Arbuckle Memorial Hospital Authority

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to provide a medical screening that included lab work and diagnostic testing for one (Patient #8) of 20 patients. This failed practice had the likelihood to result in unrecognized EMC, delayed treatment and adverse health outcomes for patients. (see 2406) Based on record review and interview, the facility failed to ensure stabilizing treatment was provided to one (Pt #19) of 20 patient records reviewed. This failed practice had the likelihood to result in poor outcomes for patients and unborn children. (See Tag 2407) Based on record review and interview, the hospital failed to ensure completion of transfer documentation for one (Pt # 19) of 20 patient records reviewed. This failed practice had the likelihood to result in the risk of life-threatening outcomes for patients and unborn children. (See Tag 2409)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to provide a medical screening that included lab work and diagnostic testing for one (Patient #8) of 20 patients. This failed practice had the likelihood to result in unrecognized EMC, delayed treatment and adverse health outcomes for patients. Findings: Review of a policy titled “CODE Stroke CT Protocol for Nursing” updated on 06/06/25 read in part: “1. Patients who have experienced any of the following warning signs for stroke or other significant neurological symptoms within 8 hours and have a resulted negative FASST scale indicate a stroke team consult/activation and immediate physician alert and evaluation and immediate neurological imaging. * Sudden severe headache * Sudden Confusion * Sudden trouble walking * Sudden trouble seeing with one or both eyes * Sudden numbness * Dizziness (examples include but are not limited to: disequilibrium, ataxia vertigo, nystagmus, incoordination) 2. Patients who have at least one stroke symptom and the onset time is less than 8 hours from the Last Time Known Well or an onset of unknown time (Wake-Up Protocol) will be treated immediately per the Acute Stoke Treatment protocols with the following to be completed... 3. Orders on ED Stroke Order Set: * VS per protocol (q 15 minutes) * Continuous Pulse Ox * Insert large bore Peripheral IV Heplock x 2 sites (18 g AC preferred) * Activate Stroke Team * Notify physician of BP greater than 185/105 * Education: Smoking Cessation and Second-hand smoking advice * O2 via device to keep O2 sat greater than 92% * Diet NPO * CBC w/diff, PTT, PT, INR, BMP * CT head w/o contrast * EKG 12 lead 4. Patient to be placed on monitor and escorted by ER RN. Vital signs and Neurological status to be monitored continuously and documented every 15 minutes.” Patient #8 Review of the medical record showed the patient presented to the ED on 10/12/25 at 7:42 pm with a symptom of left foot dragging while walking and an elevated BP and did not show laboratory or diagnostic testing was ordered. Review of a document titled “Triage” dated and 10/12/25 at 8:58 pm read in part: 1. “8:15 pm 10/12/25 BP 188/80... physician notified” 2. “8:17 pm 10/12/25 To room via wheelchair. General/Neuro/Psych: Alert. Appears in no acute distress. (Confused but at baseline)” 3. “8:51 pm 10/12/25 BP 177/69” 4. “8:58 pm 10/12/25... The patient left in a wheelchair and via private vehicle. Family member driving.” Review of the History of Present Illness dated 10/13/25 at 5:48 am read in part, 1) “Chief Complaint L leg weakness. This started just prior to arrival and is now gone...” 2) “HTN and L leg weakness. Patient was walking when she felt like her ‘shoe was sticking to the floor’ and daughter felt like her left foot was dragging.” Review of the medical record from (facility name withheld) showed the patient presented to the ED on 10/16/25 with symptoms of speech difficulty, left sided weakness, extreme fatigue, and a dragging left leg. The discharge summary dated 10/19/25 at 8:19 am read in part, “The patient was admitted with a diagnosis of acute right thalamic intracerebral hemorrhage attributed to hypertensive etiology.” On 01/15/26 at 10:13 am, Staff K stated: 1. The patient was pleasantly confused. 2. The patient didn’t receive any medications for elevated BP. 3. No testing was ordered. On 01/15/26 at 1:05 pm, Staff I stated: 1. The patient had taken BP meds before coming to the ED. 2. She had a history of HTN and was back to baseline prior to discharge. 3. No testing was done.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 53719 Based on record review and interview, the facility failed to ensure stabilizing treatment was provided to one (Pt #19) of 20 patient records reviewed. This failed practice had the likelihood to result in poor outcomes for patients and unborn children. Findings: Pt #19 Review of the medical record showed the patient presented to the ED on 12/12/25 at 5:26 PM at 35 weeks pregnant with complaints of contractions. The record showed physician examination of the patient as having no contractions and showed the patient was transferred to another hospital as positive for contractions with a diagnosis of labor. The medical record did not show the patient was stable for transfer. Specifically: 1. Review of the Clinical Report - Nurses dated 12/12/25 at 5:30 PM, read in part, “patient states her contractions started yesterday and states they have gotten ‘extremely close’ patient states they feel like she could not make it to [town name omitted] ...Chief complaint: POSSIBLE CONTRACTIONS......This started yesterday.” 2. Review of Clinical Report - Physicians/Mid Levels dated 12/12/25 at 5:42 pm read in part, “Gestational age is 35 weeks this started today and is still present. The patient complains of regular weak contractions... G 9; P 8; Ab 0... Physical Exam: ...fetal movement noted...Bimanual exam performed. Normal external exam. No contractions present... 1 centimeter dilated...Course of Care: I have talked to OB [personal obstetrician for Pt #19]; she wanted us to give Terbutaline and a [Liter] of fluids. Pt does not appear in danger of immanent [sic] delivery and is stable to transfer...Clinical Impression: Term Labor. Third trimester pregnancy.” 3. Review of the Medication Administration Record showed on 12/12/25 at 6:11 pm the patient was administered Terbutaline 0.5 mg subcutaneously and Normal Saline IV fluids. 4. Review of the Patient Transfer Form dated 12/12/25 at 6:12 pm showed: a. “Observations...Pregnant. + Contractions”. b. No information was entered for Patient Status/Risks & Benefits for stable or unstable patient query fields. c. “Indications of Patient Stability at Time of Transfer: VSS. Dilation 1 cm” d. “Diagnosis at Time of Transfer: Labor” e. “Reason for Transfer: OB” 5. The Physician’s Certification Statement dated 12/12/25 showed no documented response to the following query: “Other conditions affected by travel in such a way that without ambulance transportation, harm would come to the patient. What harm might be expected?” No information was provided. 6. Review of the Physician Certification for Transfer dated 12/12/25 and without time supplied, read in part, “I have also informed the patient/family/or guardian that the risks of transfer outweigh the increased risks to the patient. I have also informed the patient/family/or guardian of the probable risks of not being transferred.” The document listed no specific risks or benefits. 7. Review of nursing note dated 12/12/25 at 6:20 pm read in part “Transferred.” A later nursing entry, dated and timed 12/12/25 at 6:31 pm read in part, “Report was given to a nurse via a phone call...report was acknowledged and care was transferred.” Review of an EMS Prehospital Care Report from [name omitted] dated 12/12/25 at 6:07 pm, read in part, “Primary Impression: Preterm labor with preterm delivery...RN reported that the Pt was 35 weeks pregnant, grava 9, and para 8 RN reported that Pt arrived to the ER due to contractions that started the day prior. Pt reported that she had to be induced for all other pregnancies.... Pt stated she was having contractions 2-3 minutes apart and has been for over 8 hours. Patient stated that the contractions stared the day prior...Physical examine preformed [sic] by sending Physician reveled [sic] 2 mm of dilation. Review of OB Discharge Summary Note dated 12/14/25 from [name omitted] facility read in part, “Date of admission: 12/12/2025. Admitting diagnosis: 34+week IUP with preterm contractions not resolved by medical managment...Patient is a G9 P8...who present in transfer from sulfa[sic] ER after she came in contracting. On arrival she was contracting approximately every 6 minutes with uterine irritability and despite IV hydration continued to contract...She was admitted and continued on IV hydration and started on nifedipine for contractions. She was given a full course of betamethasone....By 12/14/25 she...was no longer contracting and doing well...She was discharged home [on 12/14/25 at 10:18 am] and continued on nifedipine 10 mg every 4 hours until 36 weeks...” Review of Discharge Summary dated 1/19/2026 from [name omitted] facility read in part, “date of admit: 1-19-2026, diagnosis: term pregnancy...Date of Delivery: 1-19-2026: Time of Delivery: [2:24 pm] Delivery Type: spontaneous vaginal delivey...Baby: Liveborn female, Apgars 8/9, weight 7 [pounds], 11.9 [ounces]...Discharge Date: 01/20/2026” Review of a policy titled “EMTALA Treatment and Procedures” read in part, “The physician/PA must document benefits and risks involved with transfer in ER record. The benefit/risks calculations must take into account the health and safety of the unborn child.” Review of a policy titled “Transfer Policy” read in part, “Arbuckle Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable according to EMTALA standard. This standard also states that a pregnant woman in active labor is not legally stable until the baby and placenta have been delivered...If a patient is to be transferred for medical necessity the following guidelines must be followed:...The individual risks and benefits must be documented and the patient’s medical record must support these...Emergency medical conditions under EMTALA law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the patient if not treated in the near future. Emergency medical conditions include but are not limited to...Pregnancy with contractions (defined as unstable).” On 01/15/26 at 9:46 am, Staff H stated: 1. There was no protocol for assessing if the patient was in labor. 2. They did not know how they could determine active labor with limited equipment. They had no fetal contraction monitor or Tocodynamometer and pH paper was not good. 3. The patient appeared comfortable and contractions were not felt. The patient had nine pregnancies and knew contractions. 4. The facility did not have ultrasound services to check position. There was no way to check position. 5. The facility did have a doppler for fetal heart tones. They did not obtain fetal heart tones because there was good movement. 6. They felt better if patients could be treated at a facility that had the equipment to monitor properly. On 01/15/26 at 10:17 AM, Staff L stated: 1. The patient thought they were in labor. VS and history were obtained. They assured the patient was ready in exam position. 2. They did not have a monitor; but could have obtained fetal heart tones. 3. They should have obtained the fetal heart tones for the patient.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure completion of transfer documentation for one (Pt # 19) of 20 patient records reviewed. This failed practice had the likelihood to result in the risk of life-threatening outcomes for patients and unborn children. Findings: Pt #19 Review of the medical record showed the patient presented to the ED on 12/12/25 at 5:26 PM with complaints of contractions and did not show a summary of risks and benefits on the physician certification of transfer. Specifically: 1. Review of the Clinical Report - Nurses dated 12/12/25 at 5:30 PM, read in part, “patient states her contractions started yesterday and states they have gotten ‘extremely close’ patient states they feel like she could not make it to [town name omitted] ...Chief complaint: POSSIBLE CONTRACTIONS......This started yesterday.” 2. Review of Clinical Report - Physicians/Mid Levels dated 12/12/25 at 5:42 pm read in part, “Gestational age is 35 weeks this started today and is still present. The patient complains of regular weak contractions... G 9; P 8; Ab 0... Physical Exam: ...fetal movement noted...Bimanual exam performed. Normal external exam. No contractions present... 1 centimeter dilated...Course of Care: I have talked to OB [personal obstetrician for Pt #19]; she wanted us to give Terbutaline and a [Liter] of fluids. Pt does not appear in danger of immanent [sic] delivery and is stable to transfer...Clinical Impression: Term Labor. Third trimester pregnancy.” 3. Review of the Medication Administration Record showed on 12/12/25 at 6:11 pm the patient was administered Terbutaline 0.5 mg subcutaneously and Normal Saline IV fluids. 4. Review of the Patient Transfer Form dated 12/12/25 at 6:12 pm showed: 1. “Observations...Pregnant. + Contractions”. 2. No information was entered for Patient Status/Risks & Benefits for stable or unstable patient query fields. 3. “Indications of Patient Stability at Time of Transfer: VSS. Dilation 1 cm” 4. “Diagnosis at Time of Transfer: Labor” 5. “Reason for Transfer: OB” 6. The Physician’s Certification Statement dated 12/12/25 showed no documented response to the following query: “Other conditions affected by travel in such a way that without ambulance transportation, harm would come to the patient. What harm might be expected?” No information was provided. 7. Review of the Physician Certification for Transfer dated 12/12/25 and without time supplied, read in part, “I have also informed the patient/family/or guardian that the risks of transfer outweigh the increased risks to the patient. I have also informed the patient/family/or guardian of the probable risks of not being transferred.” The document listed no specific risks or benefits. 8. Review of nursing note dated 12/12/25 at 6:20 pm read in part “Transferred.” A later nursing entry, dated and timed 12/12/25 at 6:31 pm read in part, “Report was given to a nurse via a phone call...report was acknowledged and care was transferred.” Review of an EMS Prehospital Care Report from [name omitted] dated 12/12/25 at 6:07 pm, read in part, “Primary Impression: Preterm labor with preterm delivery...RN reported that the Pt was 35 weeks pregnant, grava 9, and para 8 RN reported that Pt arrived to the ER due to contractions that started the day prior. Pt reported that she had to be induced for all other pregnancies.... Pt stated she was having contractions 2-3 minutes apart and has been for over 8 hours. Patient stated that the contractions stared the day prior...Physical examine preformed [sic] by sending Physician reveled [sic] 2 mm of dilation. Review of OB Discharge Summary Note dated 12/14/25 from [name omitted] facility read in part, “Date of admission: 12/12/2025. Admitting diagnosis: 34+week IUP with preterm contractions not resolved by medical managment...Patient is a G9 P8...who present in transfer from sulfa[sic] ER after she came in contracting. On arrival she was contracting approximately every 6 minutes with uterine irritability and despite IV hydration continued to contract...She was admitted and continued on IV hydration and started on nifedipine for contractions. She was given a full course of betamethasone....By 12/14/25 she...was no longer contracting and doing well...She was discharged home and continued on nifedipine 10 mg every 4 hours.” Review of Discharge Summary dated 1/19/2026 from [name omitted] facility read in part, “date of admit: 1-19-2026, diagnosis: term pregnancy...Date of Delivery: 1-19-2026...Discharge Date: 01/20/2026” Review of a policy titled “EMTALA Treatment and Procedures” read in part, “The physician/PA must document benefits and risks involved with transfer in ER record. The benefit/risks calculations must take into account the health and safety of the unborn child.” Review of a policy titled “Transfer Policy” read in part, “Arbuckle Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable according to EMTALA standard. This standard also states that a pregnant woman in active labor is not legally stable until the baby and placenta have been delivered...If a patient is to be transferred for medical necessity the following guidelines must be followed:...The individual risks and benefits must be documented and the patient’s medical record must support these...Emergency medical conditions under EMTALA law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the patient if not treated in the near future. Emergency medical conditions include but are not limited to...Pregnancy with contractions (defined as unstable).” On 01/15/26 at 9:42 am, Staff H stated: 1. There was no protocol and they don’t know how they could determine active labor with limited equipment. 2. They would feel better if the patient could be treated at a facility that has the equipment to monitor properly. On 01/13/26 at 9:20 am, Staff D stated: 1. There should not be blank areas in the transfer paperwork. It was their expectation that it should be completed. 2. It was a requirement to have the Physician’s Certification Statement completed.”

“An unannounced Life Safety Code survey was conducted on 11/24/25 at Arbuckle Memorial Hospital Authority located in Sulphur, Oklahoma. The facility was surveyed under NFPA 101, 2012 Edition, Existing and NFPA 99, 2012 Edition, Existing. The entrance conference was conducted on 11/24/25 at 12:20 p.m. with the Safety Director and Director of Maintenance. The facility was a one story building. The facility was fully sprinkler protected. Deficiencies were cited as a result of this survey. An exit conference was conducted on 11/24/25 at 3:50 p.m. with the Administrator, Safety Coordinator and the Director of Maintenance. The results of the survey were generally discussed and no other documentation was provided by the facility.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to complete all the required inspections of the automatic sprinkler system. This deficient practice has the potential to affect 17 of 17 patients, who resided in the facility, as identified by the Safety Coordinator on 11/24/25. The facility census was 17. Findings: 1. The facility inspection records were reviewed on 11/24/25 from 12:40 p.m. to 2:00 p.m. and no documentation was found to show the 5 year internal sprinkler inspection had been performed between October of 2020 through November 2025. 2. On 11/24/25 from 12:40 p.m. to 2:00 p.m., the Safety Director and the Director of Maintenance were present during the facilities records review and they were interviewed. Both acknowledged there was no documentation that a 5 year internal sprinkler inspection had ever been performed.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 46363 Based on observation and staff interview, the facility failed to provide appropriate equipment for 1 of 1 emergency generator, as required by NFPA 99 Remote Emergency Stop (Table 6.4.1.1.16.2 safety indications and shutdowns). This deficient practice has the potential to affect 17 of 17 patients that resided in the facility, as identified by the Safety Coordinator on 11/24/25. The facility census was 17. Findings: 1. A tour of the facility was conducted on 11/24/25 from 2:00 p.m. to 3:40 p.m. and the facilities generator did not have a remote emergency stop button (kill switch). 2. On 11/24/25 from 2:00 p.m. to 3:40 p.m. the Safety Coordinator and Maintenance Director were present during the tour of the facility on 11/24/25 from 2:00 p.m. to 3:40 p.m. and they were interviewed. Both acknowledged that the generator did not have a remote stop button (kill switch).”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 32662 Based on observation and interview, the facility failed to ensure supplies stored in 1 of 2 emergency crash carts for patients care and services were not expired (Broselow Pediatric Cart 1) Findings: An bservation in trauma room 2, on 08/27/25 at 9:30 a.m. in the presence of acting director of nursing showed the following supplies stored in the pediatric emergency crash cart were expired: Pink drawer; 1 Broselow/ Henkle Pediatric Emergency system intubation module; lot # 0004248507 expired on 2/28/25. Pink drawer; 1 Broselow/ Henkle Pediatric Emergency system intravenous module; lot # 0004241778 expired on 2/28/25. Orange drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen airway module; lot # 00041246993 expired on 5/31/25. Green drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen delivery module; lot # 0004246983 expired on 5/31/25. Yellow drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen airway module; lot # 0004140099 expired on 3/31/25. During an interview on 08/27/25 at 9:30 am, the acting Director of Nursing stated that the carts were checked regularly by staff assigned.”

“RESPONSIBILITIES OF MD OR DO CFR(s): A doctor of medicine or osteopathy is present for sufficient periods of time to provide medical direction, consultation, and supervision for the services provided in the CAH, and is available through direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This Standard is not met as evidenced by: 32662 Based on observation, record review and interview, the facility failed to ensure 2 of 2 physicians (Physician D and E) who provided care and services to patients at the facility participated in emergency management training. Findings: Physician (D) On 08/25/25 at 2.40 p.m. Physician (D) was observed providing care and services to patients in the emergency room. A review of credentialing files showed the physician was reappointed on 2/21/25 - 2/21/27 to provide care and service to patients at the facility. Review of credentialing and training files showed no evidence that the physician participated in emergency management training for the facility. Physician (E) Review of credentialing files showed the physician was reappointed on 11/20/23 - 11/20/25 to provide care and service to patients at the facility. Review of credentialing and training files showed no evidence that the physician participated in emergency management training for the facility. During an interview on 08/27/25 at 9:30 a.m, the CEO stated physicians (D and E) were contract staff and did not participate in emergency management training for the facility.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 32662 Based on observation, record review and interview, the facility failed to address nutritional needs for 2 (Patients # 1 and 2) of 7 sampled patients. Findings: Patient #1 On 08/25/25 at 1:32 p.m. Patient #1 was observed in his room lying in bed with foley catheter in place, heplock to his right arm and oxygen 4l/ minute via nasal cannula. The patient was alert to person, place, time and situation. During an interview on 08/25/25 at 1:32 pm, the Chief Nursing Officer stated the patient was admitted with a stage three wound to his coccygeal area and deep tissue damage to his heal. Observiation on 08/26/25 at 9:07 a.m. with Registered Nurse (I) showed Patient #1 had a stage three wound to coccyx, excoriation of the buttock, groin and scrotum and a blackened area to his left heel. Registered Nurse (I) provided wound care to the patient. Review of the clinical record showed the patient was readmitted to the facility on 08/25/25, post discharge from the hospital on 08/23/25 with admitting diagnosis of pneumonia. Review of the nurse progress notes dated 08/25/25 showed the following measurement of the wounds: Sacrum unstageable and redness 2 cm x1.5 cm x 0.5 cm. Left heal unstageable and redness 3 cm x 3.5 cm, right foot lateral plantar unstageable deep tissue injury 1.5 cm x0.5 ccm. Review of the attending physician’s history and physical, dated and signed by the attending physician 08/25/2025, showed no documentation of the patient having a sacral wound or any skin impairment. Documentation and assessment in the physician’s history and physical was as follows: “integumentary; warm pink and dry.” Review on 08/26/2025 of the clinical record (Laboratory values) showed the following findings: 08/23/2025; albumin 2.2 g/dl, 08/25/25 albumin 1,7 g/ dl and 08/26/25 albumin 1.7 g/dl. Reference range 3 - 5 g/dl. Review of the clinical record showed a physician’s order for regular diet. A review of nursing notes, dated 08/26/25 showed the following documentation: “ Meals other, patient refused.” During an interview on 08/26/25, Registered Nurse (I) stated, “The patient is not evaluated by the nutritionist, the nurse just gives him ensure.” Review of the patient’s record showed no documentation of a nutritional assessment, no documentation of nutritional supplement intake, and no documentation as to the amount of ensure the patient consumed. During an interview on 08/26/25 at 11.45, the dietary manager stated they had no documentation of the patient receiving nutritional supplement. Patient #2 Review of the clinical record showed the patient was admitted to the facility on 08/18/25 with admitting diagnosis of pyelonephritis, sepsis, weakness and disability. The record showed the patient was discharged to swing bed on 08/21/2025. Review of the Patient ’ s laboratory values showed the following findings: 08/18/25: albumin 3.1 g/dl 08/19/25: albumin 2.6 g/dl 08/22/25: albumin 2.6 g/dl Reference range 3 - 5 g/dl Continued review of the record showed a nutritional assessment dated 8/21/25 with the following documentation. “FND will provide appropriate nutritional supplement/ snack.” Review of the nurses progress notes showed no documentation of the patient receiving nutritional supplement or the amount consumed. Patient #4 Review of the clinical record showed the patient was admitted to the facility on 08/11/25 with admitting diagnosis of status post femur fracture repair and presented with a stage 2 ulcer to his sacral area. A review of a nurse progress note (SuperBill Details) dated 08/13/25 for wound assessment showed the following “pressure ulcer of sacral region, stage 3” Review of wound measurement dated 08/20/2 showed stage 3, 3.7 x 1.5 cm. Review of the patient ’ s laboratory values showed the following findings: 08/18/25: albumin 2.4 g/dl Reference range 3 - 5 g/dl A physician’s order dated 08/11/25 showed: “diet order, regular, consistency 5 - minced and moist, liquids midley thick.” A dietary assessment dated 8/20/25 showed: “Recommendation, offers house supplement with meals for extra K cal.” A progress note dated 0 8/11/2025 - 8/26/2025 showed no documentation if house supplements were served with meals and the amount consumed by the patient. On 08/26/25 at 3:45 pm, the Chief Nursing Officer stated there were no additional supplement consumption documents available for patients #2 and #4.”

“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: 32662 Based on observation, record review, and interview,direct care staff failed to practice infection control practices of cleaning contaminated supplies and washing hands after direct contact with contaminated supplies in two of three (Pharmacy Manager A and Licensed Vocational Nurse B) staff observed Findings Review of the facility’s current policy and procedure on handwashing hygiene updated March 31, 2020, directed staff as follows: “ Hospital personnel shall wash their hands, to prevent the spread of infection: (1) When coming on duty (2) before applying and after removing gloves (3) When hands are obviously soiled (4) Before and after contact with individual patient (5) Before and after personal use of the toilet (6) After Sneezing, coughing, blowing or wiping the nose or mouth (7) On leaving isolation area or after handling articles from an isolation area (8) After handling used sputum containers, soiled urinal, catheters and bedpan (9) Before eating (10) On completion of duty.” Observation on 08/26/2025 at 7;30 a.m. Pharmacy Manager (A) was observed pulling intravenous ciprofloxacin from the Omnicell machine for administration to Patient #2. showed during the process of removing the medication, the bag with the medication fell to the floor. The pharmacy manager picked up the medication in the contaminated packet and gave it to Licensed Vocational Nurse (B) who took it, went to the clean counter which stored patient care supplies for medication administration, placed the contaminated packet containing the medication on the clean counter, and picked up clean supplies of intravenous lines and to administer medication to patient #2. Continued observation showed Licensed vocational (B) proceeded to the patient’s room, holding supplies for administration of the patient’s intravenous antibiotic (with the contaminated package) holding the ciprofloxacin intravenous medication. Licensed vocational (B) placed the contaminated package and the supplies on the computer station, then picked up a clean pair of gloves from the box of gloves stored in the patient’s room. The nurse did not wash or sanitize her contaminated hands prior to applying clean gloves. Licensed vocational (B) then proceeded to the patient’s bedside and rearranged the patient’s bed linen. Review of patient #2’s clinical record showed the patient was admitted to the facility with a diagnosis of sepsis currently on antibiotic therapy. Licensed vocational nurse (B) Observation on 08/26/25 at 8:10 a.m. showed, Licensed Vocational Nurse (B) was observed pulling oral medication from the Omnicell machine located adjacent to the pharmacy. Continued observation showed while removing the medication from the Omnicell machine, the patient’s oral medication fell to the floor. Licensed Vocational Nurse (B) retrieved the medication from the floor, handed it to the Director of Nursing and continued removing medication with her contaminated hands to be administered to a patient. Licensed Vocational Nurse (B) did not wash or sanitize her contaminated hands used to retrieve the medication from the floor. The Surveyor notified the Facility ’ s Chief Nursing Officer of her observation. During an nterview on 08/26/25 at 8:09 a.m., regarding the procedure for supplies that falls to the floor, the Pharmacy Manager stated, “I should have wiped it off.””