Salem Memorial District Hospital

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 48359 Based on observation, interview and policy review, the Organizational Structure failed to: - Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital; (C-0962) - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for two current emergency department (ED) patients of two ED patients observed; (C-2523) - Follow their policy and procedure for medication removal from the automated dispensing machine (ADM, computerized system designed to deliver requested medications or supplies) for three patients (#4, #6 and #7) of four medication administrations observed; (C-2523) - Follow their policy for intravenous (in the vein) site labeling for four patients (#4, #6, #7 and #9) of four patients observed; (C-1208) - Maintain a sterile field (completely clean and free from germs surface on which to place sterile equipment or supplies that are considered free from microorganisms) for one patient (#8) of one sterile procedure observed; (C-1208) - Clean patient care equipment for four patients (#4, #6, #7 and #9) of four patients observed; (C-1208) - Create clean barriers for four patients (#4, #6, #7 and #9) of four patients observed; (C-1208) - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) for four patients (#4, #6, #7 and #9) of four patients observed; (C-1208) - Ensure single use items were not used for multiple patients; (C-1208) - Follow their policy for patient’s home medication storage for one patient (#6) of one patient’s home medication storage observed; and (C-1016) - Ensure policies were reviewed biennially for 856 policies of 1,196 policies reviewed. (C-1022) These failures had the potential to affect the quality of care and safety of all patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR Subpart F 485.627 Condition of Participation (CoP): Organizational Structure. Please refer to C-0962, C-1004, C-1016, C-1022 and C-2523.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to follow their policy for patient’s home medication storage for one patient (#6) of one patient’s home medication storage observed. The hospital failed to ensure policies were reviewed biennially for 856 policies of 1,196 policies reviewed. This failure had the potential to affect the quality of care and safety of all patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR Subpart F 485.635 Condition of Participation (CoP): Provisions of Services. Please refer to C-1016 and C-1022. 50151”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-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 coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Follow their policy for intravenous (in the vein) site labeling for four patients (#4, #6, #7 and #9) of four patients observed; - Maintain a sterile field (completely clean and free from germs surface on which to place sterile equipment or supplies that are considered free from microorganisms) for one patient (#8) of one sterile procedure observed; - Clean patient care equipment for four patients (#4, #6, #7 and #9) of four patients observed; - Create clean barriers for four patients (#4, #6, #7 and #9) of four patients observed; - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) for four patients (#4, #6, #7 and #9) of four patients observed; and - Ensure single use items were not used for multiple patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR Subpart F 485.640 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship Programs. This failure had the potential to affect the quality of care and safety of all patients. Please refer to C-1208 for details. 50151 51509”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for two current emergency department (ED) patients of two ED patients observed. The hospital failed to follow their policy and procedure for medication removal from the automated dispensing machine (ADM, computerized system designed to deliver requested medications or supplies) for three patients (#4, #6 and #7) of four medication administrations observed. Review of the hospital’s policy titled, “Telemetry Monitoring,” reviewed 05/01/2024, showed: - Telemetry monitoring must be initiated for patients with clinical indications per ED telemetry criteria (e.g., chest pain, fainting, irregular heartbeat, heart attack, etc.). - Continuous monitoring will be maintained with alarm parameters set. - The nurses are responsible for assessing and responding to any telemetry alarms. - Changes in rhythm must be communicated to the provider immediately and documented. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also know as Immediate Jeopardy (IJ). As of 06/10/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included the immediate education of all staff present regarding the need for continuous telemetry monitoring and the hospital’s updated process for the telemetry monitoring. All remaining staff members were educated prior to the start of their next shift. Review of the hospital’s policy titled, “Medication Management: Dispensing,” revised 05/31/20, showed only one patient’s medications should be removed from the ADM at one time to avoid confusing or mixing up medications. These failed practices placed all patients admitted to the hospital at increased risk for their safety and resulted in noncompliance with 42 CFR 485.614 Condition of Participation Patient’s Rights. Please refer to C-2523 for details.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 48359 Based on observation, interview, and policy review, the Organizational Structure failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR Subpart F 485.614 Condition of Participation (CoP): Patient’s Rights, 42 CFR Subpart F 485.640 CoP: Infection Prevention and Control and Antibiotic Stewardship Programs and 42 CFR Subpart F 485.635 CoP: Provisions of Services. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Board Bylaws of Salem Memorial District Hospital,” adopted 01/10/23, showed the board shall select and appoint a CEO who shall be its direct executive representative in the management of the hospital. The CEO is the individual appointed by the board to act on the board’s behalf in the overall administrative management of the hospital, subject only to the orders, policies, or bylaws, enacted or amended, by the board. The CEO shall serve as a liaison among the board, the administration, and the Medical Staff. The CEO shall be given the necessary authority and responsibility to operate the hospital, hospital facilities, and all its activities and departments, subject only to such policies as may be adopted and such orders as may be issued by the board. The Medical Staff, hospital personnel, and any auxiliary organizations of the hospital shall be responsible to the board through the CEO. The CEO shall act as the duly authorized representative of the board in all matters in which the board has not designated some other person to so act. Review of the hospital’s document titled, “Chart of Organization,” revised 07/12/24, showed all administrative leaders reported to Staff S, CEO and the CEO reported to the Board of Directors. During an interview on 06/11/24 at 2:04 PM, Staff S, CEO, stated that she assumed the role of CEO in 07/2024.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to follow their policy for patient’s home medication storage for one patient (#6) of one patient’s home medication storage observed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Medication Management Storage: Controlled Substances,” revised 03/07/25, showed all controlled drugs in Schedules II, III, IV and V will be stored in double locked security. Review of the hospital’s policy titled, “Medication Management: Administration,” revised 01/21/16, directed staff to always store narcotics separately under lock and key, maintaining a “double check” count system. Observation on 06/10/25 at 8:50 AM, showed: - Staff M, Licensed Practical Nurse (LPN), opened a locked box in Patient #6’s room and retrieved a pill bottle which contained nine clonazepam (a schedule II-controlled substance medication used to treat anxiety, that is regulated by the government based on the potential for abuse). - Staff M removed one tablet and administered it to the patient. - Staff M filled out the controlled substance inventory record. There was not a second nurse to verify the pill count for the double check, before or after the medication was administered. During an interview on 06/11/25 at 2:04 PM, Staff S, Chief Executive Officer (CEO), stated that she expected staff to follow all policies and procedures. Narcotics were to be stored with double locked security. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected staff to follow all policies and procedures. Storing a patient’s home narcotic in their room’s locked box did not meet the policy’s expectations. During an interview on 06/10/25 at 2:10 PM, Staff J, Pharmacy Director, stated that narcotics were to be stored behind double locked security. She expected witnessed narcotic counts with every administration. She believed storing narcotics in a patient’s room lock box did not meet the policy’s expectation for double locking. During an interview on 06/10/25 at 9:00 AM, Staff M, LPN, stated that a second nurse witness was not needed to verify her count of the medication, before and after the dose was administered. The medication was stored within a locked box in the patient’s room, the medication was secured. She was unsure who had the passcode to unlock the box. 50151”

“PATIENT CARE POLICIES CFR(s): These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to ensure policies were reviewed biennially for 856 policies of 1,196 policies reviewed. This failure had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Development of Policies and Procedures,” revised 04/01/20, showed: - Patient care policies and procedures are reviewed biennially; - The patient care department director and the policy and procedure committee will complete the review by the first business day in December of even years; - Non-patient care policies, and procedures are reviewed biennially; - The non-patient care department director and the policy and procedure committee will complete the review by the first business day in December of odd years; and - Patient care and non-patient care procedures will also be updated as best practices change when applicable. Record review of the hospital’s undated document titled, “Policies and Procedures by Department,” showed: - 340 policies of 1,196 polices were reviewed within the biennial timeframe. - The Medical-Surgical department had 245 policies were not reviewed biennially. Six policies had no recorded date of revision, review or approval, and 239 policies were reviewed on 01/13/23. - 55 Swing Bed policies were not reviewed biennially. The last approval dates ranged from 06/30/04 to 01/13/23. - The Health Information Management (HIM) department had 17 policies not reviewed biennially. The last revised date ranged from 02/18/18 to 08/22/22. - The Quality Improvement and Risk Management department had 12 policies not reviewed biennially. The policies were last reviewed 01/29/19. - The Housekeeping department had seven policies not reviewed biennially. The policies were last reviewed 01/12/23. - The Maintenance department had 24 polices not reviewed biennially. The policies were last reviewed 01/12/23. - The Human Resources (HR) department had 10 polices not reviewed biennially. The last revised dates ranged from 11/07/14 to 12/01/23. - The Materials Management department had 17 policies not reviewed biennially. There was no recorded date of revision, review or approval. - The Revenue Cycle department had 21 policies not reviewed biennially. The last approval date was 01/30/15. During an interview on 06/11/25 at 2:04 PM, Staff S, Chief Executive Officer (CEO), stated that she expected all policies to be reviewed biennially. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected all policies were reviewed biennially. She was aware of the deficient policies. The hospital had an opportunity for improvement with the policy review process.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Follow their policy for intravenous (in the vein) site labeling for four patients (#4, #6, #7 and #9) of four patients observed; - Maintain a sterile field (completely clean and free from germs surface on which to place sterile equipment or supplies that are considered free from microorganisms) for one patient (#8) of one sterile procedure observed; - Clean patient care equipment for four patients (#4, #6, #7 and #9) of four patients observed; - Create clean barriers for four patients (#4, #6, #7 and #9) of four patients observed; - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) for four patients (#4, #6, #7 and #9) of four patients observed; and - Ensure single use items were not used for multiple patients. This failure had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Intravenous Infusion,” revised 01/17/19, directed staff to label the IV site with the date, time and nurse’s initials when the IV was initiated. Observation on 06/10/25 at 8:50 AM, on the Medical-Surgical unit, showed Patient #6’s IV site was not labeled with the date, time or nurse’s initials. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Patient #4’s IV site was not labeled with the date, time or nurse’s initials. Observation on 06/10/25 at 9:20 AM, on the Medical-Surgical unit, showed Patient #9’s IV site was not labeled with the date, time or nurse’s initials. Observation on 06/10/25 at 9:25 AM, on the Medical-Surgical unit, showed Patient #7’s IV was not labeled with the date, time or nurse’s initials. During an interview on 06/10/25 at 1:20 PM, Staff G, Infection Preventionist, stated that she expected IV sites to be labeled with the sticker provided in the IV start kit with the catheter size, date, time and initials of the nurse who initiated the IV. During an interview on 06/10/25 at 9:15 AM, Staff N, Registered Nurse (RN), stated that IV sites should be labeled with the date, time and nurse’s initials when the IV was initiated. Review of the “Infusion Therapy Standards of Practice, Ninth Edition,” published 01/2024, showed guidelines for accessing implanted port-a-cath (a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) devices included maintaining asepsis (process that is intended to minimize contamination from pathogens) with sterile gloves and masks. Although requested the hospital did not provide a policy on a sterile field. Observation on 06/10/25 at 9:05 AM, in the Preoperative Area, showed: - Staff A, Registered Nurse (RN), prepared a sterile field on a bedside table, to access Patient #8’s port-a-cath. - Staff M contaminated the sterile field when she reached over the sterile field and turned her back to the sterile field without a hair net. - Staff A accessed Patient #8’s port-a-cath with a dirty glove. - Patient #8 did not wear a mask and was not instructed not to breath on the access site during the procedure. During an interview on 06/11/25 at 2:04 PM, Staff S, Chief Executive Officer (CEO), stated that she expected staff to maintain a sterile field and ensure the patient wore a mask when a port-a-cath was accessed. Staff were frequently educated on infection prevention strategies. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected staff to maintain a sterile field and ensure the patient wore a mask when a port-a-cath was accessed. During an interview on 06/10/25 at 1:20 PM, Staff G, Infection Preventionist, stated that she expected a mask to be worn for an aseptic procedure such as a port-a-cath access. Review of the hospital’s policy titled, “Standard and Transmission-Based Precautions,” effective 02/09/21, showed equipment must be handled in a manner to prevent transmission of infectious agents to include proper cleaning and disinfecting before use on another patient. Observation on 06/10/25 at 8:45 AM, on the Medical-Surgical unit, showed Staff M, Licensed Practical Nurse (LPN), retrieved a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) from the nurses’ station and failed to clean the WOW prior to entering and exiting Patient #6’s room. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Staff M, LPN, failed to clean the WOW prior to entering and exiting Patient #7’s room. Staff M failed to clean the WOW before placing the WOW in the nurses’ station. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to clean the WOW prior to entering and exiting Patient #4’s room. Staff N failed to clean the WOW before placing the WOW in the nurses’ station. Observation on 6/10/25 at 9:20 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to clean the WOW prior to entering and exiting Patient #9’s room. Staff N failed to clean the WOW before placing the WOW in the nurses’ station. During an interview on 06/11/25 at 2:04 PM, Staff S, CEO, stated that she expected staff to follow all policies and procedures. She expected equipment to be cleaned between patients. During an interview on 06/11/25 at 12:50 PM, Staff R, CNO, stated that she expected staff to follow all policies and procedures. She expected the WOWs were cleaned between patients. During an interview on 06/10/25 at 1:20 PM, Staff G, Infection Preventionist, stated that she expected all equipment to be cleaned before entering a patient’s room. Review of the hospital’s document titled, “Standard and Transmission-based Precautions Guide,” revised 02/01/21, directed staff to clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patients and frequently touched surfaces in the patient care environment. Observation on 06/10/25 at 8:45 AM, on the Medical-Surgical unit, Staff M, Licensed LPN, failed to clean the surface prior to preparing Patient #6’s medications. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, Staff M, LPN, failed to clean the surface prior to preparing Patient #7’s medications. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to clean the surface prior to preparing Patient #4’s medications. Observation on 06/10/25 at 9:20 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to clean the surface prior to preparing Patient #9’s medications. Observation on 6/10/25 at 11:45 AM, on the Medical-Surgical unit, Staff N, RN, failed to clean the surface prior to obtaining a blood sugar level for Patient #4. During an interview on 06/11/25 at 2:04 PM, Staff S, CEO, stated that she expected clean surfaces for all patient supplies and medications. During an interview on 06/11/25 at 12:50 PM, Staff R, CNO, stated that she expected a clean surface or barrier for all patient supplies and medications. During an interview on 06/10/25 at 1:20 PM, Staff G, Infection Preventionist, stated that she expected a clean surface or barrier for patient supplies and all patient care. Review of the hospital’s policy titled, “Hand Hygiene,” effective 11/19/20, showed hand hygiene will be performed between all patient contacts, before donning and after removing gloves. Observation on 06/10/25 at 8:45 AM, on the Medical-Surgical unit, showed Staff M, LPN, failed to perform hand hygiene between glove changes when she administered medications to Patient #6. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Staff M, LPN, failed to perform hand hygiene between glove changes when she administered medications to Patient #7. Observation on 06/10/25 at 9:00 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to perform hand hygiene prior to entering Patient #4’s room and prior to donning gloves for medication administration. Observation on 06/10/25 at 9:20 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to perform hand hygiene between glove changes when she administered medications to Patient #9. Observation on 6/10/25 at 11:45 AM, on the Medical-Surgical unit, showed Staff N, RN, failed to perform hand hygiene prior to entering Patient #4’s room and prior to donning gloves for blood sugar testing. During an interview on 06/11/25 at 2:04 PM, Staff S, CEO, stated that she expected hand hygiene was performed as recommended by the Centers for Disease Control and Prevention (CDC). During an interview on 06/11/25 at 12:50 PM, Staff R, CNO, stated that she expected hand hygiene was performed as recommended by the CDC. During an interview on 06/10/25 at 1:20 PM, Staff G, Infection Preventionist, stated that she expected hand hygiene with all glove changes. Review of the hospital’s document titled, “Contrast Infuser Training,” prepared 02/2022, showed single-patient tubing sets had a use life of one patient. Review of the “Swabbable Valve Transfer Set,” label showed for use with one container of media only. Review of the “0.9% Chloride Injection,” label showed single use container, and the volume was 500 milliliters (mL, unit of measure). Review of the CDC’s “Injection Safety Guidelines,” published 2007, showed to not use medications packaged as single-dose or single-use for more than one patient. Observation with concurrent interview on 06/09/25 at 1:00 PM, in the computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) room, showed one bag of 0.9% Chloride Injection fluid spiked with a Swabbable Valve Transfer Set hanging on the contrast infuser pole with 100 ml remaining in the bag. Staff I, Radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) Technician, stated that the same bag of fluid and tubing were used for multiple patients. During an interview on 06/10/25 at 1:00 PM, Staff Q, Radiology Director, stated that the tubing was “capped” between patients and was ready for use with the next patient. He did not know if the tubing and/or fluids were single-use or multi-use items. Each CT scan with contrast used approximately 100 mL of fluid. One bag of fluid was used for up to five patients. During an interview on 06/11/25 at 2:04 PM, Staff S, Chief Executive Officer (CEO), stated that she expected single use items to be used as recommended. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected single use items were only used for one patient, it was common sense. During an interview on 06/10/25 at 2:20 PM, Staff J, Pharmacy Director, stated that a 0.9% Chloride bag was a single use item and were not to be used for multiple patients. Patient care items were to be used as recommended by the manufacturer. 50151 51509”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39354 Based on observation, interview, record review and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for two current emergency department (ED) patients of two ED patients observed. The hospital failed to follow their policy and procedure for medication removal from the automated dispensing machine (ADM, computerized system designed to deliver requested medications or supplies) for three patients (#4, #6 and #7) of four medication administrations observed. Review of the hospital’s policy titled, “Telemetry Monitoring,” reviewed 05/01/2024, showed: - Telemetry monitoring must be initiated for patients with clinical indications per ED telemetry criteria (e.g., chest pain, fainting, irregular heartbeat, heart attack, etc.). - Continuous monitoring will be maintained with alarm parameters set. - The nurses are responsible for assessing and responding to any telemetry alarms. - Changes in rhythm must be communicated to the provider immediately and documented. Review of Patient #1’s medical record dated 05/06/25, showed he was an 84-year-old who presented to the ED with trouble breathing. The ED physician ordered telemetry monitoring. Review of Patient #2’s medical record dated 05/06/25, showed he was a 59-year-old who presented to the ED with confusion and chest pain. The ED physician ordered telemetry monitoring. Observation on 06/09/25 at 2:10 PM, in the ED, showed two patients (#1 and #2) on telemetry, no staff were present to observe the monitor. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected continuous telemetry monitoring observation. During an interview on 06/09/25 at 2:10 PM, Staff D, Registered Nurse (RN), stated that the telemetry monitor was not continuously monitored. If the nurses and doctor were busy, they listened for the telemetry monitor to alarm. During an interview on 06/09/25 at 2:10 PM, Staff C, Paramedic, stated that the telemetry monitor was not continuously monitored. Review of the hospital’s policy titled, “Medication Management: Dispensing,” revised 05/31/20, showed only one patient’s medications should be removed from the ADM at one time to avoid confusing or mixing up medications. Observation with concurrent interview on, 06/10/25 at 8:45 AM, on the Medical-Surgical unit, showed: - Staff M, Licensed Practical Nurse (LPN), removed medications for Patient #4, Patient #6 and Patient #7 from the ADM and placed the medications in plastic cups labeled with the patient’s room numbers. - Staff M entered Patient #6’s room with the three plastic cups of medications. She administered Patients #6’s medications. - Staff M stated that, she knew she was only supposed to remove one patient’s medications from the ADM at a time but that was the way “everyone always did it.” During an interview on 06/10/25 at 2:10 PM, Staff J, Pharmacy Director, stated that she expected medications to be removed from the ADM one patient at a time. There was a risk of error when multiple patient’s medications were removed at the same time. During an interview on 06/11/25 at 2:04 PM, Staff S, Chief Executive Officer (CEO), stated that she expected staff to follow all policies and procedures. She expected medications to be removed from the ADM one patient at a time. Removing more than one patient’s medication at a time increased the risk of error for medication administrations. During an interview on 06/11/25 at 12:50 PM, Staff R, Chief Nursing Officer (CNO), stated that she expected staff to follow all policies and procedures. She expected medications were removed from the ADM one patient at a time. 48359 50151”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 39354 Based on record review and interview, the hospital failed to ensure the Emergency Preparedness plan was reviewed and updated at least every two years. The hospital census was six. Review of the hospital’s Emergency Preparedness plan, on 06/11/25 at 8:30 AM, showed there was no documentation that the Emergency Preparedness plan had been reviewed and updated at least every two years. During an interview on 06/11/25 at 8:55 AM, Staff R, Chief Nursing Officer (CNO), stated that she was responsible for the Emergency Preparedness plan. She had updated part of the Emergency Preparedness plan but did not update the entire plan. She was unsure of the last time the Emergency Preparedness plan had been reviewed and updated. No updates had been made within the last two years.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 39354 Based on observation and interview, the hospital failed to install exit signage in the kitchen area. This failure had the potential to affect all hospital occupants that used the kitchen area. The hospital census was six. Observation during the Life Safety Code tour on 06/10/25 between 8:30 AM and 2:10 PM, showed there were no exit signs located in the kitchen area to identify the route of exit in the event of an emergency. During an interview on 06/10/25 at 2:10 PM, Staff L, Maintenance Director, stated that exit signs shoud be in kitchen area and he was unsure why there were no exit signs. The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, states: - 7.10.2 Directional Signs. - 7.10.2.1 A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. - 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.”