Citizens Medical Center

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 17450 Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Infection Prevention Control an Antbiotic Stewardship. The hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by: 1. Failure to perform leak testing on endoscopes per hospital policy and manufacturers recommendations (Tag A0749); 2. Failure to have hand sanitizer available to staff on the patients halls and OR that was not expired (Tag A0749); 3. Failure to ensure clean endoscopes were not taken into dirty areas prior to being used on patients (Tag A0749); 4. Failure to ensure that sterilized instruments were stored in areas that had monitored humidity and temperature controls (A0749); 5. Failure to ensure that the autoclave was stored and utilized in a clean area and not in staff offices (A0749); 6. Failure to ensure staff who sterilized instruments donned appropriate PPE (A0749); 7. Failure to maintain the OR scrub sink in a clean and sanitary manner in order to prevent bacterial growth (A0749); 8. Failure to have a qualified infection control practitioner who is knowledgeable in infection control procedures (A0748). This resulted in an Immediate Jeopardy situation. S1ADM was notified on 06/23/2026 at 3:30 PM. The hospital proided the following plan of removal for the Immediate Jeopardy situation: 1. Leak testing will be done by hospital policy and manufacturers recommendations. Leak testing will be done prior to cleaning. The scope will be cleaned, then stored until next use. All OR staff will be trained on the appropriate cleaning of the scopes. To be completed by end of day 06/24/2026. 2. Hand sanitizer will be changed out prior or at expiration in all appropriate areas including halls and OR. The hand sanitizer was replaced on 06/23/2026. 3. Endoscopes will be taken straight from storage area to patient use area and not to be taken to dirty room after cleaned. To be completed by end of day 06/24/2026. 4. We are recleaning all the instruments needed for the two cases tomorrow. Tech will wear appropriate PPE. All instruments will be sterilized, carried and stowed in OR where temperature and humidity are monitored, as soon as cooled enought to safely carry. All remaining instruments will be cleaned and sterilized using the above method prior to use. We have ordered temperature and humidity monitors, aned they are to be delivered on 06/25/2026. They will be put in service as soon as they arrive. A policy will be written to montor the temperature and humidity for the correct ranges and document it daily. Date of correction 06/25/2026. 5. Autoclave area has been cleared of all desks. The area will be cleaned tonight. No staff will have offices in this area. The action was completed on 06/23/2026. 6. All staff that sterilize instruments will wear the appropriate PPE. All OR staff will be educated on the new policy verbally by the DNS and by Read and Sign by the end of day on 06/24/2026. 7. The OR scrub sink will be cleaned with the scale and lime remover tonight and will be maintained in a sanitary manner to prevent bacterial growth. This was complete3d on 06/23/2026. Housekeeping will monitor daily. 8. I met with the Infection Control Nurse and told her, she must be 100% knowledgable of the Infection Control Procedures, such as appropriate scope cleaning, sink cleaning, sanitizer availability, not just in OR but hospital wide. The Infection Control Nurse has completed an online course on The Concept of Infection Control. She will also complete the following online courses, Infection Prevention Basics EPI Intensive, Instrument Reprocessing & Sterilization EPI Intensive and High-Level Disinfection, EPI Intensive. We are going to purchase her a membership for APIC so that she continues to learn. These courses will be completed by end of the day. I also have spoken with a neighboring hospital and their Infection Control Nurse has agreed to mentor her. On 06/25/2026 at 11:15 AM, the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of complaince for the Condition of Infection Control be be cleared therefore the deficiency remains at a Condition Level (see findings at A0748, A0749, A0750 and A0773).”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure the services performed under contract were provided in a safe and effective manner. This deficient practice was evidenced by providing no documented evidence that all services provided by contract had been evaluated for safety and efficiency. Findings: Review of the QAPI plan provided to the surveyor by S2DON as the current QAPI plan revealed no documentation the contracted services had been evaluated for safety and efficiency. In an interview on 06/25/2026 at 11:22 AM S1ADM verified he was unaware the contracted services were supposed to be evaluated for safety and efficiency.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50453 Based on record reviews and interview, the facility failed to ensure each patient’s right to informed consent. The deficient practice is evidenced by failure of the anesthesia provider to document the planned type of anesthesia on the anesthesia consent for 7 (#14-#20) of 7 patient anesthesia consents reviewed. Findings: Patient #14 Review of Patient #14’s medical record revealed Patient #14 received General Anesthesia for a Right Elbow Lateral Epicondyle Debridement with common exterior tendon repair. Patient #15 Review of Patient #15’s medical record revealed Patient #15 received General Anesthesia for circumcision. Patient #16 Review of Patient #16’s medical record revealed Patient #16 received IV Sedation for a Colonoscopy with Biopsy and Polypectomy. Patient #17 Review of Patient #17’s medical record revealed Patient #17 received IV Sedation for a Colonoscopy. Patient #18 Review of Patient #18’s medical record revealed Patient #18 received IV Sedation and Topical Anesthesia for an Esophagogastroduodenoscopy with Biopsy and Colonoscopy. Patient #19 Review of Patient #19’s medical record revealed Patient #19 received General Anesthesia for a Right above the Knee Amputation. Patient #20 Review of Patient #20’s medical record revealed Patient #20 received General Endotracheal Anesthesia for a Laparoscopy with appendectomy. Review of the anesthesia consent forms for Patient #14-Patient #20, revealed the form authorized the physician/nurse anesthetist to perform or administer General Anesthesia, I.V. Sedation, or regional anesthesia as they may deem reasonable and necessary. Review of the documented risks and complications revealed the following list: 1. Allergic, Abnormal or hypersensitivity reaction to drugs or equipment, which may be fatal. 2. Aspiration (inhalation into the bronchi (airway) or lung: of stomach contents, stomach acids and foreign objects. 3. Laryngeal and/or vocal cord trauma or edema (injury to or swelling of vocal cords). 4. Heart attack or other heart problems. 5. Death. 6. Brain damage. 7. Shock. 8. Nerve damage ranging from loss of sensation to total paralysis. 9. Chipped or broken teeth. 10. Esophageal injury. 11. Burns. 12. Malignant hyperthermia (dangerously high fever which may result in death). 13. Injury to lips, tongue and inside of mouth or airway injury. 14. Breathing difficulties. 15. Eye injuries. Further review of the form for Patient #14 - Patient #20 failed to reveal the type of anesthesia the patient was scheduled to receive and the specific risks associated with that type of anesthesia. The form also had no place to add risks specific to the patient due to comorbid medical conditions. In an interview on 06/25/2026 at 12:41 PM, S2DON confirmed the anesthesia consents for Patient #14 - Patient #20 did not specify the type of anesthesia or associated risks that would be administered specific to each patient.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure the medical record contained documentation as to whether or not the patient had an advanced directive in 4 (#3, #4, #5, #7) of 7 medical records reviewed. Findings: Review of the hospital’s policy titled, “Advanced Directives”, effective date of 02/2023 revealed in part: All patients will be informed of the hospital’s policy regarding the patient’s right to make decisions concerning medical care and to form advanced directives. This will be provided to inpatients as well as outpatients seeking care in the Emergency Department, Outpatient Surgery, or Treatment Room. This will be presented at the time of registration and a copy will be given to all patients who seek treatment in those areas, but not necessarily to patients having outpatient labs drawn or routine x-rays performed. The form titled “Advanced Directive Acknowledgement” will be read and signed by the individual or the designated individual. In the case that the individual cannot read, the “Advanced Directive Acknowledgement” form will be read to them, or if a language barrier exists, an interpreter will be acquired to read and explain it to them. This form will be signed, placed in the chart, and will follow the patient throughout the course of their stay at the hospital, emergency room, and outpatient surgery. A copy of the Louisiana State Law will also be provided when the “Advanced Directive Acknowledgement” is signed. Review of Patient 3’s medical record did not reveal an Advance Directive Acknowledgement form. Review of Patient 4’s medical record did not reveal an Advance Directive Acknowledgement form. Review of Patient 5’s medical record did not reveal an Advance Directive Acknowledgement form. Review of Patient 7’s medical record did not reveal an Advance Directive Acknowledgement form. In an interview on 06/25/2026 at 12:30 PM S2DON verified the above mentioned information.”

“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: 48050 50453 Based on observations, record reviews and interviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice is evidence by: 1) failure to maintain a safe environment for psychiatric patients in the Emergency Department (ED); 2) failure to ensure ED staff had updated PALs resources for pediatric emergency; and 3) failure to have access to pediatric doses for first line medications in pediatric code cart. Findings: 1)Failure to maintain a safe environment for psychiatric patients in the Emergency Department Observations of the ED during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed in part: Room ‘j’: identified by S2DON as the room used to place psychiatric patients who arrive to the ED. Observations of Room ‘j’ revealed multiple items that could potentially be used to cause harm to patients or others, including: a stretcher, exam table, a mounted power strip on the wall with an extension cord, oxygen tanks, amongst other items. Further observations of Room ‘j’ revealed 2 exterior doors that could be locked from within the room, requiring a key to unlock and access the room if a patient were to lock themselves inside the room. Observations of the bathroom located within Room ‘j’ revealed that the bathroom door locks from inside the bathroom. Further observations of the bathroom revealed the following: an approximately 3 foot call bell cord, plastic bag in trash can, handrails that are ligature risk, sink with exposed pipe, overhead light with fluorescent bulbs, hook on back of door secured with screws. In an interview during the tour, S4RN confirmed that the ED nurse is responsible for monitoring and observing psychiatric patients if they are unable to pull a staff member from another area. In an interview during the tour, S2DON confirmed the above-mentioned findings in Room ‘j’. S4RN and S2DON confirmed they were unable to locate the key to unlock the doors of Room ‘j’ or the bathroom. S2DON and S4RN further stated they did not know how they would access Room ‘j’ or the bathroom if a psychiatric patient locked themselves inside, other than calling maintenance. 2)Failure to provide updated PALs resources for pediatric emergencies Observations of the ED during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed in part: Pediatric emergency cart in Room ‘h’ with a Broselow Tape dated 2011. A Broselow Tape is used for reference during a pediatric emergency code. In an interview on 06/22/2026 at 1:30 PM, S2DON verified the hospital’s Broselow Tape was not the most current edition available. 3)Failure to have access to pediatric doses for first line medications in pediatric code cart. Observations of the ED during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed in part: Room ‘h’: pediatric emergency code cart with no first line medications needed during a pediatric emergency. In an interview on 06/24/2026 at 2:00 PM S2DON verified the hospital does not have pediatric doses of first line medications used during a pediatric emergency. In an interview on 06/25/2026 at 8:45 AM S8RN verified if a pediatric emergency happened in the ED the staff would have to access adult dose first line medications and calculate pediatric doses to use during a code.”

“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: 48050 Based on record review and interview the hospital failed ensure the nursing and auxiliary staff had demonstrated competencies. The deficient practice is evidenced by failure to document competencies for 7 (S4RN, S5RN, S6LPN, S13OM, S14ST, S17RN, S18RN) of 7 clinical staff whose personnel files were reviewed; and 2) failure to ensure 1 of 1(S7CRNA) CRNA employed by the hospital had required certifications. Findings: 1) Failure to document competencies for 7 (S4RN, S5RN, S6LPN, S13OM, S14ST, S17RN, S18RN) of 7 clinical staff whose personnel files were reviewed Review of the personnel files for current clinical staff S4RN, S5RN, S6LPN, S13OM, S14ST, S17RN and S18RN revealed they had not received documented skills checks to ensure competencies in their job duties. On 06/24/2026 at 11:00 AM, S2DON reviewed the above personnel files and confirmed the staff had no documented skills check offs to ensure competencies in their job duties. 2) Failure to ensure 1 of 1(S7CRNA) CRNA employed by the hospital had required certifications. Review of the personnel file for S7CRNA revealed no current BLS, ACLS, and PALS certifications. 17450”

“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: 17450 Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to assess the wound of 1(#8) of 1 patients with a wound in a total sample of 20. Findings: Review of the medical record for Patient #8 revealed an admission date of 06/20/2026. The patient was admitted from the ED with diagnoses including chest pain and CHF. There was no documentation indicating the patient had any skin issues. Review of the initial RN assessment dated 06/20/2026 at 1:20 AM revealed the patient’s skin was within normal limits and had no mention of any wounds. Review of the nurse’s notes dated 06/20/2026 at 7:18 AM revealed sero-sanguineous drainage noted to left foot dressing. There was no documented assessment of the wound to the left foot. Review of the nurse’s notes dated 06/20/2026 at 8:29 AM revealed the left foot dressing was changed. There was no documented assessment of the wound and there was no physician order to treat the wound. On 06/25/2026 at 8:45 AM, interview with S3RN confirmed that there was no documented assessment of the patient’s left heel wound or any physician orders to treat the wound.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure all medical record entries were complete. This deficient practice is evidenced by failing to ensure medical records contained sufficient information to identify the patient for 13 (#1-#6, #14-#20) of 14 (#1-#7, #14-#20) medical records reviewed. Findings: Patient #1 A review of Patient #1’s medical record revealed the following documents completed by hospital staff: Statement of Patient Rights dated 04/29/2026 Advance Directive Acknowledgement dated 04/29/2026 Facility Disclosure Form dated 04/29/2026 Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 04/29/2026 Physician Certification for Transfer of Patient from the Emergency Department with no date documented Patient Transfer Form (pages 2-5) dated 04/29/2026 Further review of Patient #1’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #2 A review of Patient #2’s medical record revealed the following documents completed by hospital staff: Statement of Patient Rights dated 04/24/2026 Advance Directive Acknowledgement dated 04/24/2026 Facility Disclosure Form dated 04/24/2026 Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 04/24/2026 Further review of Patient #2’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #3 A review of Patient #3’s medical record revealed the following documents completed by hospital staff: Consent for Treatment and Agreement to Pay page 2 dated 03/24/2026 Statement of Patient Rights dated 03/24/2026 Advance Directive Acknowledgement Form not found Facility Disclosure Form dated 03/24/2026 Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 03/24/2026 Further review of Patient #3’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #4 A review of Patient #4’s medical record revealed the following documents completed by hospital staff: Consent for Treatment and Agreement to Pay page 2 dated 03/22/2026 Statement of Patient Rights dated 03/22/2026 Advance Directive Acknowledgement form not found Facility Disclosure Form dated 03/22/2026 Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 03/22/2026 Further review of Patient #4’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #5 A review of Patient #5’s medical record revealed the following documents completed by hospital staff: Consent for Treatment and Agreement to Pay page 1-2 dated 02/02/2026 Statement of Patient Rights dated 02/02/2026 Advance Directive Acknowledgement form not found Facility Disclosure Form dated 02/02/2026 Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 02/02/2026 Further review of Patient #5’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #6 A review of Patient #6’s medical record revealed the following documents completed by hospital staff: Consent for Treatment and Agreement to Pay page 2 dated 01/14/2026 Statement of Patient Rights dated 01/14/2026 Facility Disclosure Form no date documented Patient Right to Notify Family Member/Representative and Physician of Hospital Admission dated 01/14/2026 Nursing Progress Notes pages 1-2 with no date documented Further review of Patient #6’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. Patient #14 A Review of Patient #14’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/11/2026 Further review of Patient #14’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned document. Patient #15 A Review of Patient #15’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/27/2026 Consent for Treatment and Agreement to Pay, page 1-2 dated 05/21/2026 Facility Disclosure Form, not dated Patient Right to Notify Family Member/Representative and Physician of Hospital Admission, dated 05/21/2026 Statement of Patient Rights, page 1-2 dated 05/21/2026 Further review of Patient #15’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned documents. Patient #16 A Review of Patient #16’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/19/2026 Consent for Treatment and Agreement to Pay, page 1-2 dated 05/15/2026 Facility Disclosure Form, not dated Patient Right to Notify Family Member/Representative and Physician of Hospital Admission, dated 05/15/2026 Statement of Patient Rights, page 1-2 dated 05/15/2026 Further review of Patient #16’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned documents. Patient #17 A Review of Patient #17’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 06/15/2026 Further review of Patient #17’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned document. Patient #18 A Review of Patient #18’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/05/2026 Further review of Patient #18’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned document. Patient #19 A Review of Patient #14’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/11/2026 Statement of Patient Rights, page 1-2 dated 05/04/2026 Advance Directive Acknowledgement dated 05/04/2026 Further review of Patient #19’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned documents. Patient #20 A Review of Patient #20’s medical record revealed the following documents completed by hospital staff: PreAnesthesia Evaluation dated 05/30/2026 Further review of Patient #20’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above-mentioned document. In an interview on 06/25/2026 at 12:30 PM, S2DON confirmed the above mentioned medical record documents did not contain information to identify the patient. S2DON further confirmed the hospital did not have a policy related to medical records and patient identifiers. 50453”

“PHARMACIST RESPONSIBILITIES CFR(s): 482.25(a)(1) [§482.25 Condition of Participation: Pharmaceutical Services The hospital.... must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision.... §482.25(a)(1) - A full-time, part-time, or consulting pharmacist must be responsible for developing, supervising, and coordinating all the activities of the pharmacy services. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure the pharmacist developed polices to ensure the safe mixing and administration of potassium chloride by nursing staff. The deficient practice was evidenced by failure of the pharmacist to oversee the development or review current policies/procedures in use related to nurses mixing potassium chloride IV infusions to ensure patient safety. Findings: Tour of facility on 06/22/2026 from 11:33 AM - 1:45 PM revealed multiple potassium chloride intravenous (IV) vials unsecured in Room ‘b’ and Room ‘k’. In an interview on 06/22/2026 at 12:20 PM S2DON verified nurses routinely mix IV Potassium Chloride for administration. In an interview on 06/23/2026 at 9:25 AM S9Pharm verified nurses routinely mix IV Potassium Chloride for patient use. S9Pharm, who had been employed at the hospital for approximately 20 years, further verified not being involved in the hospital’s policy titled “Potassium Chloride IVPB” which details the procedure for nurses to mix IV Potassium Chloride for administration.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 48050 Based on observation and interview, the facility failed to ensure all drugs and biologicals were kept in a secure area and locked when appropriate. Findings: Tour of the facility on 06/22/2026 from 11:30 AM to 1:45 PM revealed an unlocked medication cabinet in Room b used for after-hours medication storage and an unlocked medication cart on Hallway B. In an interview on 06/22/2026 at 12:00 PM, S2DON verified the medication cabinet in Room b should be locked at all times and only accessed after hours when pharmacy is not available. In an interview on 06/22/2026 at 1:15 PM, S2DON verified the medication cart on Hallway B should be locked at all times.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use. Findings: Observations during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed the following expired medications available for use: Med/Surg Unit Crash Cart: (4) Amiodorone 150mg/3mL vials, expired 11/2025; (3) Dextrose 50% Injection 25g/50ml syringe, expired 04/01/2026; (1) Dextrose 50% Injection 25g/50ml syringe, expired 06/01/2026; (4) Epinephrine 1mg/10ml Luerjet Syringe, expired 10/2025; (2) Adrenalin 30mg/30ml vial, expired 05/2026; and (4) Naloxone Hydrochloride 2mg/2ml, expired 12/2025. Med/Surg Respiratory Cart: (25) Levalbuteral Inhalation Solution 0.63, expired 02/2026; (1) Levalbuteral Inhalation Solution 0.63, expired 09/2025; (5) Levalbuteral Inhalation Solution 0.63, expired 07/2025; (1) Levalbuteral Inhalation Solution 0.63, expired 03/2025; and (3) Albuterol 125/3ml Solution, expired 03/2026. Room ‘b’ medication cabinet: (1) Hyosone oral drops, expired 3/2026; (1) Cefprozil oral suspension 125/5mL, expired 4/2026; (10) Amicor 500mg tabs, expired 5/2026; (8) Acetylcysteine solution vials 4mL, expired 1/2026; (12) Diphenhydramine oral solution 12.5mg/5mL, expired 12/2025; (13) Megestrol Acetate 400mg/10mL, expired 2/2026; (10) Bethanechol Chloride 10mg tabs, expired 02/28/2026; (3) Theophylline 200mg tabs, expired 03/20/2026; (10) Doxepine Hcl 25mg tabs, expired 02/2026; (6) Nifedipine 10mg tabs, expired 3/2026; (4) Nitroglycerin 0.1mg transdermal patches, expired 11/2025; (4) Nitroglycerin 0.2mg transdermal patches, expired 4/2026; (4) Nitroglycerin 0.4mg, transdermal patches, expired 12/2025; (4) Scopalomine transdermal patches, expired 01/2026; (10) Hydroxizine 50mg/1mL vials, expired 4/2026; (13) Potassium Phosphate 22mEq/5ml, expired 05/31/2026; and (2) Chlorothiazide Sodium 500mg, expired 04/2026. Room ‘b’: (5) Sodium Chloride 0.9% irrigation bags, expired 10/2025; and (1) Hydrogen Peroxide Solution 3% 237ml with a discarded sticker dated 01/2026. Room ‘b’ refrigerator: (1) Humulin R (100 units/per ml) 10ml vial with a discard sticker dated 04/12/2026; (1) Novolog Mix 70/30 10 ml vial with a discard sticker date 05/01/2026; (7) Diltiazem 25mg/5ml vials, expired 01/2026; (20) Diltiazem 50mg/10ml vials, expired 04/2026; (8) Diltiazem 125mg/25ml vials, expired 04/2026; (1) Novolog (100units/ml) 10ml vial expired 05/31/2026; (24) Promethazine Hydrochloride suppositories 25mg, expired 05/31/2026; (27) Heparin 50units/5ml syringes, expired 07/2025; and (1) Thiamine 200mg/2ml vial with a discard sticker dated 05/03/2026. Hall B Medication Cart: (1) Albuterol Sulfate 3mg/3ml, expired 05/2026; (1) D5W IV fluids 1000ml, expired 11/2025; (1) Heparin 300units/3ml IV flush, expired 05/2026; (1) Lactate Ringers IV fluids 500ml, expired 08/2025; (1) Open Peptobismol bottle, expired 04/2026; (1) Nitro Bid 2% ointment, expired 11/2025; and (1) Sterile NS 0.9%, 100ml bag, expired 04/15/2026. Room ‘k’: (1) Albuterol sulfate inhalation solution 0.5%, expired 01/2025; (1)Betasol Propionate 0.05% cream, expired 05/2026; (2) Dorzolamide Hydrochlorine opthalmic solution, expired 10/2025; (4) Sodium Chloride 3000ml irrigation bag, expired 10/2025; and (1) Sodium Chloride 3000ml irrigation bag, expired 07/2025. In an interview during the tour, S2DON confirmed the above-mentioned findings. Observations during a tour on 06/22/2026 from 2:48 PM - 4:09 PM revealed the following expired medications available for use: Room ‘n’: (1) Atropine 8mg/20ml, expired 06/2024; (1) Bridion 200mg/2ml, expired 06/26/2025; (2) Flumazenil 0.5mg/5ml, expired 11/2025; and (1) Lidocaine Hydrochloride 1mg, expired 03/2025. In an interview during the tour, S13OM confirmed the above-mentioned findings. Observations during a tour on 06/23/2026 from 9:22 AM - 10:12 AM revealed the following expired medications available for use: Room ‘r’: (11) 6% Hetastarch in 0.9% Sodium Chloride, 500ml, expired 03/2026; (11) 6% Hetastarch in 0.9% Sodium Chloride, 500ml, expired 04/2026; (1) 0.45% Sodium Chloride, 1000ml, expired 09/2025; (10) 70% Dextrose, 500 ml, expired 02/2026; (1) Lansoprazole, 3mg/ml suspension, expired 05/12/2026; (9) Sterile Water 10ml, expired 01/2026; (1) Normal Saline 0.9% 20ml IV flush, expired 04/30/2026; (1) Noraml Saline 0.9% 5ml IV flush, expired 07/31/2019; and (1) Normal Saline 0.9% 5ml IV flush, expired 04/03/2020. In an interview during the tour, S9Pharm confirmed the above-mentioned findings. 50453 48050”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to have an approved therapeutic diet manual with a publication or revision date of not more than 5 years old. Findings: Review of hospital policy “Delivery of Services: Food & Dietetic Services,” adopted March 2021, revealed in part, “ A current therapeutic diet manual is reviewed and approved at least annually by the dietician, dietary manager, and medical staff. The publication date of the manual must not be more than 5 years old. Copies of the dietary manual will be available to nursing, medical and dietary staff.” Review of hospital therapeutic diet manual titled “Oklahoma Therapeutic Diet Manual,” 14th Edition, revealed the manual was published in 2012. An interview on 06/24/2026 at 12:15 PM, S10DM confirmed the hospital therapeutic diet manual, titled “Manual of Medical Nutrition Therapy,” 6th Edition, was published in 2010 and was more than 5 years old.”

“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: 48050 50453 Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This was evidenced by failing to ensure preventative maintenance was maintained on all hospital equipment. Findings: Review of the hospital’s policies and contracts revealed there was no documentation that the facility had a preventative maintenance program for equipment. Observations during a tour on 06/22/2026 from 11:33 AM to 1:45 PM revealed the following: Emergency Cart on the Med-Surg unit had a portable suction with preventative maintenance due 10/2024 Cardiac Monitor in the Nuclear Medicine Department with preventative maintenance due 10/2023 Vital Sign Machine in the Perioperative Room with preventative maintenance due 02/2025 Portable Ultrasound machine in the Cardiology Department with preventative maintenance due 01/2026 In an interview on 06/25/2026 at 11:22 AM, S1ADM confirmed the above mentioned equipment did not have preventative maintenance performed. S1ADM further verified the facility did not have a policy/procedure for preventative maintenance on equipment.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure supplies and equipment were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by failing to ensure expired or unusable supplies were removed from the patient care area. Findings: Observations during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed the following expired supplies that were available for patient use: Med/Surg Unit Crash Cart: (1) IV start Kit, expired 05/2018; and (1) Quick-Combo defibrillator pads, expired 01/09/2024. Med/Surg Respiratory Cart: (5) Tracheostomy Heat and Moisture exchangers, expired 06/2025. Room ‘b’: (2) Lumbar Puncture 22g x 3, 5 atraumatic Kit, expired 07/01/2025; (16) Glucerna 1.5cal/8fl oz, expired 05/01/2026; (8) 2.0 Two Cal eternal feeding 1L, expired 11/01/2025; (3) Encore Perry Style Sterile gloves, size 7.5, expired 07/27/2025; (4) Encore Perry Style Sterile gloves, size 8.5, expired 09/27/2025; (3) General Purpose Probe Cover, expired 06/19/2026; (3) Cir-Flex Transducer Cover, expired 04/01/2026; and (6) Xeroform Occlusive Gauze 5x9”, expired 02/28/2026. Room ‘c’: (1) Disposable pulse oximeter, expired 05/2025; (1) Disposable pediatric pulse oximeter, expired 06/2025; (2) Pediatric Specimen Cath Kit, expired 09/28/2024; (10) Self Catheter 8 french, expired 06/22/2025; (4) Self Catheter 8 french, expired 04/26/2026; and (9) Self Catheter 10 french, expired 06/01/2025; (3) Self Catheter 10 french, expired 04/12/2026. Hall B Medication Cart: (14) IV needle 18g 1 ¼”, expired 10/13/2025; (1) Dial a Flow IV tubing, expired 11/03/2023; and (1) Xeroform Occlusive Gauze 5x9”, expired 02/28/2026. Room ‘h’: (1) 6.0 tracheostomy tube, expired 06/30/2025; (8) 22 gauge IV jelco, expired 12/29/2025; (6) 22 gauge IV jelco, expired 02/21/2026; (1) 24 gauge IV jelco, expied 03/03/2025; (2) 24 gauge IV jelco, expired 03/23/2025; (2) 24 gauge IV jelco, expired 07/10/2025; (1) 24 gauge IV jelco, expired 04/27/2025; (17) Luer Lock tip syring 1ml, expired 04/13/2026; (3) Lumbar Puncture 22g x 3, 5 atraumatic Kit, expired 07/01/2025; (1) Mucosal Atomization Device Nasal, expired 06/28/2024; (1) Mucosal Atomization Device Nasal, expired 09/06/2026; (1) Mucosal Atomization Device Nasal, expired 06/28/2024; (2) Pneumothorax Set, 14 french, expired 04/21/2026; and (1) Pneumothorax Set, 14 french, expired 03/03/2026. Room ‘j’: (1) Foley kit, expired 05/31/2025; (1) Female catheter kit, expired 03/31/2026; and (1) Urethral tray with catheter, expired 01/01/2026. Room ‘k’: (5) Rapid Rhino 4.5cm, expired 04/27/2026; (3) Rapid Rhino 5.5cm, expired 05/19/2026; and (7) Rapid Rhino 7.5cm, expired 05/28/2026. In an interview during the tour, S2DON confirmed the above-mentioned findings. Observations during a tour on 06/22/2026 from 2:48 PM - 4:09 PM revealed the following expired supplies that were available for patient use: Room ‘n’: (1) Shiley tracheal tube with stylet 6.0, expired 09/03/2024; and (1) Shiley tracheal tube with stylet 5.0, expired 12/31/2024. In an interview during the tour, S13OM confirmed the above-mentioned findings. Observations during a tour on 06/23/2026 from 9:22 AM - 10:12 AM revealed the following expired supplies that were available for patient use: Room ‘r’: (19) EZ Scrub Surgical Scrub Brush, expired 10/2025; (1) Lansoprazole 3mg/ml suspension, expired 05/12/2026; (1) Insulin Needle Syringe, expired 04/2018; (3) 22g x 1” IV catheter, expired 01/2017; (2) Hypodermic Needle 27g, expired 04/20/2022; and (1) BD Safety Glide Needle 23g x1, expired 05/2019. In an interview during the tour, S9Pharm confirmed the above-mentioned findings. Room ‘h’ closet: (75) 22 guage needles, expired 02/15/2026; (25) 23 guage needles, expired 01/09/2026; and (25) 30 guage needles, expired 02/18/2026. In an interview during the tour, S2DON confirmed the above-mentioned findings. 50453 48050”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that an individual who is qualified through education, training, experience or certification in infection prevention and control is responsible for the infection prevention and control program of the hospital. Findings: Review of the current staff list revealed that S5RN was designated as the infection control nurse for the hospital. Review of the personnel file for S5RN revealed no documented evidence of training, experience or certification in infection prevention and control. Further review of the personnel file revealed no signed job description for infection control nurse. On 06/23/2026 at 2:07 PM, interview with S5RN revealed that she had been oriented to the role by the prior infection control nurse, but had not received any formal training and was not currently being supervised by anyone who is trained in infection prevention and control. On 06/24/2026 at 11:00 AM, interview with S2DON confirmed that S5RN had no documented competency check offs related to infection control. 50453”

“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: 17450 Based on observation, record review and interview, the hospital infection prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital as evidenced by: 1) Failure to perform leak testing on endoscopes per hospital policy and manufacturers recommendations; 2) Failure to have hand sanitizer available to staff on the patients halls and OR that was not expired; 3) Failure to ensure clean endoscopes were not taken into dirty areas prior to being used on patients; 4) Failure to ensure that sterilized instruments were stored in areas that had monitored humidity and temperature controls; 5) Failure to ensure that the autoclave was stored and utilized in a clean area and not in staff offices; 6) Failure to ensure staff who sterilized instruments donned appropriate PPE; 7) Failure to maintain the OR scrub sink in a clean and sanitary manner in order to prevent bacterial growth; 8) Failure to ensure opened and unusable supplies were not stored on or inside the anesthesia cart in the OR; and 9) Failure to monitor sterile supplies for expiration dates and remove patient use when expired. Findings: 1) Failing to perform leak testing on endoscopes per hospital policy and manufacturers recommendations. On 06/22/2026 at 3:15 PM, S14ST was asked the procedure for leak testing on the endoscope. S14ST stated that she perfoms a leak test on the endoscope at the beginning of each day, before the first procedure. S14ST stated that she removes the clean endoscope from the clean storage cabinet in PACU and walks the scope to the scope cleaning room (dirty room), performs the leak test and then takes the scope to the OR for use on the patients. Review of hospital policy titled, “Procedure to Ensure Cleaning of Flexible Scopes and Proper I.C. Precautions,” effective date 07/2016, revealed in part: “EQUIPMENT CLEANING, DISINFECTION & STERILIZATION PROCEDURES: To prevent buildup of bioburdens, development of biofilms and drying of secretions, pre-cleaning should take place at the point of use immediately following each procedure. Endoscopes will be processed following the manufacturer’s (Olympus) guidelines, AORN guidelines and ANSI/AAMI guidelines.” Review of the ANSI/AAMI manufacturer guidelines, provided by the hospital, revealed in part: “5.4 Leak Testing: 5.4.1 General considerations: Leak testing should be performed as soon as possible after the endoscope arrives in the processing area and before immersion of the endoscope into processing solutions.” 2) Failing to have hand sanitizer available to staff on the patients halls and OR that was not expired. On 06/22/2026 at 12:55 PM, observation on the 100 Hall revealed a hand sanitizer dispenser was on the wall. Further observations of the hand sanitizer revealed it had expired on 05/16/2025. On 06/22/2026 at 2:45 PM, observation of the hand sanitizer dispenser that was on the wall in the OR revealed it had expired on 06/15/2022. 3) Failing to ensure clean endoscopes were not taken into dirty areas prior to being used on patients On 06/22/2026 at 3:15 PM, S14ST was asked the procedure for leak testing on the endoscope. S14ST stated she perfoms a leak test on the endoscope at the beginning of each day, before the first procedure. S14ST stated that she removes the clean endoscope from the clean storage cabinet in PACU and walks the scope to the scope cleaning room (dirty room), performs the leak test and then takes the scope to the OR for use on the patients. 4) Failing to ensure that sterilized instruments were stored in areas that had monitored humidity and temperature controls On 06/22/2026 at 3:40 PM, observations were made with S14ST of the sterile processing room that stored the autoclave. Observation revealed the autoclave was built into the wall of the room. This room also included two desks where staff was observed performing their daily office work. A table was observed next to one of the desks. S14ST stated that she wraps clean instruments on this table prior to placing them in the autoclave for sterilization. Further observations at that time revealed several instrument packs that had been autoclaved were stored on a small shelf next to the autoclave. When S14ST was asked how long these packs sit on the shelf until they are placed in the cabinets in the OR, S14ST stated “when I have time”. Observations in this room revealed there was no temperature or humidity monitoring and S14ST confirmed this. In an interview on 06/23/2026 at 9:44 AM, S13OM confirmed the Room ‘o’ is not temperature or humidity controlled. 5) Failing to ensure that the autoclave was stored and utilized in a clean area and not in staff offices. On 06/22/2026 at 3:40 PM, observations were made with S14ST of the sterile processing room that stored the autoclave. Observation revealed the autoclave was built into the wall of the room. This room also included two desks where staff was observed to perform their daily office work. A table was observed next to one of the desks. S14ST stated that she wraps clean instruments on this table prior to placing them in the autoclave for sterilization. Observations of Room ‘o’ at this time, revealed an unlocked door off the main hallway that provides unrestricted access into Room ‘o.’ Further observations revealed an additional door in Room ‘o’ that provides unrestricted access into the OR. Observations on 06/23/2026 at 9:40 AM, revealed the door located off the main hallway was unlocked, allowing unrestricted access into Room ‘o.’ 6) Failing to ensure staff who sterilized instruments donned appropriate PPE On 06/22/2026 at 3:40 PM, observations were made with S14ST of the sterile processing room that stored the autoclave. Observation revealed the autoclave was built into the wall of the room. This room also included two desks where staff was observed to perform their daily office work. When S14ST was asked if any PPE was worn when wrapping the clean instruments and placing them in the autoclave, S14ST stated no. 7) Failing to maintain the OR scrub sink in a clean and sanitary manner in order to prevent bacterial growth. Observations on 06/22/2026 at 3:30 PM and on 06/23/2026 at 1:09 PM of the OR scrub sinks revealed 2 faucets with flakey crusted white and reddish/brown substance around the faucet periphery, around the individual water vents and completely covering the head of the central screw. In an interview on 06/23/2026 at 1:10 PM, S13OM confirmed the above-mentioned findings. S13OM also stated that housekeeping is responsible for cleaning the faucets for the OR scrub sinks. 8) Failing to ensure opened and unusable supplies were not stored on or inside the anesthesia cart in the OR. On 06/22/2026 from 2:45 PM until 4:09 PM, a tour of the OR revealed the following expired and/or unusable supplies that were available to be used on patients: OR room #2 had a single use laryngoscope handle, an open 20mL syringe, two electrodes, opened oxygen and suction tubing and an open container of 4x4 guaze lying on top of the anesthesia cart. Observation of the anesthesia cart revealed the following items stored inside the cart: (3) single use laryngoscope handles unpackaged; (4) single use laryngoscope blades unpackaged; (23) Ultane Senflurane 250ml bottles, empty/partially used in the bottom drawer of the cart; (1) round container of Ice Breakers candy stored in the 3rd drawer of the cart; and (1) camoflauge case for eye glasses. In an interview during the tour, S13OM confirmed the above mentioned findings. S13OM also confirmed that used/open items and personal items should not be stored in the anesthesia cart. 9) Failure to monitor sterile supplies for expiration dates and remove patient use when expired. Observations during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed the following expired supplies that were available for patient use: Med/Surg Unit Crash Cart: (1) IV start Kit, expired 05/2018; and (1) Quick-Combo defibrillator pads, expired 01/09/2024. Med/Surg Respiratory Cart: (5) Tracheostomy Heat and Moisture exchangers, expired 06/2025. Room ‘b’: (2) Lumbar Puncture 22g x 3, 5 atraumatic Kit, expired 07/01/2025; (16) Glucerna 1.5cal/8fl oz, expired 05/01/2026; (8) 2.0 Two Cal eternal feeding 1L, expired 11/01/2025; (3) Encore Perry Style Sterile gloves, size 7.5, expired 07/27/2025; (4) Encore Perry Style Sterile gloves, size 8.5, expired 09/27/2025; (3) General Purpose Probe Cover, expired 06/19/2026; (3) Cir-Flex Transducer Cover, expired 04/01/2026; and (6) Xeroform Occlusive Gauze 5x9”, expired 02/28/2026. Room ‘c’: (1) Disposable pulse oximeter, expired 05/2025; (1) Disposable pediatric pulse oximeter, expired 06/2025; (2) Pediatric Specimen Cath Kit, expired 09/28/2024; (10) Self Catheter 8 french, expired 06/22/2025; (4) Self Catheter 8 french, expired 04/26/2026; and (9) Self Catheter 10 french, expired 06/01/2025; (3) Self Catheter 10 french, expired 04/12/2026. Hall B Medication Cart: (14) IV needle 18g 1 ¼”, expired 10/13/2025; (1) Dial a Flow IV tubing, expired 11/03/2023; and (1) Xeroform Occlusive Gauze 5x9”, expired 02/28/2026. Room ‘h’: (1) 6.0 tracheostomy tube, expired 06/30/2025; (8) 22 gauge IV jelco, expired 12/29/2025; (6) 22 gauge IV jelco, expired 02/21/2026; (1) 24 gauge IV jelco, expied 03/03/2025; (2) 24 gauge IV jelco, expired 03/23/2025; (2) 24 gauge IV jelco, expired 07/10/2025; (1) 24 gauge IV jelco, expired 04/27/2025; (17) Luer Lock tip syring 1ml, expired 04/13/2026; (3) Lumbar Puncture 22g x 3, 5 atraumatic Kit, expired 07/01/2025; (1) Mucosal Atomization Device Nasal, expired 06/28/2024; (1) Mucosal Atomization Device Nasal, expired 09/06/2026; (1) Mucosal Atomization Device Nasal, expired 06/28/2024; (2) Pneumothorax Set, 14 french, expired 04/21/2026; and (1) Pneumothorax Set, 14 french, expired 03/03/2026. Room ‘j’: (1) Foley kit, expired 05/31/2025; (1) Female catheter kit, expired 03/31/2026; and (1) Urethral tray with catheter, expired 01/01/2026. Room ‘k’: (5) Rapid Rhino 4.5cm, expired 04/27/2026; (3) Rapid Rhino 5.5cm, expired 05/19/2026; and (7) Rapid Rhino 7.5cm, expired 05/28/2026. In an interview during the tour, S2DON confirmed the above-mentioned findings. Observations during a tour on 06/22/2026 from 2:48 PM - 4:09 PM revealed the following expired supplies that were available for patient use: Room ‘n’: (1) Shiley tracheal tube with stylet 6.0, expired 09/03/2024; and (1) Shiley tracheal tube with stylet 5.0, expired 12/31/2024. In an interview during the tour, S13OM confirmed the above-mentioned findings. Observations during a tour on 06/23/2026 from 9:22 AM - 10:12 AM revealed the following expired supplies that were available for patient use: Room ‘r’: (19) EZ Scrub Surgical Scrub Brush, expired 10/2025; (1) Lansoprazole 3mg/ml suspension, expired 05/12/2026; (1) Insulin Needle Syringe, expired 04/2018; (3) 22g x 1” IV catheter, expired 01/2017; (2) Hypodermic Needle 27g, expired 04/20/2022; and (1) BD Safety Glide Needle 23g x1, expired 05/2019. In an interview during the tour, S9Pharm confirmed the above-mentioned findings. Room ‘h’ closet: (75) 22 guage needles, expired 02/15/2026; (25) 23 guage needles, expired 01/09/2026; and (25) 30 guage needles, expired 02/18/2026. In an interview during the tour, S2DON confirmed the above-mentioned findings. 50453”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50453 Based on observation, record review, and interview, the hospital failed to have an effective infection prevention and control program. This deficient practice was evidenced by: 1) failure to maintain a clean and sanitary environment; 2) failure to record the temperatures of all dietary refrigerator/freezer equipment on a daily basis; and 3) failure to ensure food was stored in a safe and sanitary manner. Findings: 1) Failure to maintain a clean and sanitary environment. On 06/22/2026 at 12:35 PM, observation of “clean” patient rooms with S2DON revealed the following: Room d had brown drips on the wall under near the outlet. Room x had multiple dead bugs and insects in the windowsill and on the blinds. Room y had a dried brown substance on the call bell. On 06/22/2026 at 12:55 PM, observation of “clean” patient rooms with S2DON revealed the following: Room z had peeling laminate on the overbed table and a water leak stain on the ceiling that had a black center. At that time, S2DON stated the area on the ceiling looked like mold. Room aa had multiple dead insects in the windowsill. Room bb had debris and old food crumbs on floor. Room cc had a sticky black substance on the arm of bedside chair and debris and trash on the floor. On 06/22/2026 at 1:20 PM, observation of ED exam room h with S2DON revealed the room was clean and ready for a patient. Observation of the room at that time revealed a rolling trashcan with multiple pieces of bright red bloody guaze in it. At 1:25 PM, prior to EMS rolling a patient into the room, the surveyor notified S1ADM and he stated that the trash should have been removed when the room was cleaned. On 06/22/2026 at 2:45 PM, observation of OR room n with S13OM revealed the following: The Steris light over the table had a brown substance dripping down it. At that time, S13OM stated that it looked like rust. The Mayo table and Bovie machine had multiple areas of rust on them. On 06/22/2026 at 3:00 PM, observation of the ultrasound machine that was sitting near the OR nurses station revealed it was coated in a thick build-up of dust. On 06/23/2026 at 10:30 AM, observation of the nuclear medicine room with S1ADM revealed dried brown spots on the machine. At that time, S1ADM stated the brown spots must have occurred when the ceiling leaked. Further observations of the machine revealed black hairs and debris on it. S1ADM stated the staff should have cleaned the room and the machine after last use. S1ADM further stated that this nuclear medicine room is only used once per week. On 06/23/2026 at 11:50 AM, observation revealed the portable x-ray machine was stored in the outpatient waiting room. Observation of the machine revealed it was coated in a thick build-up of dust. 2) Failure to record the temperatures of all dietary refrigerator/freezer equipment on a daily basis. Tour of the hospital’s kitchen on 06/25/2026 from 10:00 AM to 10:30 AM with S19Cook revealed the following: Fish Freezer Temperature Log missing recorded temperatures for 06/19, 06/20, and 06/21/2026 Meat Freezer Temperature Log missing recorded temperatures for 06/19, 06/20, and 06/21/2026 And acceptable range of 0 degrees to 32 degrees even though all temperatures recorded in June 2026 were negative degrees Vegetable Freezer Temperature Log missing recorded temperatures for 06/19, 06/20, and 06/21/2026 and acceptable range of 0 degrees to 32 degrees even though all temperatures in June 2026 were negative degrees Back Cooler Temperature Log missing recorded temperatures for 06/19, 06/20, and 06/21/2026 and acceptable range of 32 degrees to 35 degrees even though multiple temperatures recorded in June 2026 were above 35 degrees. Back Cooler Temperature Log missing recorded temperatures for 06/19, 06/20, and 06/21/2026 and acceptable range of 32 degrees to 35 degrees even though multiple temperatures recorded in June 2026 were above 35 degrees. In an interview on 06/25/2026 at 10:18 AM S19Cook verified above mentioned information. S19Cook further verified that maintenance is notified when refrigerator and/or freezer temperatures are not within acceptable ranges, but unsure of process and no documented recheck of temperature after reported out of range. 3) Failure to ensure food was stored in a safe and sanitary manner. Observations during a tour on 06/22/2026 from 11:33 AM - 1:45 PM revealed the following: Room ‘a’: -Tomato Soup 7.25 oz can, expired 05/2026, quantity 2; -Tomato Juice, expired 04/2025, quantity 6; -Tomato Juice, expired 11/2025, quantity 6; -V8 Juice, expired 05/2025, quantity 6; and -V8 Juice, expired 11/2025, quantity 6. In an interview during the tour, S2DON confirmed the above-mentioned findings were expired. 17450 48050”

“IC PROFESSIONAL DOCUMENTATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 50453 Based on record review and interview, the Infection Control Officer failed to document infection surveillance, prevention and control activities. This deficient practice is evidenced by failing to show any evidence of ongoing activities of tracking and trending infections, handwashing surveillance, and environmental rounds. Findings: The hospital failed to provide any evidence of ongoing infection control surveillance, prevention, and control activities upon request. On 06/22/2026 at 8:35 AM, during entrance conference, a document request was provided which outlined the initial request for a copy of the hospital’s current infection control activities. On 06/23/2026 at 2:07 PM, a 2nd request for infection control activities was made to S5RN. S5RN confirmed she was over infection control. In an interview with S5RN at this time, S5RN was asked by surveyor if she had performed any infection control observations. S5RN stated that when she took over as infection control, policies/procedures were already in place and staff knew how to follow them. S5RN confirmed that she has not performed any observations to verify that staff are performing infection control prevention activities correctly. S5RN confirmed that she did not have any data that she has obtained over the past 4 years in her position. By exit conference on 06/25/2026 at 1:00 PM, no additional documented evidence of infection control activity was provided to the surveyors. This included tracking and trending infections, environmental rounds and handwashing surveillance.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the operating room followed acceptable professional standards of practice. This deficient practice was evidenced by failure to ensure the “Time Out Procedure” was conducted prior to the incision or surgical procedure for 7 (#14-#20) of 7 surgery patients reviewed. Findings: Review of hospital policy titled, “Safe Surgery Policy,” not dated, revealed in part: “III. Policy: An interactive Surgical Time Out will be conducted by the patient care team immediately prior to incision or surgical procedure.” Review of hospital policy titled, “Time Out Processing Policy,” effective date 06/2013, revealed in part: “PURPOSE: To promote safety by providing guidelines for verification of correct site, correct procedure, and correct patient for invasive/surgical procedure(s). This policy applies to all invasive/surgical procedures including bedside invasive procedures performed at the facility. POLICY: 1. The “Time Out” process shall be completed and documented prior to starting the procedure and ideally, prior to the introduction of the anesthesia process unless contraindicated.” Patient #14 Review of Patient #14’s surgical record revealed the patient had a Right Elbow Lateral Epicondyle Debridement with common exterior tendon repair on 05/11/2026 with a procedure start time of 12:43 PM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #15 Review of Patient #15’s surgical record revealed the patient had a circumcision on 05/27/2026 with a procedure start time of 7:20 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #16 Review of Patient #16’s surgical record revealed the patient had a Colonoscopy with Biopsy and Polypectomy on 05/19/2026 with a procedure start time of 7:06 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #17 Review of Patient #17’s surgical record revealed the patient had a Colonoscopy on 06/15/2026 with a procedure start time of 8:04 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #18 Review of Patient #18’s surgical record revealed the patient had a Esophagogastroduodenoscopy with Biopsy and Colonoscopy on 04/17/2026 with a procedure start time of 7:06 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #19 Review of Patient #19’s surgical record revealed the patient had a Right Above the Knee Amputation on 05/05/2026 with a procedure start time of 8:22 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. Patient #20 Review of Patient #20’s surgical record revealed the patient had a Laparoscopy with appendectomy on 05/30/2026 with a procedure start time of 9:26 AM. Review of the time out procedure failed to reveal documented evidence that the time out was completed prior to the incision or surgical procedure. In an interview on 06/25/2026 at 12:41 PM, S2DON confirmed the above-mentioned findings. S2DON further confirmed that there was no time documented for Patient #14 - Patient #20 in the surgical record to indicated that the time out was performed prior to the incision or surgical procedure.”

“PRE-ANESTHESIA EVALUATION CFR(s): 482.52(b)(1) [The policies must ensure that the following are provided for each patient:] A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure all pre-anesthesia evaluations were performed within 48 hours prior to surgery or procedure by an individual qualified to administer anesthesia in accordance with state law and with hospital policies and procedures. The deficient practice was evidenced by failing to document the date and time of completion on the pre-anesthesia evaluation for 6 (#14, #16-#20) of 7 (#14-#20) pre-anesthesia records reviewed. Findings: Review of hospital policy titled, “Description of the Anesthesia Department,” effective date 01/2014, revealed in part: “III. PRE-ANESTHETIC EVALUATION AND CARE: Prior to performing any anesthetic, the CRNA must perform a pre-anesthesia evaluation as defined by the Centers for Medicare and Medicaid (CMS). The evaluation must be performed within 48 hours prior to surgery or procedure requiring anesthetic services. A pre-anesthesia evaluation must be performed for each patient who receives general, regional or monitored anesthesia care. The delivery of the first dose of medication(s) for the purpose of anesthesia induction marks the end of the 48 hour timeframe. d. The pre-anesthesia note will include the date and time. REQUIRED RECORDS AND REPORTS: The following records and reports will be maintained for each patient: a. A pre-anesthesia note will be placed in the patient’s medical record indicating the patient’s physical status, special problems, contemplated surgery, date and time.” Patient #14 Review of Patient #14’s medical record revealed a Pre-Anesthesia Evaluation dated 05/11/2026. Further review failed to reveal documented evidence of the time the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. Patient #16 Review of Patient #16’s medical record revealed a Pre-Anesthesia Evaluation dated 05/19/2026. Further review failed to reveal documented evidence of the time the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. Patient #17 Review of Patient #17’s medical record revealed a Pre-Anesthesia Evaluation dated 06/15/2026. Further review failed to reveal documented evidence of the time the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. Patient #18 Review of Patient #18’s medical record revealed a Pre-Anesthesia Evaluation signed by S7CRNA. Further review failed to reveal documented evidence of the date and time that the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. Patient #19 Review of Patient #19’s medical record revealed a Pre-Anesthesia Evaluation dated 05/05/2026. Further review failed to reveal documented evidence of the time the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. Patient #20 Review of Patient #20’s medical record revealed a Pre-Anesthesia Evaluation signed by S7CRNA. Further review failed to reveal documented evidence of the date and time that the pre-anesthesia evaluation was completed by S7CRNA per hospital policy. In an interview on 06/25/2026 at 12:41 PM, S2DON confirmed the above-mentioned findings.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure a post-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia in accordance with state law, hospital policies, and procedures. The deficient practice was evidenced by failing to document the time of completion in the post-anesthesia evaluation for 1 (#16) of 7 (#14-#20) post-anesthesia records reviewed. Findings: Review of hospital policy titled, “Description of the Anesthesia Department,” effective date 01/2014, revealed in part: “REQUIRED RECORDS AND REPORTS: The following records and reports will be maintained for each patient: c. Within 48 hours after the operation, a post-anesthesia note will be placed in each patient’s medical record describing the presence of anesthesia-related complication(s). d. Each post-anesthesia note will specify the date and time of evaluation.” Patient #16 Review of Patient #16’s medical record revealed a Post-Anesthesia Note with a date of 05/19/2026. Further review failed to reveal documented evidence of the time the post-anesthesia evaluation was completed per hospital policy. In an interview on 06/25/2026 at 12:41 PM, S2DON confirmed the above-mentioned findings.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 53491 Based on visual observation the facility failed to provide a fire alarm system that when activated properly provides positive alarm sequence, automatic occupant notification via audible and visual signals. When the building is equipped with life safety systems, that offer complete coverage, the occupants maintain a sense of security in an emergency. This deficiency has the potential to affect of residents. During the facilit tour on June 23, 2026 it was observed that in the following locations speaker/strobes were not working: 400 hall, back hall, and inside the kitchen. Interview with Hospital Administrator revealed the facility was not aware the speaker/strobers were not working properly during the fire alarm function test.”

“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: 53491 Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 9 of 9 residents. During the facility tour on June 23, 2026 it was observed that the sprinkler system is missing its 5 year internal inspection. Interview with Hospital Administrator revealed the facility was not aware that the 5 year internal inspection has not been completed for the automatic sprinkler system.”

“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: 53491 Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 9 of 9 residents. During the facility tour on June 23, 2026 it was observed that the hospital was missing 4th quarter fire drills from 2025 and missing 2nd quarter fire drills for 2026. Interview with Hospital Administrator revealed the facility was not aware fire drills were not conducted for the 4th quarter of 2025 and the 2nd quarter of 2026.”

“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: 53491 Based on visual observation the facility failed to assure that the fire and/or smoke barrier doors in the facility were inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80). The deficient practice has the potential to affect 9 of 9 residents. During the facility tour on June 23, 2026 it was osberved that the fire and/or smoke doors have not been inspected and tested annually. Interview with Hospital Administrator revealed the facility was not aware that the fire and smoke doors shall be inspected and tested annually.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 53491 Based on visual observation, the facility failed to assure that the annual testing and inspection of all receptacles outlets was completed. The facility shall ensure it is in compliance with NFPA 99 and the requirments. The deficient practice had the potential to affect 9 of 9 residents. During the facility tour on June 23, 2026 it was observed that the facility failed to conduct testing and documentation on all the electrical outlets throughout the hospital. Testing hasn’t been completed since 2021. Interview with Home Administrator revealed the facility was not aware that all testing and documentation was not being completed for the receptacles/electrical outlets.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48537 Based on record review and interview, the hospital failed to ensure patient rights and informed consent for treatment was obtained prior to the initiation of care in the emergency department. This deficient practice was made evident on 5 (Patients #4, #7, #11, #14, and #18) of 20 sample patients reviewed for signed patients’ rights and informed consent for treatment prior to receiving care in the emergency department. Findings: Review of the medical record for Patient #4 revealed she presented to the ED on 10/06/2025 at 5:15 PM and was triaged as emergent for stroke-like symptoms. No patient rights or informed consent for treatment were signed. Review of the medical record for Patient #7 revealed she presented to the ED on 08/11/2025 at 7:06 AM and was triaged as urgent for near syncope, dizziness and possible CVA. No patient rights or informed consent for treatment were signed. Review of the medical record for Patient #11 revealed she presented to the ED on 08/19/2025 at 9:47 AM and was triaged as urgent for lethargy and being non-verbal. No patient rights or informed consent for treatment were signed. Review of the medical record for Patient #14 revealed she presented to the ED on 09/02/2025 at 1:02 PM and was triaged as urgent for near syncope. No patient rights or informed consent for treatment were signed. Review of the medical record for Patient #18 revealed she presented to the ED on 10/08/2025 at 7:06 PM and was triaged as emergent for right-sided facial droop. No patient rights or informed consent for treatment were signed. On 11/03/2025 at 11:20 AM, an interview was conducted with S1ADM. S1ADM confirmed the aforementioned findings.S1ADM stated due to the above patients’ conditions when they arrived to the ED, the staff were unable to obtain signed consents at the time of their arrivals because the staff were focused on stabilizing the patients and should have gone back to have the patient or designative representative sign the consents.”

“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: 48537 Based on record review and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1) the hospital failed to provide an appropriate medical screen examination (MSE) for a patient within the capabilities of the hospital’s emergency department (ED). The deficient practice was evidenced by failure to review all testing performed on Patient #4 with an emergency medical condition prior to transfer to a hospital which did not have the capability to provide the required specialized care (see findings in tag A-2406); 2) the hospital failed to provide stabilizing medical treatment for an emergency medical condition prior to transferring to a hospital providing a higher level of care. This deficient practice was evidenced by failing to initiate a heparin infusion prior to transfer of a patient (#3) with a free-floating thrombus in the distal cervical internal carotid artery (ICA) on the computed tomography angiography (CTA) (see findings in tag A-2407); and 2) the hospital failed to ensure the appropriate transfer of a patient with an emergency medical condition. The deficient practice is evidenced by the hospital’s emergency department physician not specifying risks for transfer for 2 (Patients #3 and #4) emergency department room patients sampled for appropriate transfers (see findings tag A-2409).”

“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: 48537 Based on record review and interviews, the hospital failed to provide an appropriate medical screen examination (MSE) for a patient within the capabilities of the hospital’s emergency department (ED). The deficient practice was evidenced by failure to review all testing performed on Patient #4 with an emergency medical condition prior to transfer to a hospital which did not have the capability to provide the required specialized care. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” effective 03/2023 revealed in part: “Purpose: The purpose of this policy is to set forth policies and procedures for use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). Policy Statement: It is the policy of The Hospital that all individuals who come to this hospital requesting emergency services receive an appropriate medical screening examination (MSE) as required by EMTALA, 42 U.S.C. Section 1395 and all Federal regulations. Under EMTALA the hospital: 1. Will provide an adequate medical screening examination (MSE) to any individual who comes to the emergency department when they present for care to the hospital’s dedicated emergency department.. Definitions: For the purposes of this Policy, the following terms and definitions apply: G. Medical Screening Examination: All patient who come to The Hospital for emergency medical treatment shall receive a MSE - 1. The scope of the MSE must be tailored to the presenting complaint and the medical history of the patient; 3. The examination must include all services within the capabilities of the hospital, which in the judgement of the emergency physician or other treating physician; 4. It is an on-going process; 5. The ED record must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer.” Medical record review of Patient #4 revealed the patient arrived at Hospital A’s emergency department (ED) in a privately owned vehicle (POV) driven by her husband and was brought into the ED registration area by wheelchair on 10/06/2025 at 5:12 PM. Patient # 4 was triaged at “emergent” for a headache, sudden onset of dizziness, unable to use left upper extremity and right lower extremity was weak. Patient #4’s symptoms were documented to have started around 11:00 AM on 10/06/2025. Upon arrival at the ER on 10/06/2025 at 5:13 PM, Patient #4 had a National Institutes of Health Stroke Scale (NIHSS) score of 5. Patient #4 received a score in the following sections: 5. Motor Arm - 5a. Left Arm=Drift; limb holds 90 (or 45 degrees, but drifts down before full 10 seconds, does not hit bed or other support; 6. Motor Leg - 6b. Right Leg=Drift; leg falls by the end of the 5-second period but does not hit the bed; 7. Limb Ataxia - 2=Present in both limbs; 9. Best Language - 1=Mild-to-Moderate Aphasia; some obvious loss of fluency or facility of comprehension without significant limitation on ideas expressed or form of expression. Review of the ED nursing notes for Patient #4 documented by S5RN on 10/06/2025 revealed in part: At 5:13 PM - 32-year-old female had to be assisted out of POV into wheelchair with chief complaint of possible cerebral vascular accident (CVA) reported by husband. Patient #4 reports “just got dizzy all of a sudden and couldn’t use left upper extremity and right lower extremity got weak.” She denies any vision changes. At 5:30 PM - Radiology notified of need for CT of head. At 5:48 PM - Radiology to get Patient #4 to CT scan via stretcher. At 6:06 PM - S4MD notified LERN [Louisiana Emergency Response Network] to transfer Patient #4. Review of the orders for Patient #4 revealed the following diagnostic imaging orders placed while in the ED at Hospital A: On 10/06/2025 at 5:26 PM, CT (Computerized Tomography) Head without (WO) contrast On 10/06/2025 at 5:50 PM, CT Chest WO contrast On 10/06/2025 at 6:20 PM, CTA (Computerized Tomography Angiogram) Head On 10/06/2025 at 6:23 PM, CTA Neck Review of Patient #4’s diagnostic imaging results taken on 10/06/2025 while at the ED at Hospital A revealed the following results: Test: CT Head WO contrast Exam Completed: 10/06/2025 at 5:29 PM Impression: No acute intracranial abnormality Exam Signed: 10/06/2025 at 6:13 PM Test: CT Chest WO contrast Exam Completed: 10/06/2025 at 5:50 PM Impression: No acute findings Exam Signed: 10/06/2025 at 7:21 PM Review of Patient #4’s medication orders revealed the following medications were given to Patient #4 while at Hospital A: On 10/06/2025 at 5:36 PM, Hydralazine 20mg/1mL IV (milligrams per milliliter intravenous) push On 10/06/2025 at 5:45 PM, Hydralazine 20mg/1mL IV push Review of the document titled “Authorization for Transfer” revealed the following items had been selected for each section: Section 1: A. The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from or occur during the transfer. Section 2: Reason for transfer - Neurology consult Section 4: A. Patient consents to the transfer. [Transfer Consent form was completed and signed by Patient #4’s husband on 10/06/2025 at 6:45 PM]. Section 5: A. The receiving facility has available space and qualified personnel for the treatment of the patient. B. The receiving facility has agreed to accept transfer and to provide appropriate medical treatment. 1. Name of the receiving facility: Hospital B 2. Name of the individual accepting transfer: ED Physician at Hospital B C. The receiving facility will be provided with appropriate medical records of the examinations and treatments of the patient. D. The patient will be transferred by qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures. 1. Means of Transport: Ground Ambulance - ALS [Advanced Life Support] 2. Personnel Accompanying Patient: EMT-P [Emergency Medical Technician-Paramedic] I certify that I have answered the above questions based upon the information available to me at the time of the patient’s transfer. I further certify that I have made the appropriate disclosures as indicated on this form. Signed by S4MD on 10/06/2025 at 6:06 PM. Further review of the ED nursing notes for Patient #4 documented by S5RN on 10/06/2025 revealed in part: At 6:40 PM - ED Physician at Hospital B accepted Patient #4. At 7:08 PM - Ground ambulance arrived at Hospital A to get Patient #4 for transfer to Hospital B. Additional review of Patient #4’s diagnostic imaging results taken on 10/06/2025 while at the ED at Hospital A revealed the following result: Test: CTA Head, CTA Neck Exam Completed: 10/06/2025 at 6:32 PM Impression: Tortuous distal cervical right ICA [internal carotid artery] with fusiform ectasia [an abnormally twisted part of the right ICA artery located in the neck near the head where the portion of the artery has an aneurysm that bulges on all sides along the segment, not just at the neck of the artery] measuring 10 mm in diameter and there is a dissection through this ecstatic segment. Patency is maintained beyond this. Dominant left vertebral artery and relatively hypoplastic right vertebral artery. The cervical right vertebral artery appears to be occluded in the upper neck region and potentially through the intracranial segment. Results of exam were discussed via telephone with S4MD at 7:28 PM on 10/06/2025. Exam Signed: 10/06/2025 at 7:30 PM (Patient #4 had left Hospital A to transfer to Hospital B 20 minutes prior to the documented time the exam resulted were discussed with S4MD.) Review of the medical record for Patient #4 from Hospital B revealed Patient #4 was immediately seen via telehealth for possible stroke and was transferred out to a higher level of care within 2 hours of arrival with a diagnosis of cerebral vascular accident and thrombosis of the right carotid artery. On 10/30/2025 at 11:00 AM, an interview was conducted with S1ADM regarding Patient #4’s transfer to Hospital B. S1ADM stated he was aware Hospital B was upset about the transfer of Patient #4 because Patient #4 was in route to Hospital B when S4MD was notified about the results of her CTA scan of her head and neck. S4MD attempted to contact the ambulance drivers to get them to divert her to another facility, with more specialized services which could better care for Patient #4’s medical needs instead of Hospital B, but he was unable to do so. S1ADM stated when he discussed the situation with S4MD, S4MD stated he had not realized the CTA head and neck had not resulted prior to transfer of Patient #4 from Hospital A to Hospital B. On 10/30/2025 at 11:00 AM, an interview was conducted with S4MD regarding the transfer of Patient #4 to Hospital B. S4MD confirmed he had not realized Patient #4’s CTA head and neck had not resulted prior to the transfer of care.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48537 Based on record review and interview, the hospital failed to provide stabilizing medical treatment for an emergency medical condition prior to transfer to a hospital providing a higher level of care. This deficient practice is evidenced by failure to provide blood thinners prior to transferring Patient #3 with a free-floating thrombus in the distal cervical internal carotid artery (ICA) on the computed tomography angiography (CTA). Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” effective 03/2023 revealed in part: “Purpose: The purpose of this policy is to set forth policies and procedures for use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). Under EMTALA the hospital: 5. Will provide necessary stabilizing treatment to an individual with an emergency medical condition; 6. Will provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capacity or capability to provide the treatment to stabilize the individual. Still, the attending physician must make a reasonable attempt to stabilize the patient in the emergency department (ED) using every resource at his/her disposal, or whatever else to reduce the changes of decompensation during the transfer.” Review of Patient #3’s medical record revealed she arrived at Hospital A’s ED in a privately owned vehicle (POV) driven by her husband and ambulated into the ED registration area on 09/16/2025 at 3:56 PM. Patient #3 was triaged as “urgent” for a near syncopal episode with stroke-like symptoms including dizziness, generalized weakness, right-sided facial drooping and a headache on the left side for “awhile”. Upon arrival at the ED on 09/16/2025 at 3:56 PM, Patient #3 had a National Institute of Health Stoke Scale (NIHSS) score of 0. At 5:06 PM, Patient #3 had a NIHSS score of 1. Patient #3 received the increased score change for section 9. Best Language: 1=Mild-to-Moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Review of Patient #3’s medication orders revealed the following medications were given to Patient #3 while at Hospital A: On 09/16/2025 at 4:48 PM, Hydralazine 5 milligram (mg)/0.25 milliliter (mL) intravenous (IV) push [Hydralazine is a commonly prescribed IV medication as one-time dose to aide in lowering elevated blood pressure] On 09/16/2025 at 5:31 PM, Nicardipine HCl (Cardene 20 mg / 0.9% normal saline at dose of 2.5 mg /20 mL via IV piggyback at an infusion rate of 20 mL/hour to Patient #3’s 18g (gauge) left AC (antecubital) PIV (peripheral intravenous) [Cardene is a commonly prescribed IV medication as continuous infusion to aide in lowering elevated blood pressure]. Review of Patient #3’s CTA of the head completed on 09/16/2025 at 6:45 PM revealed the following in part: “Impression: There is a small nonocclusive thrombus suggested within the distal cervical ICA on the left. This could represent a “free-floating thrombus” associated with unstable atherosclerotic plaque. There is no evidence of large intracranial vessel occlusion.” Review of S3MD’s note signed on 09/17/2025 at 8:35 PM revealed in part the following: “Imaging: CT scan of the brain is negative, CTA of the head and neck does not show any large vessel occlusion, partially occluded distal left cervical ICA; Differential Diagnosis: TIA, CVA, dehydration, anemia, electrolyte abnormality; Medical Decision Making and Emergency Dept Course: Patient with some stroke-like symptoms. She has had baseline laboratory work done, CT of the head done, EKG. We also did a CT scan abdomen pelvis because the patient has been having some abdominal pain vomiting and diarrhea. Patient was given 5mg hydralazine IV to lower her blood pressure which upon presentation was in the 220 range systolic. Her initial workup was normal which was expected because the patient’s symptoms had resolved relatively quickly. Shortly after returning from the CT of the head patient started having some dysarthria [motor speech disorder resulting in slurred, slow or soft speech]. At that time, her blood pressure went back up to about 210 systolic. The patient was started on Cardene drip to lower blood pressure by decreasing her AP by 20%. She then had a CTA of the head and neck. During this time we also activated LERN [Louisiana Emergency Response Network] because of the patient’s recurring symptoms. CTA did return with abnormality, but seems rather minor. No occlusion, the patient symptoms have resolved again. Blood pressure has been reduced. Patient is symptom free. She has been accepted in transfer to Hospital B. Final Emergency Dept Diagnosis: TIA, hypertensive emergency; Disposition: Transfer.” Review of the document titled “Authorization for Transfer” revealed the following items had been selected for each section: Section 1: A. The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from or occur during the transfer. Section 2: Reason for transfer - Neuro Section 4: A. Patient consents to the transfer. (Transfer Consent form was completed and signed by Patient #3 on 09/16/2025 at 7:00 PM). Section 5: A. The receiving facility has available space and qualified personnel for the treatment of the patient. B. The receiving facility has agreed to accept transfer and to provide appropriate medical treatment. 1. Name of the receiving facility: Hospital B 2. Name of the individual accepting transfer: ED Physician at Hospital B C. The receiving facility will be provided with appropriate medical records of the examinations and treatments of the patient. D. The patient will be transferred by qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures. 1. Means of Transport: Ground Ambulance - ALS I certify that I have answered the above questions based upon the information available to me at the time of the patient’s transfer. I further certify that I have made the appropriate disclosures as indicated on this form. Signed by S3MD on 09/16/2025 at 6:20 PM. Review of the emergency department record revealed on 09/16/2025 at 10:12 PM the ED physician from Hospital B documented, “Appears that symptoms started in the 2:00 a.m. [sic][hour this afternoon. Patient was outside facility, and had a CT and a CT angio that was done, but information was running [sic] given saying that the CT angio was clear, when there was actually a floating thrombus appreciated on CT angio. Due to the erroneous information given, patient accepted ED to ED here at [redacted name]. Upon learning about the CT angio upon arrival, discussed with vascular neurologist, [name redacted], who was okay with transfer for evaluation for possible thrombectomy. Patient here had been stable. Patient blood pressure did increase above 180, so will add Cardene just to make sure that blood pressure does not get too far past 180 systolic.” And at 10:55 PM the same physician documented, “Patient has not received aspirin or Plavix at outside facility. Will give.” On 11/03/2025 at 9:05 AM and 10:00 AM, attempts were made at a telephone interview with S3MD, but were unsuccessful. On 11/03/2025 at 10:10 AM, an interview was conducted with S1ADM regarding Patient #3’s transfer to Hospital B. S1ADM stated both he and S3MD were aware Patient #3 had “free floating thrombus” that had been visualized on the CTA scan, but because Hospital A did not have the capabilities to remove the thrombus she needed to be transferred to another facility. S1ADM verified the entire ED record for Patient #3, including the CT angio, was sent to the receiving hospital before Patient #3 was accepted for transfer. S1ADM stated S3MD stabilized her blood pressure by putting her on a continuous Cardene infusion prior to leaving via ground ambulance and her stroke-like symptoms had also resolved prior to her departing Hospital A. S1ADM confirmed Hospital B had received all of Patient #3’s medical records and imaging including the CTA of the head and neck prior to accepting the patient for transfer. S1ADM would not confirm whether Patient #3 should have been given something for the thrombus prior to leaving Hospital A.”

“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: 48537 Based on record review and interview, the hospital failed to ensure the appropriate transfer of a patient with an emergency medical condition. The deficient practice is evidenced by the hospital’s emergency department physician not specifying risks for transfer for 2 (Patients #3 and #4) emergency department room patients sampled for appropriate transfers. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” effective 03/2023 revealed in part: “Purpose: The purpose of this policy is to set forth policies and procedures for use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). Under EMTALA the hospital: 5. Will provide necessary stabilizing treatment to an individual with an emergency medical condition; 6. Will provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capacity or capability to provide the treatment to stabilize the individual. Still, the attending physician must make a reasonable attempt to stabilize the patient in the emergency department (ED) using every resource at his/her disposal, or whatever else to reduce the changes of decompensation during the transfer. Definitions: For purposes of this Policy, the following terms and definitions apply: Q. Physician Certification of Risks and Benefits: A physician must sign an express written certification that, based on 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 from being transferred. The certification should meet the following requirements: 1. The certification must state the reason for transfer. The narrative rationale need not be a lengthy discussion of the individual’s medical condition as this can be found in the medical record but should be specific to the condition of the patient upon transfer; 2. The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer; 3. The date and time of the physician certification should closely match the date and time of the transfer; 4. Certifications may not be backdated.” Patient #3 Review of Patient #3’s medical record revealed she arrived at Hospital A’s emergency department (ED) in a privately owned vehicle (POV) driven by her husband and ambulated into the ED registration area on 09/16/2025 at 3:56 PM. Patient #3 was triaged at “urgent” for a near syncopal episode with stroke-like symptoms including dizziness, generalized weakness, right-sided facial drooping and a headache on the left side for “awhile”. Review of the document titled “Authorization for Transfer” revealed the following items had been selected for each section: Section 1: A. The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from or occur during the transfer. Section 2: Reason for transfer - Neuro Section 3: Nothing was checked because Section 1. A. was checked. Section 4: A. Patient consents to the transfer. [Transfer Consent form was completed and signed by Patient #3 on 09/16/2025 at 7:00 PM. Further review of this document revealed no explanation of the specific risks associated with being or not being transferred prior to the transfer consent being signed and the ED physician signing the certification document.] Section 5: A. The receiving facility has available space and qualified personnel for the treatment of the patient. B. The receiving facility has agreed to accept transfer and to provide appropriate medical treatment. 1. Name of the receiving facility: Hospital B 2. Name of the individual accepting transfer: ED Physician at Hospital B C. The receiving facility will be provided with appropriate medical records of the examinations and treatments of the patient. D. The patient will be transferred by qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures. 1. Means of Transport: Ground Ambulance - ALS I certify that I have answered the above questions based upon the information available to me at the time of the patient’s transfer. I further certify that I have made the appropriate disclosures as indicated on this form. Signed by S3MD on 09/16/2025 at 6:20 PM. Review of Patient #3’s hospital records of the transfer from Hospital A to Hospital B on 09/16/2025 revealed the ED Care Timeline dated 09/16/2025 7:30 PM to 09/16/2025 11:45 PM which revealed in part the following: At 9:25 PM, Patient #3’s ED registration completed at Hospital B At 9:40 PM, Critical Alert Stroke Activation and Stroke Documentation started and order placed to Consult to telemedicine - Acute Stroke At 10:00 PM, Vascular Neurology - Has vascular neurology been notified? Yes on 09/16/2025 at 10:00 PM. Also, at 10:00 PM Telestroke Provider at beside with Patient #3. At 10:04 PM, Stroke Provider Notified via tele consult Patient #3 did not need to be transferred here and needed to be transferred to Hospital C due to need for vascular neurology/neurosurgery. At 10:13 PM, Stroke Outcome - Transferred to higher level of care at Hospital C for vascular neurology and neurosurgery. At 11:45 PM, Patient #3 was transported via emergency air transportation to Hospital C. Patient #4 Medical record review of Patient #4 revealed the patient arrived at Hospital A’s emergency department (ED) in a privately owned vehicle (POV) driven by her husband and was brought into the ED registration area by wheelchair on 10/06/2025 at 5:12 PM. Patient # 4 was triaged at “emergent” for a headache, sudden onset of dizziness, unable to use left upper extremity and right lower extremity was weak. Patient #4’s symptoms were documented to have started around 11:00 AM on 10/06/2025. Review of the document titled “Authorization for Transfer” revealed the following items had been selected for each section: Section 1: A. The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from or occur during the transfer. Section 2: Reason for transfer - Neurology consult Section 3: Nothing was checked because Section 1. A. was checked. Section 4: A. Patient consents to the transfer. [Transfer Consent form was completed and signed by Patient #4’s husband on 10/06/2025 at 6:45 PM. Further review of this document revealed no explanation of the specific risks associated with being or not being transferred prior to the transfer consent being signed and the ED physician signing the certification document.] Section 5: A. The receiving facility has available space and qualified personnel for the treatment of the patient. B. The receiving facility has agreed to accept transfer and to provide appropriate medical treatment. 1. Name of the receiving facility: Hospital B 2. Name of the individual accepting transfer: ED Physician at Hospital B C. The receiving facility will be provided with appropriate medical records of the examinations and treatments of the patient. D. The patient will be transferred by qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures. 1. Means of Transport: Ground Ambulance - ALS [Advanced Life Support] 2. Personnel Accompanying Patient: EMT-P [Emergency Medical Technician-Paramedic] I certify that I have answered the above questions based upon the information available to me at the time of the patient’s transfer. I further certify that I have made the appropriate disclosures as indicated on this form. Signed by S4MD on 10/06/2025 at 6:06 PM. On 10/30/2025 at 11:00 AM, an interview was conducted with S1ADM regarding Patient #4’s transfer to Hospital B. S1ADM stated specific risks would not have been reviewed with the Patient #4 and/or their family if S4MD felt the patient had been stabilized prior to transfer. On 10/30/2025 at 11:00 AM, an interview was conducted with S4MD regarding the transfer of Patient #4 to Hospital B. S4MD confirmed he had not realized Patient #4’s CTA head and neck had not resulted prior to the transfer of care. On 11/03/2025 at 9:05 AM and 10:00 AM, attempts were made at a telephone interview with S3MD but were unsuccessful. On 11/03/2025 at 10:10 AM, an interview was conducted with S1ADM regarding Patient #3’s transfer to Hospital B. S1ADM stated S3MD had stabilized Patient #3’s blood pressure prior to transferring her and was aware of the “free floating thrombus”, but the stroke-like symptoms had resolved prior to Patient #3’s transfer to Hospital B so she was stabilized for transfer and therefore did not need to have the risks outweigh the benefits.”