, the transferring Hospital failed to ensure that all medical records available at the time of transfer were sent with the patient to the receiving hospital and other records were sent as soon as possible after transfer, as required. Findings include: 1. On 11/19/2024, the Hospital’s policy titled, “EMTALA” (Revision Date 2/2022) was reviewed and indicated, “...C. The hospital must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: ...(2) records related to the individual’s emergency medical condition...(5) results of diagnostic studies or telephone reports of studies; (6) treatment provided; (7) results of any tests...” 2. On 11/19/2024, the clinical record from the [transferring hospital-hospital A] for Pt.#2 was reviewed. -Pt. #2 presented to the ED on 7/20/2024 at approximately at 5:56 AM with chief complaint of facial laceration. CT done (face, head and spine) on 7/20/2024 at 4:20 PM. CT results included zygomatic fracture (cheekbone). Pt. #2 was transferred to Hospital B (receiving hospital) for higher level of care due to ENT services not available at Hospital A. The transfer form indicated that all ED medical record for Pt.#2 was sent with the patient. 3. On 11/26/2024, the clinical record for Pt.#2 from the [receiving hospital-Hospital B] was reviewed and included - “...7:17 PM Patient sent with CD of CT scans, CD sent off to radiology for read of CT, or printout of previous interpretation. 11:11 PM Called [Transferring Hospital - Hospital A] and requested CT scan reads be faxed over. 11:12 PM Fax was not received after a few hours, plan to work up patient here... 11:13 PM Plan to order CT scan of facial bones ...CT Facial Bones without Contrast was completed and resulted at Hospital B on 7/21/2024 at 2:01AM. Results included closed fracture of left zygomaticomaxillary complex; Closed ptyerygoid plate fracture; and closed fracture of nasal bone ...” 4. On 11/19/2024 at approximately 10:30 AM, an interview was conducted with ED-RN (E#1). E#1 stated that all the patient’s medical record be printed and sent with the patient. E#1 stated that if the final report dictations are not complete, the report should be faxed as soon as available. E #1 stated that E #1 does not recall receiving a request for additional records from Hospital B. E #1 stated that E #1 does not remember Pt. #2.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to ensure appropriate supervision and monitoring to prevent psychiatric patient from eloping. See A-144 A. 2. The hospital failed to ensure care in a safe setting by failing to ensure staff followed the response and notification process for patients that eloped. See A-144 B. The immediate jeopardy (IJ) was identified on 7/25/2024 at 42 CFR 482.13 Patient Rights, due to the Hospital’s failure to ensure appropriate supervision for 1 of 2 patients (Pt. #1) on high suicide risk and the failure to follow the emergency response and notification processes for 2 of 2 patients (Pt. #1 and Pt. #7) on suicide risk that eloped from the Emergency Department. The IJ was announced on 6/25/2024 at 3:15 PM during a meeting with the Chief Clinical Officer, Executive Director of Nursing, and Executive Director of Quality, Informatics, and Diversity Equity and Inclusion, and was not removed by the survey exit date of 6/25/2024.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40079 A. Based on document review, video surveillance review, and interview it was determined that for 1 of 2 patients (Pt. #1) reviewed with high risk for suicidal ideation (SI) in the Emergency Department (ED), the hospital failed to ensure appropriate supervision and monitoring to prevent psychiatric patients from eloping. This has the likelihood to cause serious harm to any suicidal patient that presents to the hospital. Findings include: 1. The hospital’s policy titled, “Suicide Risk Assessment” (revised 04/2022) was reviewed and required “One to one observation (1:1) means one observer to one patient within line of sight ... If the suicide risk identifies a high suicide risk, the nursing staff will place the patient on one to one (1:1) precautions at all times by a competent health care provider who is constantly observing the patient ...V. Procedure... 4. Emergency Department ... c. If one to one ... is required based upon the patient’s level of suicide risk, the required observation will be recorded on a Constant Observation (CO) flowsheet (every 15-minute recording of a patient’s activity, behavior, and location) ...” 2. On 6/20/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to hospital ED on 06/16/24 via ambulance from a psychiatric hospital due to chest pain. The clinical record included the following: -On 06/16/24 at 11:48 AM, a Petition for Involuntary/Judicial Admission from psychiatric hospital, included, “(Pt. #1) here with plan to OD (overdose) on medication with SI.” -On 06/16/24 at 1:27 PM, the ED Triage note by E #1 (ED Charge Nurse), included, “ ... CSSRS (Columbia Suicide Severity Rating Scale) Screen: Assessed Risk: High ...” -On 06/16/24 at 3:27 PM, ED Nursing note (by E #1) included, “(Pt. #1) from (psychiatric hospital) certified and petitioned. (Pt. #1) had sitter from (psychiatric hospital) at bedside. (Pt. #1) arrived with phone ... had visitor arrive; (visitor) left shortly after arriving to bring (Pt. #1) food ... (Pt. #1) told sitter (Pt. #1) had to use the bathroom ... walked over with sitter ... (Pt. #1) eloped with IV (intravenous catheter) through open door. Security chased (Pt. #1). A vehicle was parked right outside ER(emergency room) entrance, (Pt. #1) entered vehicle and drove with door open and almost hit staff/security. CPD (Chicago Police Department) called, notified them of the details at approximately 3:25 PM.” The clinical record did not indicate that the hospital provided a competent health care provider employed by the hospital to conduct one-to-one observation for Pt. #1. There was no constant observation flowsheet completed by staff for Pt. #1. 3. On 06/20/24 at 1:30 PM, a video surveillance for the ED on 06/16/24 during Pt. #1’s elopement was reviewed with the Manager of Public Safety (E #7): -At 3:18:40 PM, Pt. #1 along with a visitor (male) walked around the side of the ED registration desk and exited the hospital via the ED entrance. There were no attempts by staff to prevent Pt. #1 from exiting the ED. -From 3:18:56 PM to 3:21:10 PM, a Registered Nurse (RN/E #8), the Security Officer (E #10), an ED Technician (E #9) and the sitter from the psychiatric hospital is observed walking out the ED entrance door toward the direction Pt. #1 eloped and then return to the ED. 4. An interview was conducted with the Manager of Public Safety (E #7) on 06/20/24 at 12:35 PM. E #7 stated that today (6/20/24) is the first time that the video footage has been reviewed by the hospital. 5. On 6/20/2024 at 1:10 PM, the Executive Director of Nursing (E #3) and the Chief Clinical Officer (E #6) were interviewed. E #3 and E#6 stated they were not made aware of this incident, and there has not been an incident report created other than a nurse’s note in the patient’s (Pt. #1’s) clinical record. E #6 stated that CPD was notified of (Pt. #1’s) elopement, and there has not been a follow up. 6. An interview was conducted with an ED Charge Nurse (E #1) on 06/21/24 at 10:10 AM. E #1 also stated that the hospital does not provide a sitter if a patient comes with a sitter from the psychiatric hospital. Regarding monitoring of suicidal patients, E #1 was not aware if the hospital provides training or competency to the sitters from the psychiatric hospital. E #1 stated E #1 was not present when Pt. #1 eloped. E #1 stated that since the incident, E #1 has not been approached by leadership or administration to discuss this incident. 7. An interview was conducted with a Registered Nurse (RN/E#2/Pt. #1’s ED RN) on 06/21/24 at 11:53 AM. E #2 stated that the hospital does not provide a sitter if they come with their own sitter from the psychiatric hospital. E #2 did not witness Pt. #1 elope from the hospital. E #2 only became aware from another ED staff that Pt. #1 asked to use the bathroom which was near an entrance and ran away when the door opened. E #2 stated that other than the sitter from the psychiatric hospital, there was no staff monitoring Pt. #1 while E #2 was attending the needs of other patients. E #2 stated that E #2 has not been approached by administration to discuss this incident or provided with education on this type of incident. B. Based on document review, and interview, it was determined that for 2 of 2 patients’ clinical records (Pt. #1 and Pt. # 7) reviewed for elopement, the hospital failed to ensure care in a safe setting by failing to ensure staff followed the response and notification process for patients that eloped. Findings include: 1. The hospital’s policy titled, “Code Gold-Elopement” (revised 08/2018) was reviewed and required, “Elopement: legally defined as a patient who is incapable of adequately protecting himself and who departs the health care facility ... Staff member discovering the absence of a patient will immediately: 1. Call the emergency number ... give the location and description of patient to the operator so that the alert can be sent out through the overhead and text paging system ...” 2. On 6/20/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the ED on 06/16/24 via ambulance from a psychiatric hospital for complaint of chest pain. The clinical record included the following: -On 06/16/24 at 11:48 AM, a Petition for Involuntary/Judicial Admission from psychiatric hospital, included, “(Pt. #1) here with plan to OD (overdose) on medication with SI.” -On 06/16/24 at 1:27 PM, the ED Triage note by E #1 (ED Charge Nurse), included, “ ... CSSRS (Columbia Suicide Severity Rating Scale) Screen: Assessed Risk: High ...” -On 06/16/24 at 3:27 PM, the ED Nursing note (by E #1) included, “(Pt. #1) from (psychiatric hospital) certified and petitioned. (Pt. #1) had sitter from (psychiatric hospital) at bedside. (Pt. #1) arrived with phone ... had visitor arrive; (visitor) left shortly after arriving to bring (Pt. #1) food ... (Pt. #1) told sitter (Pt. #1) had to use the bathroom ... walked over with sitter ... (Pt. #1) eloped with IV (intravenous catheter) through open door. Security chased (Pt. #1). A vehicle was parked right outside ER (emergency room) entrance, (Pt. #1) entered vehicle and drove with door open and almost hit staff/security. CPD (Chicago Police Department) called, notified them of the details at approximately 3:25 PM.” Pt. #1 was not apprehended. The clinical record did not indicate that a Code Gold was activated when Pt. #1 eloped from the ED. 3. Pt. #7’s clinical record indicated that on 4/22/2024 at 10:38 PM, Pt. #7 was brought to the hospital’s ED due to self-harming behavior. Suicide risk for Pt. #7 was rated as moderate. The clinical record included the following: - On 4/23/2024 at 12:44 AM, the ED nurses’ notes indicated, “(Pt. #7) went to use bathroom accompanied by sitter. Sitter attempting to redirect (Pt. #7) back to bed. Registration requesting (Pt. #7) sign consent paperwork ... Registration opened doors to speak to (Pt. #7’s) boyfriend, (Pt. #7) then ran through double doors, (Pt. #7) pushed registration clerk away from door, running through doors ...” Pt. #7 was not apprehended. The clinical record did not indicate that a Code Gold was activated when Pt. #7 eloped from the ED. 4. The hospital’s security/code response logs from 4/1/2024 through 6/20/2024 was reviewed. The logs did not indicate that Code Gold was activated when Pt. #1 and Pt. #7 eloped from the hospital’s ED. 5. On 6/20/2024 at 12:35 PM, an interview was conducted with the Manager of Public Safety (E #7). E #7 stated that a “Security Code Log” did not indicate that a Code Gold was activated for (Pt. #1’s) elopement and should have been called. E #7 stated that the Code Gold provides staff with the location and description of the patient. This information is needed to ensure all staff are aware and on the lookout. 6. On 6/20/2024 at 1:10 PM, the Executive Director of Nursing (E #3) and the Chief Clinical Officer (E #6) stated they were not made aware of these incidents, and no incident reports were created. E #6 stated that CPD was notified of (Pt. #1’s) elopement, and there has not been a follow up. The ED Director (E #11) and the ED Medical Director (MD #1) could not provide documentation regarding the outcome of the investigation regarding Pt. #7’s elopement. 7. On 6/21/2024 at approximately 12:00 PM, interviews were conducted with E #11 and the (MD#1). E #11 and MD #1 could not provide documentation that a Code Gold was activated when Pt. #7 eloped from the ED. E #11 stated it should be documented in Pt. #7’s clinical record. 8. On 6/21/24 at approximately 12:00 PM, interviews with E #1 and E #2 (ED Registered Nurses) were conducted. E #1 and E# 2 stated that they did not activate or hear that a Code Gold was activated for Pt. #1. E #1 stated that a Code Gold was not called because the patient had already left the facility. E #2 stated there was no code called since staff saw the patient leave and was no longer in the ED, therefore a Code Gold was not needed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 3 patients’ (Pt. #8 and Pt. #9) clinical records reviewed regarding use of violent restraints, the hospital failed to ensure that documentation of every 15-minute monitoring was completed, as required. Findings include: 1. On 6/25/2024, the hospital’s policy titled, “Restraint and Seclusion” (2/2022) was reviewed and included, “... V. Procedure... 3. Once the restraints are applied begin documentation in the EMR (electronic medical record) C... 3... Violent Restraint Track. Continuous monitoring with real time documentation of assessment of restrained patient at least every 15 minutes...” 2. On 6/25/2024, the clinical record of Pt. #8 was reviewed. On 6/08/2024, Pt. #8 was in the hospital’s ED (emergency department) due to alcohol intoxication. On 6/8/2024 at 1:22 AM, the physician’s progress notes indicated that Pt. #8 was placed in physical restraint, and a physician’s order for a violent restraint was also ordered. However, there was no every 15-minute documentation while Pt. #8 was placed in restraints. 3. On 6/25/2024, the clinical record of Pt. #9 was reviewed. On 6/18/2024, Pt. #9 was in the hospital’s ED due to alcohol intoxication. On 8/8/2024 from 5:26 PM through 7:29 PM, Pt. #9 was placed in violent restraints. There was no every 15-,minute documentation while Pt. #9 was placed in restraints. 4. On 6/25/2024 at approximately 10:00 AM, findings were discussed with E #11 (ED Director). E #11 confirmed that the clinical records indicated that Pt. #8 and Pt. #9 were placed in violent restraints. E #11 stated that there should be every 15-minutes documentation while Pt. #8 and Pt. #9 were in restraints.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36774 A. Based on observation, document review, and interview, it was determined that for 2 of 3 emergency crash carts (#68548 and #68535) in the ED (emergency department), the hospital failed to ensure that that crash carts were checked, as required. Findings include: 1. On 6/20/2024 from 9:45 AM through 11:30 AM, an observational tour of the hospital’s ED was conducted. The ED has a capacity of 12 beds with a current census of three patients. The ED has three emergency crash carts. The Emergency Equipment Checklist for Crash Carts with lock #68548 and #68535 were not checked on 6/12/2024 and 6/17/2024. 2. On 6/20/2024, the hospital’s policy for the ED titled, “Crash Carts: Emergency Medication Audits and Replacement” (10/2021) was reviewed and included, “ ... III ... Emergency medication carts ... will be accurately stocked and available for use in the event of sudden, unforeseen, and life-threatening patient care emergencies ... IV. Procedure.. 2. Once a day, the integrity of each crash cart will be checked by nursing and documented on the Emergency Equipment Checklist ...” 3. On 6/20/2024 at approximately 11:30 AM, findings were discussed with E #4 (ED Charge Nurse). E #4 stated that the crash carts should be checked daily. B. Based on document review and interview, it was determined that for 2 of 3 patients’ (Pt. #3 and Pt. #4) clinical records reviewed for assessment/reassessment in the ED, the hospital failed to ensure reassessment was conducted, as required. 1. On 6/20/2024, the clinical record of Pt. #3 was reviewed. On 6/20/2024, Pt. #3 was in the hospital’s ED due to leg swelling. Pt. #3 was triaged with an ESI (emergency severity index of 3/urgent). There was no reassessment for Pt. #3 from 2:55 AM through 9:47 AM (approximately 5 hours and 8 minutes). 2. On 6/20/2024, the clinical record of Pt. #4 was reviewed. On 6/19/2024, Pt. #4 was in the hospital’s ED due to suicidal ideation. Pt. #4 was triaged with an ESI of 2/emergent. On 6/20/2024 at 3:15 AM, Pt. #4 was transferred to another hospital . There was no reassessment for Pt. #4 from 6/19/2024 at 6:36 PM through 6/20/2024 at 3:15 AM (approximately 9 hours). 3. On 6/25/2024, the hospital’s policy in the ED titled, “Patient Screening, Assessment, Reassessment and Plan of Care” (2/2021) was reviewed and included, “ ... IV ... 4. Screening & Reassessments for Emergency ... i. Each patient is screened/reassessed as necessary based on their current condition and identified problems ... ii. At the direction of the licensed practitioner, patient care setting, standard of care ... reassessment of patients may include the following ... a. vital signs ...” 4. On 6/25/2024 at approximately 10:00 AM, findings were discussed with E #11 (ED Director). E #11 stated that vital signs in the ED should be checked at least every 4 hours.”