Union County General Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 54356 Based on record review and interview, the facility did not follow its own requirements for privileging a physician to provide emergency care for 1(S[staff] 26) of 4 (S13, S26, S31 and S32) physician files reviewed. The deficient practice could lead to patients receiving inadequate medical care in the emergency department The findings are: A. Record review of S26’s, clinical, employee file revealed: 1. The facilities document titled, “Union County General Hospital Emergency Medicine Physician Application for Privileges.” lists the following requirements to be privileged as an emergency department physician: a. licensure/certification/ qualifications to be “MD or DO” b. Current NM License c. Board certified by the American Board of Emergency Medicine [ABEM] or by the Osteopathic Board of Emergency Medicine [AOBEM] or fully trained in and accredited Emergency Medicine residency program recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), or One year of an ABEM or AOA approved postgraduate training program in an emergency medicine or primary care specialty with board certification in emergency medicine by the ABEM or AOBEM or the BCEM recognized by the Americal Association of Physician Specialists Board and have practiced emergency medicine on a full time basis within the past two (2) years in emergency medicine, or Board certified in the specialties of Family Practice or Internal Medicine by an ABMS Board or fully trained in a Family Practice or Internal Medicine residency program recognized by the ABMS or AOA. d.The applicant must be able to demonstrate that he/she has two (2) years’ experience in general emergency services within the last three (3) years. 2. There is no evidence of S26 meeting one or more of the additional requirements for privileging as an emergency department physician. B. During an interview on 07/15/26 at 2:00 PM, S2, non-clinical, confirmed there is no evidence in S26’s, clinical, file of meeting one or more of the three additional requirements for privileging as an emergency department physician.”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 54356 Based on record review and interview, the facility failed to meet the Condition of Participation to staff properly maintained the hospital environment. This deficient practice places patients and staff at risk or harm related to an unsafe or poorly maintained environment. A. The facility failed to ensure all equipment available to staff was in good working condition and properly maintained to ensure accuracy and safe operation. Refer to tag C-0914. B. The facility failed to maintain a clean and orderly environment and failed to follow its policies for room cleaning. Refer to tag C-0924.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 54356 Based on observation, record review and interviews, the facility failed to meet the Condition of Participation to ensure policies are reviewed and kept current to support the provision of safe patient care. This deficient practice jeopardizes patient safety by increasing the risk of inconsistent care, staff noncompliance with current standards of practice, and patient harm. The findings are: A.The facility failed to review policies at least biennially. Refer to tag C-1008 B.The facility lacked description of services policies for all services offered by the facility. Refer to tag C-1010 C.The facility failed to follow its own Medication Orders and Medical Staff Rules and Regulations. Refer to Tag C-1049”

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 54356 Based on observation, record review, and interviews, the facility failed to establish and maintain a surgical service that provided safe patient care in accordance with acceptable standards of practice. This deficient practice has the potential to compromise patient safety by increasing the risk of preventable adverse events, inconsistent delivery of care, and patient harm. The findings are: A. During an observation on 07/15/26 at 08:10 AM, Staff (S)30, clinical, was not wearing protective foot coverings during a surgical procedure. Additionally, S30 did not perform hand hygiene after removal of gloves. B. Record requests for the facility’s accepted standards of practice for surgical services revealed the facility was unable to provide the document. C. Record request of annual competencies for the Circulating Registered Nurse revealed the facility was unable to provide any competencies. D. Record review of the facility’s policy titled, “Scope of Responsibility of the PACU Staff Circulator,” outlines responsibilities of the circulating Registered Nurse (RN) which included: 1. Attends departmental meetings and in-service education and shows responsibility for own professional practice and ongoing education. 2. Demonstrates complete knowledge of infection control and Standard Precautions, actively supports and promotes strict adherence to policies and procedures as outlined in the department manuals. E. Record review of the facility’s policy titled, “Surgical Attire” stated that the purpose of the policy is to provide guidance to perioperative personnel for surgical attire, including scrub attire, shoes and head coverings. 1. Section E of the policy stated that fluid resistant shoe covers should be worn when gross contamination can be reasonably anticipated. 2. Section J of the policy stated, “Perioperative personnel working in semi-restricted and restricted areas of the facility will receive education and complete competency verification activities on surgical attire worn in the perioperative areas.” F. Record review of the facility’s policy titled, “Hand Hygiene” stated hand hygiene should occur after removal of gloves and mask. G. During an interview on 07/15/26 at 10:30 AM, S12 (clinical) could not identify which accepted standards of practice the facility followed and stated she had not completed any annual competencies during her six months in the operating room, believing HR was responsible for arranging them. S12 also had not noticed that Staff 30 was not wearing foot coverings during the procedure and did not perform hand hygiene after glove removal. When asked to identify the location of a hand hygiene dispenser in the recovery room, S12 was unable to locate one. H. During an interview on 07/15/26 at 1:30 PM, S3, non-clinical, confirmed there were no annual or training competencies on file for the circulating nurse position. Additionally, S3 stated there was not a job description on file with the facility for a circulating nurse.”

“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: 54356 Based on record review and interviews, the facility failed to meet the Condition of Participation by failing to implement and maintain an infection prevention and control program that conducts surveillance for hospital-acquired infections (HAIs) and collaborates with the pharmacy to ensure an antibiotic stewardship program that promotes appropriate antibiotic use. This deficient practice places patients at increased risk for preventable healthcare-associated infections, inappropriate antibiotic use, antimicrobial resistance, treatment delays, adverse drug events, and avoidable patient harm. The findings are: A. The facility failed to implement and maintain an infection surveillance and antibiotic stewardship system that actively tracked the appropriateness of antibiotic coverage for HAIs. Refer to tag C-1225. B. The facility failed to implement and maintain an infection surveillance and antibiotic stewardship program that is addressed during QAPI (Quality Assurance and Performance Improvement) meetings for discussion of appropriateness of antibiotic coverage for HAIs. Refer to tag C-1229. C. The facility failed to implement an antibiotic stewardship program that monitors and improves proper use of antibiotics. Refer to tag C-1244. D. The facility failed to implement and maintain an infection surveillance and antibiotic stewardship system that communicates and collaborates with all facility’s departments for the appropriateness of antibiotic coverage for HAIs. Refer to tag C-1248.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 54356 Based on record review and staff interviews, the facility failed to meet the Condition of Participation requiring the development and maintenance of a comprehensive emergency preparedness plan that includes a risk assessment, identifies the population served, and addresses surge capacity needs during an emergency. This deficient practice placed patients at risk for serious harm, injury, or death because the facility was not adequately prepared to respond to an emergency. The findings are: A.The facility failed to ensure that the emergency plan was based on an updated hazard vulnerability assessment. Refer to tag E-0006. B.The facility failed to ensure that the emergency plan addressed the facility’s patient population. Refer to tag E-0007. C.The facility failed to ensure that the emergency policies and procedures included a plan to address surge needs in the event of an emergency. Refer to tag E-0024.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 54356 Based on observation, interview, and record review, the facility failed to ensure all equipment available to staff was in good working condition and properly maintained to ensure safe operation. This failure could result in equipment being unsafe for use and lead to patient harm. The findings are: A. During an observation on 07/13/26 at 2:00 PM in Room 110, two Vapotherm devices (a medical device that provides heated, humidified oxygen at precise concentrations) were observed without equipment maintenance stickers. Additionally, the patient lifting device/scale displayed inspection tags showing clearance only through 09/2024. B. During an observation on 07/13/26 at 2:10 PM in the inpatient unit shower room, surveyors observed that the legs of the shower chair lacked rubber tips, leaving exposed metal tubing in contact with the floor, creating a potential slippage and injury hazard. C. During an observation on 07/13/26 at 2:15 PM in the radiology x ray room, surveyors observed that the wall suction regulator (a device used to provide suction in emergencies) failed to operate. The device had no tag, was dusty, and lacked the required tubing to connect the regulator to the suction canister and the canister to the Yankauer (a plastic attachment to suction oral airways). D. During an interview on 07/13/26 at 2:15 PM, Staff (S) 10, clinical, stated they attempted to turn on the suction device but were unable to do so. S10 stated that during an emergency, they would have to run to the CT (Cat Scan) room to obtain a portable suction device. E. During an interview on 07/14/26 at 09:40 AM, S11, non clinical, stated the facility did not have a master equipment list with current inventory or scheduled inspection/maintenance dates. S11 stated they could not confirm whether the Vapotherm devices or the lift/scale were in good working condition. S11 stated the contracted company followed the equipment maintenance process for the facility’s medical equipment and obtained a master list the following day. F. Record review of the contracted company master list on 07/15/26 revealed the Vapotherm devices and patient lift/scale were not listed. G. During a follow up interview on 07/15/26 at 2:40 PM, S11 stated the two Vapotherm devices expired in 09/2022 and 08/2025 and were retired. The patient lift/scale was retired in 09/2024. S11 stated they did not know how retired equipment should be tagged, removed from the facility, or processed to ensure it was not used on patients.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 54356 Based on observation, record review, and interview, the facility failed to maintain a clean and orderly environment and failed to follow its policies for room cleaning. This failure resulted in conditions that could support the buildup of infectious microbes and place patients at risk for waterborne or airborne infections. The findings are: A. During an observation on 07/13/26 at 2:10 PM, in patient room 111, surveyors observed a thick layer of calcification on the shower head that could flake off. B. During an observation on 07/13/26 at 2:15 PM, in the inpatient unit storage room, surveyors observed a thick layer of dust on top of the warming cabinet for bed bath wipes and a full garbage can. The same garbage and undisturbed dust were still present during observations on 07/14/26 and 07/15/26. C. During an observation on 07/13/26 at 2:15 PM, in the patient nutrition room on the inpatient unit, surveyors observed a large piece of food between the floor-model ice machine and a refrigerator. The food remained present during a follow up observation on 07/15/26. D. During an observation on 07/13/26 at 2:15 PM, in the same nutrition room, surveyors observed a large ice machine with two plastic bags on top and a large scoop placed on top of the bags. There was no machine cleaning log or signage indicating cleaning or proper scoop storage. E. During an observation on 07/13/26 at 2:30 PM, in the radiology department, surveyors observed thick visible dust on the wall suction unit in the x ray room, on glove boxes, and on the filing cabinet in the radiology viewing work room. F. During an observation on 07/16/26 at 08:30 AM, in the Operating Room (OR), surveyors observed visible soiling resembling blood on the hose of the Bair Hugger (a warming device used during OR procedures) and thick visible dust on the top of the storage cabinet. Three staff were cleaning the room post procedure. On return at 10:00 AM, the same day, after cleaning was completed, the soiling and dust were still present. G. Record review of the facility’s cleaning and disinfecting policy dated 03/2026 revealed procedures requiring staff to disinfect horizontal surfaces clockwise around the room using properly diluted germicide, wipe all surfaces daily, and maintain storage areas free of refuse and discarded items. H. During an interview on 07/15/26 at 08:00 AM, Staff (S)19, non clinical, acknowledged the calcified shower head, garbage, and dusty surfaces and stated they were unaware the patient room contained a shower. S19 stated they had calcium removing solutions and confirmed environmental services were responsible for cleaning the warming cabinet and garbage areas. S19 acknowledged the large piece of food on the nutrition room floor should have been removed. I. During an interview on 07/14/26 at 10:00 AM S1, non-clinical, stated the ice machine was supposed to be emptied and cleaned weekly and assigned to a specific staff member. S1 stated there was no log or verification process to confirm cleaning frequency or method. J. During an interview on 07/16/26 at 10:00 AM, S16, clinical, observed the post cleaning conditions and acknowledged the soiled material on the Bair Hugger hose and the dust on the storage cabinet remained. S16 called housekeeping back to re clean the area.”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 54356 Based on record reviews and interviews, the facility failed to conduct and document Ongoing Professional Performance Evaluations (OPPE) for 5 (Staff [S] S13, S26, S30, S31, and S32) out of 5 (S13, S26, S30-32) staff files reviewed. This deficiency could lead to ineffective practitioner evaluations and decreased oversight of patient care quality. The findings are: A. Record review of the credentialing and privileging files for S13, S26, S30, S31, and S32, clinical, revealed no OPPE documentation. B. Interview on 07/15/26 at 2:30 PM, S2, non-clinical confirmed the facility lacked an OPPE and FPPE practitioner evaluation process. C. Interview on 07/15/26 at 3:00 PM, with S13, clinical, confirmed facility lacked an OPPE and FPPE practitioner evaluation process.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 54356 Based on record reviews, the facility failed to review policies at least biennially for four of four policies reviewed. This deficiency could result in the facility implementing outdated practices, leading to inconsistent care, increased risk of adverse events, and compromised patient safety. The finds are: A.Record review of the following policies revealed the last review date exceeding two years: 1. All emergency department policies dated August 2020. 2. Patient Rights and Responsibilities policy dated 04/17/23. 3. Patient Grievance & Complaint Policy dated 04/17/23. 4. Advance Directives policy dated 04/17/23.”

“PATIENT CARE POLICIES CFR(s): (i) A description of the services the CAH furnishes, including those furnished through agreement or arrangement. This Standard is not met as evidenced by: 54356 Based on record review and interviews, the facility lacked description of services policies for all services offered. This deficient practice could result in staff providing inconsistent or incomplete services, increasing the risk of errors and compromising patient safety. The finds are: A. Record review revealed missing description of services policies for: 1. Nursing services 2. Dietary/Nutritional Services 3. Radiological Services 4. Surgical Services B.During an interview on 07/16/26 at 09:15 AM, S1, clinical, and S2, non-clinical, confirmed the description of services policies were not complete.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (ii) Policies and procedures for emergency medical services. This Standard is not met as evidenced by: 54356 Based on observation, record review and interview, the facility failed to maintain current policies and procedures for the Emergency department. This failure could likely result in not integrating new care protocols and utilizing outdated practices placing patients at risk of poor outcomes. The findings are: A. During an observation on 07/16/26 at 8:00 AM at the Emergency Department desk, surveyors observed a binder containing the department’s policies and procedures. B. Record review of all the policies and procedures in the Emergency Department binder revealed the policies were last reviewed on 08/2020. C. During an interview on 07/16/26 at 8:00 AM, Staff (S)8, clinical, confirmed the binder contained the current policies and procedures for the Emergency Department and stated the policies are created by the Medical Director and medical staff.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 54356 Based on observation and interviews, the facility failed to ensure proper storage of single unit dose medications and proper security of medications in patient care areas. This deficient practice has the potential to compromise medication integrity, increase the risk of unauthorized access or diversion, and place patients at risk for medication errors and adverse outcomes. The findings are: A.An observation on 7/13/26 at 3:30 PM in the emergency trauma room 2, revealed an unlocked crash cart. B.An observation on 7/14/26 at 2:00 PM, revealed that nine prefilled single-unit-dose syringes of prednisolone (a liquid glucocorticoid medication used to treat inflammation) stored in an Omnicell medication dispensing cabinet lacked protective caps on the syringe tips. The absence of protective caps creates the potential for medication leakage or contamination, increasing the risk of medication errors due to inaccurate dosing and infection control concerns. C. During an interview on 7/14/26 at 3:30 PM, S1, clinical, confirmed the protective caps were missing from the prefilled prednisolone syringes. D. During an interview on 7/15/26 at 11:30 AM, S17, clinical, confirmed the protective end caps should be present on prefilled syringes and stated all crash carts should be always locked.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 54356 Based on observation, record reviews and interviews, the facility failed to follow its own Medication Orders and Medical Staff Rules and Regulations limiting the use of verbal orders to urgent or emergent situations. Failure could lead to miscommunication and medication errors and affect patient care and outcomes. The finds are: C-1049 #1 A. During an observation on 07/14/26 at 10:00 AM, a physician and registered nurse (RN) exited Patient (P)1’s room together after completing a patient visit. After briefly speaking at the desk, the physician exited down the hall. The RN then opened P1’s paper chart and entered verbal orders. B. Record review of the facility’s following policies revealed: 1. Policy dated 09/16/25, “Medication Orders.” under section Verbal & Telephone Orders, stated, “The use of verbal and telephone orders should be minimized. Verbal orders should be limited to emergency situations or where the individual is physically unable to enter or write the order into the record (e.g., during a procedure). Telephone orders should be limited to the immediate clinical needs of the patient.” 2. Medical Staff Rules & Regulations, dated 02/23/26, 1.3 General Conduct of Care, Section E, stated, “Verbal orders shall be limited to urgent situations where immediate written communication is not feasible.” 3. Policy dated 08/27/18, “Emergency Department Verbal Orders”, lacked a procedure for read-back verification process. 4. Policy, dated 09/22/25, “Doctor’s Verbal and Phone Orders”, stated, “Document by R.B.V.O (Read, Back, Verbal Order) Dr’s Name/Nurse Signature or R.B.T.O (Read, Back, Telephone, Order).” The policy lacked the required elements, including situations in which verbal orders may be used; as well as limitations or prohibitions on their use; list of the elements required for inclusion in the verbal order process; established protocols for clear and effective communication and verification using nationally accepted read-back verification practices; and identification of categories of clinical staff authorized to receive and act upon a verbal order. C. Record review of P1’s medical record for admission dated 07/09/2026 revealed admission orders written by the admitting physician on 07/09/26 (untimed). All subsequent orders entered during the patient stay were written as verbal orders on eight different occasions: 07/10/26 at 05:27 AM. 07/10/26 at 10:21 AM. 07/10/26 (untimed order) 07/11/26 6:25 PM. 07/13/26 at 08:22 AM. 07/13/26 at 8:28 AM. 07/13/26 at 1:00 PM. 07/14/26 at 10:00 AM. D. During an interview on 07/14/26 at 12:45 PM Staff (S) 6, clinical, stated that during the daily patient rounds, the physician does not enter orders electronically or write them on the order form. Instead, the nurse writes down all verbal orders and transcribes them into the electronic medical record. E. During an interview on 07/14/26 at 1:30 PM, S1, clinical, confirmed the physicians use verbal orders extensively, especially during patient rounds, and do not confine the usage to emergent situations. F. During an interview on 07/15/26 at 3:00 PM, S13, clinical, confirmed physician usage of verbal order is not limited to emergent or immediate clinical needs. Verbal orders are used during daily patient rounds. S13 also confirmed not entering orders into the electronic medical record. C-1049 #2 Based on record review and interview, the facility failed to ensure proper administration and documentation of drugs and biologicals for 1 (P[patient]14) patient of 21 (P1- P21) charts reviewed. This deficient practice limited the facility’s ability to accurately track medications administered during an emergency and to evaluate the effectiveness of the care delivered. The findings are: A.Record review of the facility’s policy titled, “Medication Administration Policy “dated on 09/16/25, showed the policy required staff to administer medications consistent with the practitioner’s order, in accordance with Federal and State law, upon orders from an authorized practitioners responsible for the patient’s care, and within accepted standards of care. B.Record review of P14’s Electronic Medical Record (EMR) for admission dated 01/02/26 to 01/03/26 showed the following: 1. A nursing note dated on 01/03/26 at 12:34 AM stated “Pulse check performed, no pulse present. CPR resumed. 1 amp of epi given IVP.” 2.A physician’s progress note written by Staff (S)26, clinical, dated 01/03/26 at 12:56 AM documented the following: “Time of death after one round of epinephrine was 12:38 AM.” 3.EMR showed staff did not document epinephrine administered during the Cardiopulmonary Resuscitation (CPR) event in the Medication Administration Record (MAR) or in the code blue record. The review also showed there was no order for epinephrine. C.During an interview on 07/14/26 at 2:15 PM, S4, clinical, confirmed the facility’s policy does not include a code blue record sheet or a process for documenting emergency medications. Additionally, S4 confirmed staff are expected to follow the Medication Administration Policy. D.During an interview on 07/15/2026 at 10:00 AM, S17, clinical, confirmed there was no verbal order for epinephrine in the EMR and stated there was no documentation process in place for tracking medications administered during CPR. E.During an interview on 07/16/26 at 9:30 AM, S17, clinical, stated they could not recall the process for documenting emergency medications in the MAR. Staff 17 confirmed there was no documentation of the epinephrine administration in the MAR and the only reference to the medication appeared in the nursing note.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to consistently create and update nursing care plans based on an assessment of the patient’s nursing care needs, treatment goals, and appropriate physiological, psychosocial and discharge needs for all 16 [P(patients) P1-P15 and P19] of the 16 (P1-P15, P19) inpatient charts reviewed. This failure could likely result in inadequate recognition and provision of care specific to the individual patient’s needs. The findings are: A. Record review of the following medical records revealed incomplete or non-updated care plans: 1. Review of P1’s medical record for admission dated 07/09/2026 revealed on 07/14/26 two documented nursing care needs present; subsequent nursing entries only indicated ‘reviewed’. There were no notes or outcomes related to goals set for the patient and the plan was incomplete. The patient was discharged on 07/14/26. 2. Review of P3’s medical record for admission dated 07/07/2026 revealed a nursing care need and goal entered; the plan was not updated. The patient was discharged on 07/13/26. 3. Review of P4’s medical record for admission dated 07/12/2026 revealed a nursing care need and goal entered; the plan was not updated. The patient was discharged on 07/13/26. 4. Review of P5’s medical record for admission dated 07/08/2026 revealed a nursing care need and goal entered; the plan was not updated. The patient was discharged on 07/15/26. 5. Review of P6’s medical record for admission dated 07/12/26 revealed a nursing care need and goal entered; the plan was not updated. The patient was discharged on 07/14/26. 6. Review of P7’s medical record for admission dated 07/05/26 revealed a nursing care need and goal entered; the plan was not updated. The patient was discharged on 07/07/26. B. Record review of the following medical records revealed there was no care plan entered: 1. Review of P2’s medical record for admission dated 07/12/2026 revealed a nursing care plan was not entered. The patient was discharged on 07/13/26. 2. Review of P19’s medical record for admission dated 03/06/2026 revealed a nursing care plan was not entered. The patient was discharged on 03/08/2026. 3. Review of P8’s medical record for admission dated 01/21/2026 revealed a nursing care plan was not entered. The patient was discharged on 01/25/2026. 4. Review of P9’s medical record for admission dated 05/15/26 revealed a nursing care plan was not entered. The patient was discharged on 05/18/2026. 5. Review of P10’s medical record for admission dated 09/18/26 revealed a nursing care plan was not entered. The patient was discharged on 09/31/2026. 6. Review of P11’s medical record for admission dated 09/08/25 revealed a nursing care plan was not entered. The patient was discharged on 09/31/2025. 7. Review of P12’s medical record for admission dated 04/08/2026 revealed a nursing care plan was not entered. The patient was discharged on 04/10/2026. 8. Review of P13’s medical record for admission dated 12/29/2025 revealed a nursing care plan was not entered. The patient was discharged on 01/03/2026. 9. Review of P14’s medical record for admission dated 05/24/26 revealed a nursing care plan was not entered. The patient was discharged on 06/1/2026. 10. Review of P15’s medical record for admission dated 09/22/2025 revealed a nursing care plan was not entered. The patient was discharged on 09/25/2025. C. During an interview on 07/15/2026 at 11:55 AM, Staff (S) 4, clinical, stated that if the care plan was entered or updated it would show in the flow sheets and cross over to the assessments. If the care plans are not seen in either of those locations, then it was not entered. D. During an interview on 07/15/2026 at 4:07 PM, S4, clinical, stated the only policy the facility had regarding care plan was for swing beds. There was no policy for initiating and updating care plans for inpatients. E. During an interview on 07/15/2026 at 3:15 PM, S8, clinical, confirmed nursing documentation was not consistent with care plans or patient’s problem list.? S8 stated, “I thought the problem list was a care plan.” F. During an interview on 07/15/26 at 4:07 PM, S4, clinical, stated the only policy the facility had regarding care plan was for swing beds. There was no policy for initiating and updating care plans for inpatients.”

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 47302 Based on record review and interviews, the facility failed to ensure the patient’s condition, progress, and medical decision making were documented for 4 (Patient (P)4, P5, P16 and P19) out of 25 (P1-P25) patient charts reviewed. This deficient practice could lead to poor patient outcomes due to poor communication amongst healthcare providers. The findings are: A. Record review of P16’s medical record for admission dated 03/19/26 revealed patient presented with abdominal pain, vomiting, diarrhea, and cramps. 1. Review of the history and physical on 03/19/26 at 7:00 PM, revealed that the provider ordered intravenous (IV, administered through the vein) dilaudid (medication given for pain), IV Zofran (medication given for nausea), IV Rocephin (antibiotic) and 1 liter (L) of normal saline (fluids, hydration given through the vein). 2. Review of the nurse’s progress notes on 03/20/26 at 3:09 AM, revealed the nurse documented the antibiotic finished and fluids were running. At 03:12 AM the nurse documented the fluids had finished. 3. Review of the medication administration record (MAR) revealed no documentation of any medications administered. The nurse did not document which medications were given or the times of administration. B. Record review of P19’s history and physical for admission dated 03/06/26 at 5:05 AM, revealed the patient presented with abdominal pain, vomiting, and nausea. The patient was diagnosed with a helicobacter pylori infection (a bacteria that causes an infection in the stomach). The provider also ordered a urine test to determine if the patient had a urinary tract infection (UTI). 1. Review of P19’s laboratory results from the urine test resulted on 03/06/26 at 6:37 AM, revealed the patient had a UTI. The specimen was sent for further testing to determine what type of bacteria was causing the infection, with results from finalized on 03/08/26 at 11:15 AM. 2. The patient was discharged on 03/08/26 at 6:08 AM. Review of the physician’s progress notes for 03/06/26, 03/07/26, and 03/08/26 revealed no discussion of the urine test results and no treatment for the urinary tract infection prescribed. C. During an interview on 07/15/26 at 11:55, AM Staff (S) 4, non-clinical, confirmed there was no documentation of the urine results during the hospital stay or after the patient was discharged when the results were received. D. Record review of P5’s medical record for admission dated 07/08/26 revealed P5 underwent an exploratory laparotomy with removal of omental enteric abscess (surgically cut open the abdomen and removed tissue that was infected) on 07/09/26. Post-operative orders included: 1. Daily CBC (complete blood count) and CMP (complete metabolic panel) (laboratory tests run on patient’s blood) for 3 days. 2. Multiple medications for pain, infection, nausea, in addition to the patient’s home medications. Ketorolac, (a non-steroidal anti-inflammatory, used treat pain) was listed as an allergy but clarified that it was an alert due to the patient’s renal function. This medication requires adjustment or discontinuation with decreased renal function which is measured in the CMP lab. 3. An order to measure all in and out fluids since the patient had a tube into the stomach to pump out stomach fluid and gases, and a catheter tube inserted into the bladder to drain urine. 4. Review of the Recovery Room phase (the place a patient goes after surgery to have care until they are stable enough to be returned to the nursing unit) revealed the patient entered the recovery room at 4:00 PM. The patient’s blood pressure (BP) was 104/71 mmHg (millimeters of mercury) and their oxygen saturation level was 90% on 2 lpm (the blood pressure is normal, the oxygen should be above 92% and the patient was receiving 2 liters per minute of extra oxygen). Pain score was 10 so 1 mg of IV Dilaudid was given (a potent narcotic) and five minutes later 2mg of IV Versed (a fast acting sedative) was given. (Alternate write up to the above, you may choose to use it or leave it) Review of the recovery room documentation beginning at 4:00 PM showed unstable vital signs and administration of pain medication, sedatives, and vasoactive medication. Despite persistent hypotension, the patient was signed out of recovery at 4:45 PM. Recovery room discharge criteria require stable vital signs within the range of pre operative values; the documented vital signs did not meet those criteria. a. At 4:15 PM the BP was 85/58 mmHg (very low) and the oxygen was put up to 5lpm with a saturation of 92%. b. At 4:35 PM the BP was 77/54 mmHg (very low) and 100 mcg of Neo synephrine (a medication to raise BP) was given IV. c. At 4:40 PM the BP was 84/54 mmHg (very low). d. At 4:45 PM the RN (Registered Nurse) in the recovery room signed the patient out to the floor. The note stated the patient had been hypotensive after receiving pain meds and the CRNA (Certified Registered Nurse Anesthetist) was present. The discharge criteria for the recovery room stated blood pressure and pulse should be within realm of the pre-op numbers and stable. The vital signs on discharge were not in the realm of pre-op numbers and were not stable. e. At 5:00 PM the BP was 65/45 mmHg. There is no accompanying note that the RN notified the Physician or completed any other actions. f. At 5:15 PM the BP was 66/38 mmHg. There is no accompanying note that the RN notified the Physician or completed any other actions. The respiratory rate was 9. An acceptable range is 12-20 breaths per minute. The oxygen saturation was charted as 94% but there is no notation how much oxygen the patient is receiving or assessment of responsiveness. g. At 5:30 PM the BP was 84/50 mmHg. There is no accompanying note that the RN notified the Physician or completed any other actions. 5. Review of the physician progress notes for the first day after the operation on 07/10/26 at 9:49 AM revealed no documentation of lab results review, fluid balance, kidney function, or a full assessment of the patient’s status. 6. Review of the physician progress notes for the third day after the operation on 07/12/26 at 7:44 AM does not include a full patient status assessment or documentation of fluid balance, surgical site evaluation, cardiac and respiratory assessments or vital signs. E. Record review of P4’s medical record for admission dated 07/12/26 revealed the patient was admitted with gallstones and was scheduled for surgery to remove them on the following morning. 1. Vital signs on the morning of 07/13/26 at 4:44 AM revealed a BP of 146/96 mmHg (higher than normal) and at 7:46 AM a BP of 149/103 mmHg. There is no record of a notification to the attending physician or surgeon, or documentation of actions or assessments related to the readings. 2. A nursing physical assessment note from 07/13/26 at 10:49 AM revealed the RN received the patient back to the unit after surgery and began post-operative vital signs monitoring. The note referenced an upcoming patient transfer to another facility but did not include an assessment of the patient’s surgical site, respiratory, cardiovascular, or neuro status which would be expected after surgery.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 54356 Based on record review and interviews, the facility failed to implement and maintain an infection surveillance and antibiotic stewardship system that actively tracked the appropriateness of antibiotic coverage for healthcare-associated infections (HAIs). As a result, the facility may delay the identification of inappropriate or ineffective antimicrobial therapy, contribute to antimicrobial resistance, increase the risk of untreated or worsening infections, and place patients at risk for adverse outcomes. The findings are: A. Record review of the facility’s policy titled, “Antimicrobial Stewardship Program” stated “The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but are not limited to the following activities:” 1.Establishment of an Antimicrobial Team 2.Provide educational activities 3.Develop antimicrobial management protocols and guidelines 4.Tracking and monitoring 5.Implement actions and recommendations 6.Collects, analyzes and reports data 7.Performance improvement B. During an interview on 7/14/26 at 10:30 AM, Staff (S)17, clinical, stated there were no antimicrobial management protocols in place, nor is there a process to track providers with antibiotic prescribing preferences. Additionally, S17 stated there has been no formal education to providers or nursing about antibiotic stewardship. C. During an interview on 7/15/26 at 12:30 PM, S20, non-clinical, stated that the Excel spread sheet and antibiogram used to track HAIs does not include any information regarding appropriate antibiotic coverage. Additionally, S20 stated these forms are provided to the pharmacist only, but that the infection preventionist and the pharmacy do not meet to discuss appropriate antibiotic usage.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the CAH’s QAPI leadership. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to implement and maintain an infection surveillance and antibiotic stewardship program that is addressed during QAPI (Quality Assurance and Performance Improvement) meetings for discussion of appropriateness of antibiotic coverage for healthcare-associated infections (HAIs). As a result, the facility may delay the identification of inappropriate or ineffective antimicrobial therapy, contribute to antimicrobial resistance, increase the risk of untreated or worsening infections, and place patients at risk for adverse outcomes. The findings are: A. Record review of the facility’s policy titled, “Antimicrobial Stewardship Program” stated “The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but are not limited to the following activities:” 1.Establishment of an Antimicrobial Team 2.Provide educational activities 3.Develop antimicrobial management protocols and guidelines 4.Tracking and monitoring 5.Implement actions and recommendations 6.Collects, analyzes and reports data 7.Performance improvement B. Record review of the facility’s QAPI meeting minutes dated 06/16/26 at 3:00 PM revealed that under the section for Antibiotic Stewardship program, no information was presented or discussed. C. During an interview on 7/14/26 at 10:30 AM, Staff (S)17, clinical, stated t she has not reported to QAPI as she does not have systems in place to track antibiotic usage and has not created any protocols or guidelines for antimicrobial management.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to implement an antibiotic stewardship program that monitors and improves proper use of antibiotics. This deficient practice has the potential to result in inappropriate antibiotic prescribing, contribute to antimicrobial resistance, delay effective treatment of infections, increase the risk of adverse drug events, and place patients at risk for poor clinical outcomes. The findings are: A.Refer to tag C1225”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iii) Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as the CAH’s infection prevention and control and QAPI programs, on antibiotic use issues. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to implement and maintain an infection surveillance and antibiotic stewardship system that communicates and collaborates with all of the facility’s departments for the appropriateness of antibiotic coverage for healthcare-associated infections (HAIs). As a result, the facility may delay the identification of inappropriate or ineffective antimicrobial therapy, contribute to antimicrobial resistance, increase the risk of untreated or worsening infections, and place patients at risk for adverse outcomes. The findings are: A.Refer to tag C1225”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAHs, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to implement and maintain an infection surveillance and antibiotic stewardship system that provides competency-based training and education to all of the facility’s staff for the appropriateness of antibiotic coverage for healthcare-associated infections (HAIs). As a result, the facility may delay the identification of inappropriate or ineffective antimicrobial therapy, contribute to antimicrobial resistance, increase the risk of untreated or worsening infections, and place patients at risk for adverse outcomes. The findings are: A.Refer to tag C1225”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure, in collaboration with the designated OPO, that the family of each potential donor is informed of its option to either donate or not donate organs, tissues, or eyes. The individual designated by the CAH to initiate the request to the family must be a designated requestor. A designated requestor is an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology for approaching potential donor families and requesting organ or tissue donation; This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure staff were properly trained in a methodology for approaching potential donor families and requesting organ or tissue donation. This deficiency could lead to missed opportunities in organ and tissue donation. The finds are: A. Request for training documents revealed the facility could not provide them. B. During an interview on 07/15/26 at 07:45 AM, S (Staff)1, clinical, stated the nursing staff receive training in the process for contacting the Organ Procurement Organization and speaking with potential donor families; however, there is no training documentation.”

“RESTRAINT AND SECLUSION CFR(s): Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm. This Standard is not met as evidenced by: 54356 Based on record review and interviews, the facility failed to ensure that 1(P (patient)15) of 21 (P1-P21) patients reviewed who was placed in restraints to manage violent or self-destructive behavior received the required risk assessment score, face-to-face evaluation, and monitoring at least every 15 minutes. This deficiency practice resulted in incomplete and inaccurate documentation in the medical record and the facility at risk for noncompliance with noncompliance with patients’ rights protections under CMS regulations. The findings are: A. Review of the facility policy titled “Use of Restraints” dated 09/2025 showed the following requirements: 1. A physician, licensed practitioner (LP), or registered nurse (RN) trained per policy must conduct a face-to-face evaluation within one hour of initiating restraint or seclusion for violent or self-destructive behavior. 2. The one-hour face-to-face evaluation must include a behavioral assessment. 3. Patients placed in restraint or seclusion for violent or self-destructive behavior must be monitored at least every 15 minutes. B. Review of P15’s electronic medical record (EMR) for the admission 05/24/26 to 05/28/26 revealed no documentation of a face-to-face evaluation following the application of restraints on the following dates: 05/26/26; 05/27/26; 05/28/26. C. Review of P15’s EMR revealed no behavioral assessment documented by a provider or nursing staff following the application of restraints on the following dates: 05/26/26; 05/27/26; 05/28/26. D. Review of P15’s EMR revealed monitoring was not completed at least every 15 minutes, as required by policy, including vital signs and other required monitoring elements, on the following dates: 05/26/26; 05/27/26; 05/28/26.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency plan was based on an updated hazard vulnerability assessment. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed a hazard vulnerability assessment dated 2024. B. During an interview on 07/15/2026 at 1:30 PM, Staff (S) 11, non-clinical, confirmed there was not an updated hazard vulnerability assessment.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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 the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency plan addressed the facility’s patient population. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include information regarding the facility’s patient population, including patients that would be at increased risk during an emergency. B. During an interview on 07/15/2026 at 1:30 PM, Staff (S) 11, non-clinical, confirmed there was no information regarding patient population in the emergency preparedness plan.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency policies and procedures included information regarding subsistence needs. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include information regarding the facility’s plans for food, water, medical or pharmaceutical supplies in the case of an emergency. The plan also did not include information regarding alternative sources of energy. B. During an interview on 07/15/2026 at 1:30 PM, Staff (S) 11, non-clinical, confirmed there was no information regarding subsistence needs. S11 explained that the facility does have generators, but the emergency plan did not discuss their use during an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency policies and procedures included a system to maintain medical documentation in the event of an emergency. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include a system to maintain medical documentation in the event of an emergency. B. During an interview on 07/15/2026 at 1:30 PM, Staff (S) 11, non-clinical, confirmed the emergency preparedness plan did not include a system for maintaining medical documentation during an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency policies and procedures included a plan to address surge needs in the event of an emergency. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include a staffing strategy to address surge needs in the event of an emergency. B. During an interview on 07/15/2026 at 1:30 PM, Staff (S) 11, non-clinical, confirmed there was no staffing strategy to address surge needs in the event of an emergency.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency policies and procedures included the arrangements with other facilities to receive patients in the event that the facility must cease operations. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include arrangements with other facilities to receive patients in the event the facility must cease operations. B. During an interview on 07/15/2026 at 1:30 PM Staff (S) 11, non-clinical, confirmed there were no arrangements with other facilities in the emergency plan.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to ensure that the emergency policies and procedures included the role of the facility to provide care at an alternate site in the event of an emergency. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include the role of the facility to provide care at an alternate site in the event of an emergency. B. During an interview on 07/15/2026 at 1:30 PM Staff (S) 11, non-clinical, confirmed there was no information regarding the provision of service at an alternate care site.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that the emergency policies and procedures included contact information for staff, other facilities and patient’s physicians. This deficient practice could place patients in the hospital and community at risk for increased harm in an emergency because the hospital is not prepared. The findings are: A. Record review of the facility’s emergency plan dated 03/2026 revealed it did not include the contact information for staff, other facilities and patient’s physicians. B. During an interview on 07/15/26 at 1:30 PM, Staff (S) 11, non-clinical, confirmed there was no contact information for staff, other facilities, or patient’s physicians in the emergency plan.”