Lower Umpqua Hospital District

“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: 44104 Based on observations, interviews, and review of documents and employee health records it was determined that the CAH failed to develop and implement an active facility-wide program for the surveillance, prevention, and control of HAIs and other infectious diseases. The hospital failed to demonstrate adherence to nationally recognized infection prevention and control guidelines for reducing the development and transmission of HAIs and antibiotic-resistant organisms. The findings identified during the survey reflect the CAH’s limited capacity to provide care and services and represent a Condition-level deficiency of CFR 485.640 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs. Findings included: 1. Refer to the Findings at Tag C-1204, CFR 485.640(a) Standard: Infection prevention and control program organization and policies. The hospital’s governing body failed to appoint an infection control professional based on medical and nursing leadership recommendations. 2. Refer to the Findings at Tag C-1206, CFR 485.640(a)(2) The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings. The hospital failed to fully develop and implement infection control policies for preventing and controlling the transmission of infections within the CAH. 3. Refer to the Findings at Tag C-1208, CFR 485.640(a)(3) 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. The hospital failed to fully develop, implement and monitor compliance with infection control policies for preventing and controlling the transmission of infections within the CAH. 4. Refer to the Findings at Tag C-1231, CFR 485.640(c) Standard: Leadership responsibilities (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. The hospital failed to fully develop and implement infection prevention policies that adhered to nationally recognized standards for reducing the development and transmission of HAIs.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 08621 Based on interview, documentation in 3 of 3 inpatient medical records of Medicare beneficiaries reviewed for the “Important Message from Medicare” (Patients 14, 16, and 17), review of CFRs applicable to hospital patients, and review of the CMS website, it was determined the hospital failed to ensure it complied with applicable Federal regulations as all Medicare beneficiaries had not been informed of their discharge appeal rights and provided with the “Important Message from Medicare” (IM) form in accordance with 42 CFR 489.27(a), which cross references the regulation at 42 CFR 405.1205. Findings include: 1.a. CFR 489.27(a), “Beneficiary notice of discharge rights”, requires: “(a) A hospital that participates in the Medicare program must furnish each Medicare beneficiary or enrollee, (or an individual acting on his or her behalf), timely notice as required by section 1866(A)(1)(M) of the Act and in accordance with [CFR] 405.1205 and [CFR] 422.620. The hospital must be able to demonstrate compliance with this requirement.” 1.b. CFR 405.1205, “Notifying beneficiaries of hospital discharge appeal rights,” includes the following requirements: “(a) Applicability and scope. (1) For purposes of [CFRs] 405.1204, 405.1205, 405.1206, and 405.1208, the term “hospital” is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals. (2) For purposes of [CFRs] 405.1204, 405.1205, 405.1206, and 405.1208, a discharge is a formal release of a beneficiary from an inpatient hospital.” (b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary’s rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures: (1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary’s admission to the hospital ... (2) Content of the notice ... (3) When delivery of the notice is valid. Delivery of the written notice of rights described in this section is valid if - (i) The beneficiary (or the beneficiary’s representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and (ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section ... (c) Follow up notification. (1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary’s representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge. (2) Follow up notification is not required if the notice required under [CFR] 405.1205(b) is delivered within 2 calendar days of discharge.” 1.c. The CMS webpage titled “Notices and Forms” was dated as “Page Last Modified: 09/06/2023 04:51 PM” and included the following information: “Hospital Discharge Notices - As under original Medicare, a hospital must issue to plan enrollees, within two days of admission, a notice describing their rights in an inpatient hospital setting, including the right to an expedited Quality Improvement Organization (QIO) review at their discharge. (In most cases, a hospital also issues a follow-up copy of this notice a day or two before discharge.) If an enrollee files an appeal, then the plan must deliver a detailed notice stating why services should end. The two notices used for this purpose are: - An Important Message From Medicare About Your Rights (IM) Form [CMS-10065], and the - Detailed Notice of Discharge (DND) Form CMS-10066. These forms and their instructions can be accessed on the webpage ‘Hospital Discharge Appeal Notice’ at: /Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices” 1.d. The “Hospital Discharge Appeal Notice” webpage referenced above in Finding 1.c. included the IM form and the instructions for completion of the IM form. The instructions included the following: * “Signature line: Have the beneficiary/enrollee or representative sign the notice to indicate that he or she has received it and understands its contents.” * “Date/Time: Have the beneficiary/enrollee or representative write the date and time that he or she signed the notice. If the document is delivered, but the enrollee or the representative refuses to sign on the delivery date, annotate the IM to indicate the date and time that the notice was delivered.” 2. The review of Patient 14’s medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 03/05/2024 at 1636, and discharged from inpatient services on 03/11/2024. The medical record contained one copy of an IM form. The form was signed by Patient 14. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065. In addition, although the patient was hospitalized as an inpatient for six (6) days, there was no evidence that the patient received the required notice again not more than two (2) calendar days before discharge. 3. The review of Patient 16’s medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 03/19/2024 at 1247. They were hospitalized as an inpatient until 03/25/2024 when they expired. The medical record contained one copy of an IM form. The form was signed by Patient 16. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065. 4. The review of Patient 17’s medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 04/29/2024 at 1925, and discharged from inpatient services on 05/08/2024. The medical record contained one copy of an IM form. The form was signed by Patient 17. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065. In addition, although the patient was hospitalized as an inpatient for nine (9) days, there was no evidence that the patient received the required notice again not more than two (2) calendar days before discharge. 44104”

“LICENSURE OF CAH CFR(s): The CAH is licensed in accordance with applicable Federal, State and local laws and regulations. This Standard is not met as evidenced by: 29708 Based on observations, interviews, review of CAH policies and procedures, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to hospital licensing and changes in the building and physical environment. Hospital licensing OAR 333-500-0045 requires that a hospital submit building plans and specifications to the SA, the State of Oregon hospital licensing authority, for review and approval prior to building construction, alterations or additions. Impacted areas may not operate until building plans review licensing processes have been completed and approval for the project(s) is received from the SA FPS Unit. The CAH failed to comply as follows: * The CAH converted an inpatient room into Outpatient Wound services without FPS Unit plans review and approval. * The CAH converted an inpatient room into Outpatient Infusion services without FPS Unit plans review and approval. * The CAH converted an inpatient room into Outpatient Respiratory Therapy services without FPS Unit plans review and approval. * The CAH converted a Pulmonary Function Test room into a negative pressure room without FPS Unit plans review and approval. Findings include: 1.a. An organizational chart that depicted the CAH’s inpatient and outpatient departments and services dated “Updated February 28 2024” reflected that the CAH provided “O/P Nursing” services. 1.b. An undated “Outpatient Nursing Services” document reflected that “The Outpatient Nursing department at Lower Umpqua Hospital District provides prompt, safe and effective care for the patients in our community and surrounding areas. Services include IV infusions ... Hydration ... Blood transfusions ... Medication injections ... Port-a-cath care and lab draws ... Wound care ... Compression ... Arterial Brachial Index ... Ostomy care ... Urinary catheter management ... Gastrointestinal tube management ... Therapeutic phlebotomy ... Our department staff include [sic] two Wound Care Certified Registered Nurses ... The department is open Monday through Saturday ...” 1.c. Observations of the CAH’s OP Wound services area, Room 114 on 06/26/2024 beginning at 1000 with the AC/ED NM and a Wound and Infusion RN, revealed it contained numerous wound and ostomy care supplies and items. 1.d. Observations of the CAH’s OP Infusion services area, Room 115 on 06/26/2024 beginning at 1055 revealed it contained numerous infusion equipment and supplies. 1.e. During interview on 06/26/2024 at 1040 with the AC/ED NM and the Wound and Infusion RN, the following information was provided: * Before OP Wound and OP Infusion services were provided in Rooms 114 and 115, respectively they were both provided in one room, inpatient Room 111. * Before OP Wound and OP Infusion services were provided in inpatient Room 111, they were provided “all over the place”. 1.f. In a text message from the AC/ED NM on 06/26/2024 at 1608, the response regarding whether the hospital had notified the SA FPS Unit of the changes to the OP Wound and OP Infusion services area, was “We did not notify FPS ...” 1.g. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of Room 114 to OP Wound services or the change of Room 115 to OP Infusion services. 2.a. An organizational chart that depicted the CAH’s inpatient and outpatient departments and services dated “Updated February 28 2024” reflected that the CAH provided “Respiratory Therapy”. 2.b. Observations in the CAH’s OP RT services area, Room 113 on 06/27/2024 beginning at 1110 with the Respiratory Therapy Manager, revealed it contained numerous RT equipment and supplies. 2.c. The following P&Ps were provided by the Respiratory Therapy Manager in response to a request for OP RT P&Ps: * The P&P titled “Nocturnal Oximetry - Outpatient,” dated last revised 10/18/2017. It included details and steps regarding “... the procedure for setting up a physician-ordered overnight Oximetry study ... Prior to starting the test ... Steps for preparing Nonin Model 2500 Oximeter ... Prepare Patient for test ... Conclude test ... Printing the Reports ...” * The P&P titled “Cardiac Stress Testing - Standard, Cariolite & Lexiscan,” dated last revised 08/24/2010. It included: “... Cardiac Stress Testing is the recording of the heart’s electrical activity and blood pressure while the heart is under the stress of increased physical demand. This is also known as exercise tolerance test ...” * The P&P titled “Pulmonary Function Testing,” dated last revised 08/16/2010. It included: “When prescribed by a physician, pulmonary function testing (PFT) will be performed by a qualified respiratory therapist to determine if a patient has a pulmonary obstructive, restrictive or diffusion defect ...” * The P&P titled “Event Monitor Setup,” dated last revised “6/07”. 2.d. During interview on 06/26/2024 at 1350 with the Respiratory Therapy Manager, the following information was provided: * Inpatient Med/Surg Unit Room 113 was converted to OP RT services in approximately “July 2023”. * OP RT services included pulmonary function tests, overnight oximetry, and occasional stress tests. * OP RT hours of operation were 0800 to 1700, Monday through Friday. * OP RT was staffed with one full-time RT and one part-time RT. 2.e. In a text message from the AC/ED NM on 06/26/2024 at 1608, the response regarding whether the hospital had notified the SA FPS Unit of the changes to the OP RT services area, was “We did not notify FPS ...” 2.f. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of an inpatient room to OP RT services. 3.a. Observations in the CAH’s negative pressure room, ED Exam Room 4 on 06/26/2024 beginning at 0935 with the AC/ED NM, revealed it contained numerous patient equipment, supplies and items including lab specimen collection supplies, patient gurney, transfer/repositioning device, mayo instrument stand, infusion pumps, and patient monitoring equipment. 3.b. During interview on 06/26/2024 at 0940 with the AC/ED NM the following information was provided: * The pulmonary function test room was converted to a negative pressure room, ED Exam Room 4 “at the end of July 2023”. Alterations to the room included “running cables and oxygen”. * The CAH had not notified the SA FPS Unit of the changes to the pulmonary function test room. 3.c. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of the pulmonary function test room to a negative pressure room. 4. In an email from CSC dated 07/05/2024 at 1132 the response to a request for “Policy and procedures that address submitting building construction, renovation, alterations and/or change of use projects for review and approval to the State Agency Facilities, Planning and Safety (FPS) prior to operation” was “NO POLICY”. 44104”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 08621 29708 Based on observations, interviews, review of CAH policies and procedures, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure that the physical environment was constructed, arranged, and maintained for patient safety and to provide adequate space for the provision of services: * Building construction/alterations had been made for Outpatient Wound services, Outpatient Infusion services, Outpatient Respiratory Therapy services, and a negative pressure room without the required approval of the SA. * Areas in the CAH, including where patient services were provided, had not been maintained in good repair and were not arranged to provide adequate space for services. Findings include: 1. Refer to Findings 1-4 under Tag C-816 that reflects building construction/alterations had been made without the required approval of the SA. 2. During tour of the Outpatient Rehabilitation Department on 06/25/2024 beginning at 1030 observations included: * The cabinet under the sink in the Rehabilitation Department wound care room was cluttered with a variety of items and solutions. The surface on the cabinet floor had areas that were peeled and chipped away and exposed the under-lying pressboard or particle board. Those conditions rendered the space not readily cleanable. 3. During tour of the Respiratory Therapy Department on 06/25/2024 beginning at 1220 observations included: * The floor in a closet outside of the department where ventilators, BiPAP/CPAP machines, and other respiratory therapy equipment was stored had low-pile carpet over a portion of the floor. Where the floor was not covered it was observed to be of an unfinished and rough material, was severely marred, and was covered with dirt and debris. In addition, there was no baseboard or other material to cover open spaces or gaps evident between the floor surface and the walls. A series of built in shelves on one wall in the room were made of unfinished wood and had rough and splintered surfaces. Boxes of supplies were stored on some of the shelves. Those conditions rendered those surfaces not readily cleanable. 4. During tour of the Laboratory Department on 06/25/2024 beginning at 1435 observations included: * The floor surface of the cabinet under the sink in the Laboratory Department was made from an unfinished pressboard or particle board material and was covered with numerous jars, jugs, containers of various solutions, and cardboard boxes of other supplies and materials. The cabinet floor surface had a series of large, drilled holes in it that clearly exposed the roughness of the pressboard or particle board composition. Further, the floor was severely stained and the surface marred by dried solution spills of various colors. Those conditions rendered the space not readily cleanable. * A large portion of the back wall of the cabinet under the sink, behind the sink plumbing fixtures, was missing. The shape of the missing cabinet wall was irregular and appeared to have been cut out after the cabinet wall was originally installed. The main plumbing pipe in the wall, to which the sink pipe was attached, was significantly exposed as were the rough surfaces of the building wall and the building ground that could be observed because the cabinet wall was not intact and closed. There may have been potential for entry of insects and rodents into the lab through that unfinished and unsealed opening. * On the wall to the left upon entry into the Laboratory Department, a black metal pipe was observed running up the outside of the wall next to a counter. At ~ counter level the pipe curved ~ 90 degrees and entered a roughly cut hole in the wall. The pipe was observed to connect to piping inside the wall. The large, roughly cut hole in the wall around where the pipes were joined was unfinished and unsealed. Broken and peeling plaster and wall materials and the interior space inside the wall were observed. 5. During tour of the Imaging Department on 06/25/2024 beginning at 1510 observations included: * Significant areas of a light bluish paint on the frame around the observation window from which the X-Ray Technician operates the X-Ray machine were observed to have peeled and chipped away to reveal an underlying coat of beige paint. There were additionally areas where the chipped or peeled paint exposed wood type material. Those conditions rendered those surfaces not readily cleanable. 6. During tour of the Nuclear Medicine Department on 06/25/2024 beginning at ~ 1600 observations included: * In addition to the nuclear medicine machine and equipment in the room, the space was crowded with the storage of patient care equipment that created difficult mobility and navigation through the room, inability to access or inspect the nuclear medicine equipment and the other patient care equipment stored in the space, and rendered the space not readily cleanable. Equipment stored in the room included, three patient beds, a large commode or shower chair type device, and two ventilator machines (one of which had a sticker with “Inspection Due” date of “10/23”). 7. Refer to Findings at Tag C-1208 that include other examples of areas not maintained or in disrepair throughout the hospital. For example: * Finding 12 reflects that scrub sinks in the surgical suite were stained, a housekeeping closet had a large hole with visible electrical wires near an operational sink, there was drywall damage in the anesthesia room and the endoscope storage room, and unmarked “clean” patient equipment was stored with sterilized instruments. * Finding 13 reflects that the EVS linen storage room contained open areas in the ceiling and walls and discoloration that was suspicious for mold and/or water damage, electrical wires protruded from ceiling, and the floor sink in housekeeping closet on a patient care unit was stained. * Finding 23 reflects that kitchen ovens in Dietary & Nutrition Services had visible and palpable layers of grease and grit, and water temperatures documented for the dishwasher were out of optimal range. 44104”

“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: 08621 29708 Based on observation, interview, and review of equipment PM documentation, it was determined that the CAH failed to fully develop and implement systems and policies and procedures to ensure that all electrical and bio-medical patient care equipment had been maintained to ensure an acceptable level of safety and quality: * Documentation did not reflect a complete inventory of all patient care equipment had been developed. * Documentation did not reflect initial PM inspections on all equipment prior to being put into service for patient use. * Documentation did not reflect timely PM inspections had been conducted for all patient care equipment that was in use or was available for use; and * Not all electrical and patient care items had an electrical or up to date PM, and electrical checks of items were inconsistent. Findings include: 1. During tour of the Respiratory Therapy Department on 06/25/2024 beginning at 1220 observations included: * A Phillips Respironics V200 Ventilator was observed in a storage closet, available for patient use along with other ventilators and BiPAP/CPAP machines in the room. A “Cascade Biomedical Services” sticker was attached to the back of the machine. Writing on the sticker showed an “Inspection Date” of “10/22” and “Inspection Due” date of “10/23.” During interview with the Respiratory Therapy Director at the time of the observation, about the inspection due date that had passed, they stated that the hospital was not using that ventilator and was trying to sell it. There was no signage or other indicator on the machine to reflect the ventilator was taken out of service, or to convey to staff that they do not use that ventilator that was overdue for inspection. 2. During tour of the Nuclear Medicine Department on 06/25/2024 beginning at ~ 1600 observations included: * Equipment stored in the nuclear medicine room and that was available for patient use included a Phillips Respironics V200 ventilator machine that had a “Cascade Biomedical Services” sticker on it with “Inspection Due” date of “10/23”. 3. During tour of the outpatient Reedsport Medical Clinic on 06/25/2024 beginning at 1130 with CM and MA, observations included: * In the medication room, a Philips Burton electric hand held UV light was available for use. There was no evidence of inventory tracking, initial or ongoing PM, electrical check or other safety checks observed. * In the staff break room, a toaster, a portable ice maker, and a microwave were observed with no evidence of inventory tracking, initial electrical or other safety checks observed. In the same break room, a single-serve coffee maker was observed with evidence of an initial electrical safety check completed by “Bio/Med” on 02/09/2023. It was not clear why all electrical appliances were not evaluated consistently for initial electrical and safety check. These findings were confirmed with the CM at the time of the observations. 4. During tour of the ED on 06/25/2024 beginning at 1525 with the AC/ED NM, a SECA infant scale was observed in a treatment room available for use with no evidence of inventory tracking and a sticker that lacked evidence of current PM. The sticker reflected: “Equipment Check Date 1/31/20 Initials [initials] “Reinsp 1/31/21 Service P.M.” These findings were confirmed with the AC/ED NM at the time of the observations. 5. During a tour of Surgical Services with the SSM on 06/26/2024 beginning at 0910 a wet/dry shaver was observed with no evidence of inventory tracking, or initial or ongoing PM. 6. During tour of the Med/Surg Unit on 06/26/2024 beginning at 1330 with the AC/ED NM, observation of an upright Frigidaire refrigerator/freezer in the medication room containing patient food and beverages revealed no evidence of inventory tracking, initial electrical or other safety checks. These findings were confirmed with the AC/ED NM at the time of the observations. 7.a. During interview with POM on 06/24/2024 during the entrance conference they provided the following description regarding the CAH’s system used to track patient care equipment and PM: * Biomed puts inventory and asset numbers on each piece of equipment. * Biomed does an electrical check on all equipment before it is put into service. 7.b. During interview and review of equipment inventory and PM records on 06/27/2024 at 0900, the following information was provided and confirmed with the POM and BT: * The Biomedical Department has a master equipment inventory list of equipment organized by department and a calendar for tracking equipment PMs that are due and those that have been completed. * New equipment arrives in the materials management area where a new intake is generated. Materials management informs the Biomedical Department when the equipment has arrived or brings the equipment to the Biomedical Department. The Biomedical Department does an initial equipment check and ongoing PM thereafter. * Regarding the UV light, toaster, portable ice maker, and microwave in the outpatient Reedsport Medical Clinic in Finding 3, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks. * Regarding the SECA infant scale in ED in Finding 4, a reinspection was due 01/31/2021 and that inspection had been missed. * Regarding the wet/dry shaver in SPD in Finding 5, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks. * Regarding refrigerator/freezer in Med/Surg Unit that contained patient food and beverages in Finding 6, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks. * The “Medical Equipment Management Plan 2024” in Finding 7.c. was provided. The BT stated that aside from that plan, the CAH had no PM P&Ps. 7.c. Review of the “Medical Equipment Management Plan 2024” reflected: * “This plan covers activities performed in the various locations of the organization, including ... Hospital campus ... Reedsport Medical Clinic ...” * “Assessment of needs for continuing technical support of medical equipment and design of appropriate calibration, inspection, maintenance, and repair services is an essential part of assuring that medical equipment is safe and reliable ... Assessment of needs for continuing technical support of medical equipment and design of appropriate calibration, inspection, maintenance, and repair services is an essential part of assuring that medical equipment is safe and reliable.” * “The organization maintains a written inventory for the inspection, testing, and maintenance of all the medical equipment used for the treatment, care, diagnosis, or therapy of the patients. The [Biomedical Department] maintains the inventory and updates it as appropriate based on risks identified. The inventory includes medical equipment maintained by the [Biomedical Department] and equipment maintained by vendors.” * “Identifying high-risk medical equipment ... The hospital identifies high-risk medical equipment on the inventory for which there is a risk for serious harm or death to a patient or staff member should the component fail. The high-risk medical equipment includes life-support equipment.” * “Identifying activities and frequencies ... A computerized maintenance management system is used to schedule and track timely completion of scheduled maintenance and service activities. The [Biomedical Department] is responsible for assuring that the rate of timely completion of schedule maintenance and other service activities meets regulatory and accreditation requirements.” * “Maintaining specific medical equipment ... The organization’s activities and frequencies for inspecting, testing, and maintaining the following items are conducted in accordance with manufacturers’ recommendations ... Medical equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements ... Medical laser devices ... Imaging and radiologic equipment ... New medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies ...” * “Equipment inventory and initial testing ... Prior to the initial use of medical equipment on patients or after major repairs or upgrades, the appropriate safety, operational, and functional tests are performed. This includes equipment owned by the organization, leased, demonstration, and rented equipment, and personally owned equipment used for the diagnosis, treatment, and monitoring of patient care needs.” * “Testing of high-risk medical equipment ... The organization assures that scheduled inspection, maintenance and testing of all high-risk equipment, including life support equipment, is performed in a timely manner ...” * “Testing of non-high-risk medical equipment ... The Organization assures that scheduled inspection, maintenance and testing of all non-high-risk equipment, including life support equipment, is performed in a timely manner.” 44104”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 08621 Based on observations, interviews, and review of fire safety and emergency preparedness policies and procedures and documentation, it was determined that the CAH failed to fully develop and implement policies and procedures to ensure compliance with all Life Safety from Fire and Emergency Preparedness requirements. Findings include: 1. Refer to the findings on the Life Safety from Fire CMS 2567 SOD reports for hospital Building-01 and Building-02, and the Emergency Preparedness CMS 2567 SOD. 44104”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. This Standard is not met as evidenced by: 08621 Based on interview and review of the CAH’s lists of services furnished under contract, arrangement or agreement it was determined that the current list of services furnished under contract, arrangement or agreement had not been maintained prior to the survey, and was not complete as it did not include all such services. Findings included: 1. An undated document titled “Service Contracts” was reviewed. It contained a list of entities and organizations with a brief description of the service. The list did not reflect all services provided to the hospital under contract, arrangement or agreement. Examples included, but were not limited to: * During tour of the Rehabilitation Department on 06/25/2024 beginning at 1030 the Rehabilitation Director stated that the hospital used the services of the Highland public swimming pool in the community for the provision of outpatient physical therapy services. That company was not on the “Service Contracts” list. * During tour of the Laboratory Department on 06/25/2024 beginning at 1435 the Laboratory Director stated that the hospital used the services of Pacific Micro for inspection and maintenance of laboratory microscopes. That company was not on the “Service Contracts” list. * During tour of the Imaging Department on 06/25/2024 beginning at 1510 the Imaging Director stated that the hospital used the services of Health Physics NW for evaluation and calibration of radiology equipment. However, that company was not on the “Service Contracts” list. 2. During interview at the time of the contracted services review on 06/27/2024 beginning at 1015, with staff that included the CEO, CNO, and DQRM, the CEO indicated that the list of services furnished under contract, arrangement or agreement had been generated for the survey and confirmed that it did not contain all applicable services including those examples described under Finding 1 above in this Tag. During the review, staff additionally identified other services not on the list that included, but were not limited to: * Compass Behavioral Health Services for QMHP services * Adapt Integrated Health Care for QMHP services * Iron Mountain for confidential record destruction * Vend West Services for water dispensing services * Stericycle for management, transportation, and disposal of medical waste 44104”

“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: 08621 29708 Based on interview and review of medical record documentation for 3 of 3 patients reviewed for nursing care plans (Patients 8, 9, and 18), it was determined the CAH failed to ensure a nursing care plan was developed, implemented and kept current for each patient based on assessment of the patient’s individualized needs. Findings include: 1.a. Review of medical record documentation for Patient 8 reflected the patient was admitted to the CAH on 06/23/2024 with diagnoses that included large bowel obstruction. The record included: * The patient underwent a surgical procedure and had multiple nursing care needs including but not limited to those related to post-operative care, abdominal surgical care, NG tube management, colonostomy care, urinary catheter care, pain management, and IV fluid management. Examples included: * An RN note dated 06/23/2024 at 0745 reflected “0725 hrs - [physician] with pt ... has ng tube in L nare with green/brown fluid in suction canister ... 0840 hrs - OR consent signed ... 1010 hrs - Pt to OR with [RN] ...” * A physician operative note dated 06/23/2024 at 1437 reflected the patient underwent a sigmoid colectomy with partial cystectomy and descending colostomy procedure on 06/23/2024. * An RN note dated 06/23/2024 at 1612 reflected that the patient arrived from recovery and complained of reflux “that is getting worse.” The physician was consulted and gave orders for pantoprozole 40 mg IV. * An RN note dated 06/24/2024 at 0642 reflected the patient had “[hiccups] all night that was causing [them] pain” and their “NG tube got clogged and [they stated they] felt sick from this”. The note reflected the patient was administered “pain medication a few times that seemed to help”. The note further reflected the patient had an abdominal dressing, a urinary catheter, wore SCDs and IV fluids were “infusing”. 1.b. Review of Patient 8’s medical record reflected there was no nursing care plan, including no goals and no interventions based on an assessment of the patient’s individualized needs. 1.c. During an interview and review of the medical record with the AC/ED NM on 06/26/2024 at 1515 they confirmed Findings 1.a. and 1.b. The AC/ED NM acknowledged the patient had multiple nursing care needs and confirmed the medical record contained no nursing care plan that addressed those. 2.a. Review of medical record documentation for Patient 9 reflected the patient was admitted to the CAH on 06/22/2024 with diagnoses that included failure to thrive and hypotension. * A physician order dated 06/22/2024 at 0731 reflected the patient was admitted to the Med/Surg Unit. The “Reason for Admission” was hypotension and the patient’s “Condition on Admission” was “Guarded”. Flowsheet documentation reflected: - On 06/22/2024 at 0615, the patient’s BP was 86/66 and “Pulse Oximetry” was “100” on room air. - On 06/22/2024 at 0647, the patient’s BP was 98/62 and “Pulse Oximetry” was “100” and unclearly reflected the patient was on room air with oxygen flow rate “2” Liters. - On 06/22/2024 at 0911, the patient’s BP was 109/68 and “Pulse Oximetry” was “99” on room air. * On 06/22/2024 at 1539, the patient’s “Pulse Oximetry” was “95” on room air. * On 06/23/2024 at 0927, the patient’s BP was 112/68 and “Pulse Oximetry” was “97” and unclearly reflected the patient was on room air with oxygen flow rate “2” Liters. * On 06/23/2024 at 1132 and 1448, the patient’s BP and “Pulse Oximetry” had decreased and were BP 94/65 and pulse oximetry “92 [low]” on room air. * On 06/25/2024 at 2034, the patient’s “Pulse Oximetry” was “91 [low]” on 2 Liters oxygen by nasal canula. 2.b. Review of Patient 9’s medical record reflected there was no nursing care plan, including no goals and no interventions including those related to the patient’s guarded condition, oxygen needs, nor diagnoses of failure to thrive and hypotension. 2.c. During an interview and review of the medical record with the AC/ED NM on 06/26/2024 at 1535 they confirmed Findings 2.a. and 2.b. The AC/ED NM stated the medical record contained no nursing care plan. 3.a. Review of the medical record for Patient 18 reflected that on 10/20/2022 they were brought to the ED by ambulance from a hotel/motel where they were living and were in observation status unit 10/24/2022 on which day they were admitted as an inpatient. They had a primary diagnosis of Failure to Thrive and were discharged to a shelter on 10/28/2022. There was no evidence in the medical record to reflect that a nursing care plan had been initiated or developed to address the problems and needs identified in the medical record for Patient 18. Those included: UTI, skin excoriation, mobility and transfer dependency, lack of social support system and reliable housing, and discharge plan challenges. 3.b. During interview at the time of the medical record review, with staff that included the DQRM, NM, and DP on 07/01/2024 beginning at 1400, staff stated that a nursing care plan for Patient 18 had not been initiated or developed for Patient 18. 44104”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 44104 Based on interview and lack of documentation, the hospital’s governing body failed to appoint an individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program based on the recommendations of medical staff leadership and nursing leadership. Findings included: 1. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, they were asked whether the IPD had been appointed by the governing body, or responsible individual, as the infection control professional responsible for the hospital’s infection prevention and control program, and whether their appointment had been based on the recommendations of medical staff leadership and nursing leadership. Both the IPD and the DQ responded that they were unsure. The DQ stated they would verify whether that had occurred. As of the exit date of the survey, no documentation was provided reflecting that the IPD had been recommended to their position by medical staff or nursing staff leadership, or that the IPD had been appointed by the governing body.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 44104 Based on observations, interview, documentation in 3 of 5 employee TB screening records (Employees 2, 3 & 4), review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure that infection prevention policies and procedures had been fully developed and implemented for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare facilities. Findings included: 1. Refer to the findings under Tag C-1208 related to: * Annual IC Risk Assessments had not been conducted and risks were not thoroughly evaluated hospital-wide. * Annual IC Plan and Program evaluation was not fully developed or implemented. * Annual TB Risk Assessment was not complete and risks were not thoroughly evaluated. * A TB Exposure and Control Plan had not been developed or implemented; TB screening for employees and contracted staff were not complete or timely in accordance with hospital P&Ps and CDC recommendations. * A healthcare Water Management Program had not been developed or implemented. * Hospital wide IC P&Ps were not fully developed and implemented to address infection prevention and control issues. Policies were unclear, inconsistent, and were not in accordance with manufacturer’s instructions or nationally recognized standards. * The hospital did not fully implement IC policies to maintain a clean and sanitary environment. * Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, in secondary containers with incomplete labels, or were not maintained in a clean or sanitary manner. * Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness. * Single-dose and multi-dose medication vials were not managed in accordance with P&Ps. * Services provided under contract, agreement, or arrangement were not evaluated for adherence to the hospital’s IC P&Ps and standards. 2. Refer to the findings under Tag C-1231 related to: * Nutrition Services policy regarding the storage of patient food were not fully developed or implemented. * Policies regarding animals in the hospital did not align with each other and were not fully developed or implemented. * Hospital wide policies regarding the labeling of refilled chemical bottles were not clearly written. * TB Exposure and Control policies were not fully developed or implemented and were unclear. * Surgical Services policies regarding the disinfection of endoscopes and continuing education were not fully developed or implemented and were unclear.”

“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: 08621 29708 44104 Based on observations, interview, documentation in 3 of 5 employee TB screening records (Employees 2, 3 & 4), review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure that infection prevention policies and procedures had been fully developed and implemented, and provisions for ongoing assessment and evaluation of those put into place. Procedures and processes based on nationally recognized standards to prevent cross-contamination, HAIs, and to ensure infection prevention had not been fully developed and enforced in the following areas: * Annual IC Risk Assessments had not been conducted and risks were not thoroughly evaluated hospital-wide. * Annual IC Plan and Program evaluation was not fully developed or implemented. * Annual TB Risk Assessment was not complete and risks were not thoroughly evaluated. * A TB Exposure and Control Plan had not been developed or implemented; TB screening for employees and contracted staff were not complete or timely in accordance with hospital P&Ps and CDC recommendations. * A healthcare Water Management Program had not been developed or implemented. * Hospital wide IC P&Ps were not fully developed and implemented to address infection prevention and control issues. Policies were unclear, inconsistent, and were not in accordance with manufacturer’s instructions or nationally recognized standards. * The hospital did not fully implement IC policies to maintain a clean and sanitary environment. * Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, in secondary containers with incomplete labels, or were not maintained in a clean or sanitary manner. * Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness. * Single-dose and multi-dose medication vials were not managed in accordance with P&Ps. * Services provided under contract, agreement, or arrangement were not evaluated for adherence to the hospital’s IC P&Ps and standards. Findings included: 1.a. An untitled document dated “25 June 2024” was provided by the hospital regarding the hospital’s annual Infection Control Risk Assessments. It was reviewed and reflected: * “The Infection Control Nurse at Lower Umpqua Hospital District has been employed by the district for three years.” * “ ... there has not been a comprehensive annual Infection Control Risk Assessment completed.” * “The requirements for an annual Infection Control Risk Assessment were brought to [their] attention in 2023, and the plan to initiate this is reflected in the Infection Control Plan ... “ * “The Infection Control Nurse had an initial consultation with [the state HAI/IP team representative] in March of 2023 ... for improvement practices ...” * “There was an on-site visit April 15th, 2024, to tour the facility ... “ * “The district’s Infection Control Nurse will be collaborating with the [the state HAI/IP team representative] ... to perform and document an annual Infection Control Risk Assessment in January 2025.” * The document closed with an unsigned signature block reflecting the IPD name, credentials and title. The hospital failed to conduct an annual Infection Control Risk Assessment per hospital policy, CDC recommendations, and nationally recognized standards. The document provided by the IPD confirmed that an Annual Infection Control Risk Assessment had not been conducted for approximately 3 years and that the hospital had no plans to correct the oversight until January of 2025, approximately 1 year and 10 months after identifying that an Infection Control Risk Assessment was required. 1.b. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD was asked for documentation of the hospital’s annual hospital-wide Risk Assessments. The IPD stated that they had not conducted a Risk Assessment since assuming the role of IPD on 12/20/2020. For clarification, the IPD was asked whether a Risk Assessment had been conducted for 2021. The IPD responded, “No.” The IPD was asked whether a Risk Assessment had been conducted for 2022, 2023, and 2024. The IPD responded “No” for each year. The IPD was asked whether they had evaluated the hospital’s contracted patient care services for adherence to IC practices such as: conducting an on-site Risk Assessment, or by reviewing contracts. The IPD responded: * Regarding contracted services for patient laundry/linen: The IPD stated “No,” they had not reviewed the contract nor conducted an on-site Risk Assessment. * Regarding the MRI mobile unit, the IPD stated, “Yes,” they had conducted an on-site review and evaluation. When asked when that evaluation occurred, the IPD stated, “Perhaps early 2023?” They further acknowledged that they had not reviewed the contract and that no documentation of the evaluation was available. * Regarding the public swimming pool used by the hospital’s Rehabilitation patients: The IPD stated “No,” they had not reviewed the agreement nor conducted an on-site Risk Assessment. Additionally, the IPD confirmed: * Neither an IC Risk Assessment nor an IC evaluation of the outpatient Wound Care Clinic had been conducted. * Neither an IC Risk Assessment nor an IC evaluation of the outpatient Reedsport Medical Clinic had been conducted. 2.a. A document titled “Infection Control Plan” with “Effective Date: 10/11/2017” and “Revised: 06/072021; 03/28/2024” was reviewed and reflected: * “The program goals are achieved through the following objectives ... Priority-directed, targeted surveillance based on the risk assessment.” * “Infection Control will develop a risk assessment at least annually or whenever significant changes occur ... “ * “Factors that are addressed in the risk assessment include, but are not limited to the following ... Geographic location and Community Environment ... Population Served ... Scope of Services provided ... Results of Analysis of Surveillance Data Collected ... Employee Health ... Emergency Preparedness ... “ * “Based on the Risk Assessment and goal prioritization, strategies are developed to address and implement actions of the Infection Control Plan.” * “Evaluation of Plan ... The Infection Control Nurse monitors the Infection Control Program, allowing the hospital to determine if procedures are working well or require revision ... The evaluation addresses changes in the scope of the program, changes in the results of the program risk analysis, emerging and re-emerging problems in the ... community that potentially affect the hospital, assessment of the success or failure of interventions for preventing and controlling infection, and responses to concerns raised by leadership and others... Documentation of program evaluation is located in the CQC meeting minutes and in the Infection Control department.” The hospital failed to fully develop and implement its Infection Control Plan and failed to thoroughly evaluate that plan at least annually, or when significant changes occurred, per hospital policy and nationally recognized standards. For example, the Infection Control Plan stated that program goals were achieved by conducting “Priority-directed, targeted surveillance based on the risk assessment”. It was unclear how the “strategies ... developed to address and implement actions of the Infection Control Plan” based on the “Risk Assessment” were determined as no risk assessment had been conducted for the past 3 years, refer to Findings 1.a. and 1.b., IPD confirmation that Infection Control Risk Assessments had not been conducted. Further, the plan reflected that “changes in the results of the program risk analysis” would be considered when evaluating the plan. However, since no IC risk assessments were conducted, it was unclear on what the hospital based its IC program evaluations for those years in which a risk assessment had not been conducted. The IC Plan reflected “The Infection Control Nurse monitors the Infection Control Program, allowing the hospital to determine if procedures are working well or require revision ...” The plan was not clear on whether it met state OAR requirements that the infection control program be managed by a qualified individual and overseen by a multidisciplinary committee with responsibility for investigating, controlling and preventing infections in the facility. The IC Plan did not describe the existence of a multidisciplinary committee that included representation from major departments and services or whether that committee’s role included provision of consultation and oversight of all aspects of the infection control program. 2.b. A document titled “Lower Umpqua District Infection Control Committee Minutes” dated “March 15, 2024” was reviewed and reflected: * “Attendance: (Name, Title, who representing (indicate chair) [sic]” * “Approval of Minutes: 1st meeting”. The minutes reflected that this was the first meeting for the Infection Control Committee. No “chair” was identified in the attendance roster. 2.c. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Findings 2.a. and 2.b. The IPD confirmed that the hospital Infection Control Committee “began March 15, 2024.” 3.a. A document titled “2023 Lower Umpqua Hospital District Tuberculosis Risk Assessment” was reviewed and reflected: * The TB Assessment addressed 8 areas as follows: * Introduction - “This risk assessment aims to evaluate the TB risk within Lower Umpqua Hospital District ... and outline measures to mitigate these risks effectively.” * Assessment Scope - “Physical Environment: Evaluate ventilation systems, room configurations, and patient flow ... Patient population: Assess demographics, prevalence of TB, and related risk factors ... Staff Training: Review training programs and awareness of TB Prevention measures ... Infection Control Practices: Examine protocols for screening, isolation, and treatment adherence.” * Risk Factors Identification - “Patient Population: High-risk demographics ... History of TB cases among patients ... Physical Environment: Ventilation adequacy in patient rooms, waiting areas, and procedural spaces ... Room configurations for isolation capabilities. Room 103 in Acute Care is identified as negative pressure. Other rooms in the Emergency Department, Acute Care ... have the capability of negative pressure via portable units.” * Current Mitigation Strategies - “Infection Control Policies: Screening Patients upon admission ... Isolation procedures for suspected or confirmed TB cases ... Staff Education and Training: TB awareness training for all healthcare personnel. Staff receive training in General Orientation and annual training ... Correct use of ... PPE ... The Respiratory Therapy Department conducts fit testing of newly hired workers and annual fit testing. Employee Health oversees PAPR training and processing. * Assessment Findings - “TB Prevalence: Low/moderate/high based on historical data and current patient demographics ... There were zero cases of inpatients with TB in 2021, 2022 and 2023 ... Employee Health Screenings: Healthcare workers are screened for Tuberculosis prior to employment. All contracted workers are required to show proof of recent Tuberculosis testing (within six months) prior to employment. New employees are assessed through screening questions and testing. Lower Umpqua Hospital District utilizes the two-step PPD testing method or QuantiFERON [sic] Gold testing as part of the new hire process. There were zero cases of positive TB tests among healthcare workers in 2022 and 2023 ... Infrastructure: Adequate airborne infection control ... Compliance: Generally compliant with TB control guidelines.” * Conclusion - “This risk assessment identifies the current state of TB risk within Lower Umpqua Hospital District ... By implementing the recommended measures and continuously evaluating TB control strategies, the hospital can effectively minimize the risk of TB transmission among patients, visitors, and staff.” * Approval: “This risk assessment is approved by: [the IPD name and title]’. The hospital failed to fully develop and implement a TB Risk Assessment per CDC recommendations and nationally recognized standards. For example, the TB Risk Assessment date lacked a month and day, and therefore it was unclear when the risk assessment was conducted. It was unclear how assessment findings were were determined. For example, under “Assessment Findings” the document reflected a determination of “Adequate airborne infection control.” However, under “Physical Environment” the document described actions instead of findings, e.g., “Evaluate ventilation systems”. Documentation of the ventilation system evaluation such as a description of type of ventilation system employed, e.g., single-pass, recirculated flow, variable air volume, etc., which air-cleaning methods were in use, e.g., HEPA filtration or UVGI, or whether air exchanges in various patient care areas adhered to nationally recognized standards were not noted. The physical environment evaluation also did not address findings on whether environmental controls were regularly checked and maintained, or whether a procedure existed for verifying the negative pressure in AII rooms when the rooms were in use, including those rooms where portable HEPA filter units were utilized. Additionally, it was unclear what was meant by “Generally compliant with TB control guidelines” and how that contributed to the overall risk of TB within the hospital environment. The “Assessment Findings” did not clearly state the hospital’s overall risk of TB and instead reflected “Low/moderate/high based on historical data and current patient demographics ...” Finally, the assessment was approved by the author and did not reflect IC Committee members’ or leadership review and approval. 3.b. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Finding 3.a. 4.a. A document titled “Tuberculosis Screening - Employees, Volunteers and Students” with “Effective Date: 5/3/2018” and last revised “06/05/2024” was reviewed and reflected: * “Approved By ... Director Infection Control [and] ... Chief Nursing Officer” * “Employees, volunteers and students shall be evaluated for Tuberculosis (TB) upon employment, annually thereafter if indicated by the annual Infection Control evaluation, and following exposures.” * “All new employees must have a TB symptom screening, risk assessment and two-step baseline TB skin test (TST) or single Interferon Gamma Release Assay (IGRA) ... or T-Spot within twelve (12) months of the date of hire, date of executed contract date or date of being granted hospital credentials. For those utilizing the two-step TST, the first step must be completed prior to the start of employment.” * “If an annual ... PPD ... is warranted per Lower Umpqua Hospital District’s ... Tuberculosis Exposure Control Plan Risk Assessment, Infection Control will implement a plan to arrange for testing through Employee Health.” The policy was not fully developed and implemented. For example, key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, or whether the policy had been evaluated by an interdisciplinary team responsible for the oversight of the infection control program. Although the references listed the “Centers for Disease Control and Prevention ... Guidelines for Preventing the Transmission of Mycobacterium tuberculosis [sic] in Health-Care Facilities”, the hospital failed to thoroughly complete the CDC’s recommended TB Risk Assessment, which lacked the hospital’s determined TB risk; refer to Finding 3.a. Therefore, it was unclear how the hospital decided the frequency of HCW TB screening and testing without an accurate TB risk evaluation. 4.b. Employee TB testing records were reviewed for Employees 1-5, and reflected: * The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 2 per hospital policy. * The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 3 per hospital policy. * The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 4 per hospital policy. The hospital failed to develop and implement a Tuberculosis Exposure Control Plan as referenced in the hospital’s “Tuberculosis Screening” policy, CDC recommendations, and nationally recognized standards. Employee TB screenings were incomplete and inconsistent with the hospital’s TB screening policy and with the hospital’s “Tuberculosis Risk Assessment”. For example, 3 of 5 employee records (Employees 2, 3, 4) lacked a completed TB symptom screening and risk assessment form as required by the TB screening policy. Documentation of Employees 2, 3, and 4 being “assessed through screening questions”, as described in the TB Risk Assessment were not provided. 4.c. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Finding 4.b. The IPD stated that an OSHA form titled “OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134” served the same purpose as the hospital’s TB symptom screening and risk assessment form. When the IPD was asked whether symptoms of TB, such as night sweats were included on the OSHA Respirator Medical Evaluation Form, the IPD stated, “No, but I ask them if they are free from infectious diseases.” When asked whether the policy reflected that the OSHA Respirator Medical Evaluation Form and the TB symptom screening form could be used interchangeably, the IPD stated, “No,” and confirmed that it was not reflected in the policy. The IPD was asked whether the hospital had a Tuberculosis Exposure Control Plan. The IPD stated, “No.” 5. An untitled, undated document provided by the hospital regarding the facility’s Water Management Program was reviewed and reflected: * “April 15th, 2024 OHA IP [the state HAI/IP team representative] visited the facility and provided the CDC resource, Developing a Water management [sic] Program to Reduce Legionella Growth and Spread in Buildings to assist us with a water management plan.” * “This plan is currently not completed.” * The document closed with a signature block reflecting the “Plant Operations” Assistant Manager’s name and signature. The hospital failed to develop and implement a Water Management Program as required by CMS, recommended by CDC and per nationally recognized standards. The hospital could not provide a hospital risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the hospital water system. 6. A policy titled “Central Service - Sterilization - Scope of Services Provided” with “Effective Date: 10/18/2003” and revised dates of “02/03/2022; 05/02/2023” was reviewed and reflected: * “Approved By ... Director of Surgical Services ... Chief Nursing Officer [and] Medical Director DFHC” * “Central Service is responsible for the processing, sterilization and quality control of all sterile supplies and equipment used in Lower Umpqua Hospital District.” * “Central Service personnel must also maintain all required quality assurance tests and documentation for each sterilizer load.” * “Personnel in each department are responsible for the initial cleaning of all items and processing as described for each department’s specific procedure.” * Regarding outpatient Reedsport Medical Clinic, “Individual department will bring items to Central Service for processing. Items to be placed in Decontam container on counter or if door locked, place on floor.” * “ ... services will be provided Monday through Friday per hospital department: *Instrument turnaround [sic] time is 48 hours for processing ... “ * “Surgical Services Department/Outpatient Surgery/GI Laboratory ... All instrument and basin sets and trays will be decontaminated, packaged and sterilized by Central Service ... Equipment ... Single packaged items ... Implants ... Other patient care items such as transducers and anesthesia supplies.” * “... Reedsport Medical Clinic ... All instruments, single packaged instruments and trays and other patient care items that must be sterilized prior to use, will be sterilized by Central Service ... Clinic staff will wipe gross debris off instruments at point of use with 4x4 gauze ... Staff should wear appropriate personal protective equipment ... including chemical resistant gloves and eye protection ... Clinic staff will spray dirty instruments with approved enzymatic spray ‘RUHOF ... Prepzyme Forever Wet ... Instruments should remain moist until they are transported to Central Service for sterile processing ... Dirty instruments will be transported in a latch/lock labeled biohazard container. Lid should remain on container at all times during transport to prevent cross contamination ... Once dirty instruments are out of biohazard container, Central Services staff will clean the container with approved low-level disinfectants such as Meritz plus, Sani-Cloth, bleach wipes, or Dispatch ... A label indicating ‘Clean’ will be affixed to the container and sterilized instruments will be returned in the cleaned container.” * “Emergency Department and Patient Care Units ... Sterile instrument sets, single packaged instruments and trays for treatment or diagnostic tests ... Other patient care items that require sterilization prior to use.” * “Radiology ... Patient care items that require sterilization prior to use.” * “Reference: Former policy ID #1004, Central Supply policy”. The policy was not fully developed or implemented and it was unclear whether the policy was based on nationally recognized standards. For example, the policy lacked professional references, such as CDC Guidelines for sterilization and disinfection, and did not reflect whether the hospital considered recommendations by other professional sources such as AORN, or APIC. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, or whether the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of patient care equipment, such as personnel from the Reedsport Medical Clinic or other patient care units. Parameters for processes such as “Instruments should remain moist until they are transported to Central Service for sterile processing” were not well described. For example, it was unclear whether the manufacturer’s IFUs for the enzymatic spray RUHOF Prepzyme Forever Wet meant that the instruments could remain in the “biohazard container” for greater that 24 hours, 48 hours, 72 hours, or “Forever” prior to processing. The policy did not specify when, after being used, instruments should be transported to Central Service for processing. It was unclear whether items in biohazard containers taken to Central Service for processing when the “door [was] locked” and placed “on floor” created other infection prevention or safety concerns as a designated area “on floor” was not specified. 7. A document titled “Olympus Reprocessing Manual ... Duodenovideoscope ... Type Q180v” with a revision history of “March 2015” was reviewed for the manufacturer’s cleaning and reprocessing instructions for the hospital’s endoscopes. It reflected: * “Warning ... Improper handling, such as touching a reprocessed endoscope and/or accessories with contaminated gloves, placing a reprocessed device on a contaminated hanger or surface, allowing devices to touch the floor, etc., will recontaminate the device.” * “Patient debris and reprocessing chemicals are hazardous. To guard against contact with dangerous chemicals and potentially infectious material, wear appropriate personal protective equipment during cleaning, disinfection, and sterilization. Such protective equipment should include appropriate eyewear, face mask, cap, moisture-resistant clothing, shoe covers, and chemical-resistant gloves that fit properly and are long enough to prevent skin exposure.” * “All cloths used in reprocessing are recommended to be lint-free. Lint or cloth fibers shed into reprocessing fluids may be injected into the endoscope channels. There is the potential for lint or cloth fibers to lodge in channels or become trapped in the air/water nozzle. If gauze is used to reprocess the endoscope, ensure that fibers do not get caught on or remain trapped by protruding components like the air/water nozzle.” * “Insert the brush into the forceps elevator recess along the forceps elevator (insert the brush into the instrument channel) until the brush handle touches the distal end of the endoscope and pull the brush out of the forceps elevator recess. Repeat the insertion and pulling out three times.” * “Brush the distal end of the endoscope except the forceps elevator and the forceps elevator recess, using the single use channel-opening cleaning brush ... or the single use combination cleaning brush ... until no debris is observed upon inspection of the distal end of the endoscope ... 2. Insert the brush at a 45 [degree] angle into the opening located in the side wall of the suction cylinder. Using short strokes, feed the brush through the instrument channel until it emerges from the distal end of the endoscope’s insertion section. 3. Inspect whether there is debris on the bristles when the brush emerges from the distal end. Clean the bristles in the detergent solution using your gloved fingertips to remove any debris. 4. Carefully pull the brush back through the channel and out of the suction cylinder. 5. Inspect whether there is debris on the bristles when the brush emerges from the suction cylinder. Clean the bristles in the detergent solution using your gloved fingertips to remove any debris. 6. Repeat Step 2 through 5 until no debris is observed upon inspection of the brush.” * “Dry the external surfaces of the endoscope, the channel plug, and the injection tube by wiping with a clean, lint-free cloth(s).” * “Proper storage procedures are as important as proper reprocessing procedures in maintaining good infection control practices. Be sure that the endoscope storage cabinet is properly maintained, clean, dry, and well ventilated. All equipment must be thoroughly dried prior to storage. Microorganisms proliferate in wet/moist environments. Keep the cabinet doors closed to protect the equipment from environmental contaminants and accidental contact.” 8.a. A policy titled “Endoscopes - High Level Disinfection” with “Effective Date: 04/21/2006” and a revised date of “07/28/2017” was reviewed and reflected: * “Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer” * “This is an abbreviated procedure. Please refer to Olympus manuals for all specifics on endoscope sterilization procedure.” * “All endoscopes shall receive mechanical cleaning prior to sterilization or disinfection.” * “Flexible endoscopes shall be cleaned with a manufacturer-approved enzymatic cleaner immediately following use.” * “The channels will be irrigated and brushed, if accessible.” * “Rinse all immersible parts of the endoscope with water.” * “Discard all detergent solutions after each use. Use single-use disposable brushes for cleaning the channels or clean and sterilize.” * “Conduct leak testing on flexible endoscopes prior to immersion. Remove endoscope from service, if it leaks, before it is cleaned and contact the manufacturer. See policy and procedure.” * “Following chemical disinfection, rinse the endoscope with sterile water.” * “Thoroughly air dry the endoscope while in the hanging position.” * “Do not store the endoscope coiled. Store endoscopes in the hanging position. Wipe the cabinet floors daily after endoscope cleaning.” 8.b. The policy was not fully developed or implemented and it was unclear whether the policy was based on nationally recognized standards. For example, the policy lacked professional references, such as CDC Guidelines for sterilization and disinfection, and did not reflect whether the hospital considered recommendations by other professional sources such as AORN, or APIC. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes. The mechanical cleaning processes for endoscopes were not well described. For example, it was unclear what was meant by “Use single-use disposable brushes for cleaning the channels or clean and sterilize.” 9.a. A policy titled “Medivators Cer-2 Optima Scope Washer - Care and Operation” with “Effective Date: 07/17/2017” and a revised date of “4/8/2024” was reviewed and reflected, in it’s entirety: * “Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer” * “Purpose: High level disinfection of flexible endoscopes using rapicide.” * “Policy: All scopes must be leak tested, brushed and wiped prior to loading in the Medivators CER-2 Optima Scope Washer. Refer to manual for detailed instruction on proper maintenance and operation. In the event of scope washer failure, please refer to Olympus Reprocessing Manual for GIF and CF scopes, chapter 3 for manual reprocessing in the Endoscopy Manual book.” 9.b. The policy was unclear and not fully developed. For example, the policy lacked references, such as CDC Guidelines for sterilization and disinfection, and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes. 10.a. A policy titled “Annual Training/Continuing Education” with “Effective Date: 11/15/2002” and a revised date of “08/03/2023” was reviewed and reflected: * “Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer” * “Policy ... All members of the surgery department staff will complete annual Relias training ... All members of the surgery department staff will have current CPR certification ... All surgery registered nurses will have current ACLS certification ... All surgery technologists will have current certification or complete 16 hours of continuing education every two years ... All members of the surgery department staff will review the following skills/equipment annually: Adult Code Cart ... Difficult Intubation Cart ... Malignant Hypothermia Cart”. * “All records of certifications will be kept in Human Resources. All department skills reviews will be logged in the employee development book in the PACU.” * Attached to this policy was a copy of a 1-page, handwritten document dated “11-21-23” and titled “Anesthesia Inservice, difficult intubation, art line set-up, intubation skills w/ Dr. [doctor’s name]. This was followed by 6 signatures, of which only 2 were legible. No other information that identified which staff attended the inservice was reflected. 10.b. The policy did not clearly state whether competencies for HLD or mechanical cleaning of endoscopes were required. The policy did not reflect whether staff performing HLD and mechanical cleaning of endoscopes were required to review processing steps periodically. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes. 10.c. In an email received on 07/08/2024 at 0823 the CSC wrote that the hospital had “No Competencies or Annual training/records re: scope washing” for the last two years. 11.a. During a tour of Surgical Services with the SSM on 06/26/2024 beginning at 0910, the ST was observed during mechanical cleaning and reprocessing of an endoscope and stated the following: * The water temperature with added detergent for precleaning was required to be below 130F. * The ST generally spent 5-7 minutes mechanically cleaning the endoscope prior to reprocessing in the AER. * The ST normally threaded the single-use brush through the “suction [channel] and all the way out of the biopsy port twice”. * The ST stated (and it was observed) that they wiped down the outside of the endoscope with a cotton washcloth after it came out of the AER. Additionally, the surveyor observed the following: * The endoscopes were hung in a wooden cabinet with glass doors. The doors to the non-hospital grade cabinet did not completely close and a quarter inch gap was observed toward the top of the cabinet door. The back wall of the cabinet had a visibly worn area where the endoscopes had rubbed against the wood. * Approximately 3 to 4 feet from the right side of cabinet, and ~ 3-4 inches from the ceiling, a 4 x 4.5 inch open area in the dry wall near the cabinet was visible. The wall had two different colors of paint and slight peeling of drywall surrounded rectangular opening. * The ST performed the mechanical cleaning in non-moisture resistant clothing, and wrist-length hospital grade gloves. * The disinfectant container of test strips for the AER reflected “Use within 6 months of opening”, however, the “Date Opened” was not noted on the container. The ST used a chemical test strip from the undated bottle to test for chemical MEC prior to HLD. 11.b. The hospital failed to fully implement the hospital’s HLD and sterilization policies, and failed to follow the manufacturer’s IFUs for meticulous manual cleaning and storage of endoscopes. For example, the manufacturer’s IFUs reflected cleaning brushes were recommended to pass through channels “until no debris is observed upon inspection of the brush.” Although the manual did specify channels where a stated number of brush passes were indicated, such as “pulling out three times” with insertion into the “forceps elevator recess”, at no other point was a set number of brush passes indicated for the “suction cylinder”. IFUs indicated that manual cleaning of “suction cylinder” should continue until no debris “is observed” and not “twice” as described by the ST. IFUs also reflected that lint-free cloths should be used for cleaning and reprocessing endoscopes; cotton washcloths do not meet nationally recognized standards for lint-free cloths. The wooden storage cabinet had visibly worn areas where the endoscopes were rubbing against the wood, increasing the likelihood of removing the protective finish of this porous and difficult to disinfect material; damaged, unprotected wood may be more prone to moisture retention, as well as bacterial and fungal contamination. Furthermore, the manufacturer’s IFUs warn “Improper handling, such as touching a reprocessed endoscope ... with contaminated gloves, placing a reprocessed device on a contaminated hanger or surface, allowing devices to touch the floor, etc., will recontaminate the device.” Additionally, mechanical cleaning was performed without the recommended PPE such as moisture resistant clothing and wrist-length gloves, contrary to the manufacturer’s recommendations. There was no guarantee that the test strips used for testing the MEC of the disinfectant provided an accurate MEC result as the expiration date of the opened bottle was not clearly marked. 12.a. During a tour of the surgical services department on 06/26/2024 with the SSM, and the IDP beginning at 0910, the following was observed: * A single-use Fiber Optic Laryngoscope blade was in the anesthesia room for patient use with an expiration date of “2024-04-10”. * An eyewash station testing log contained pre-filled dates for testing. The instructions on the log form included “Inspect every seven days.” The log had columns for Date, Time, Status, Initials, Corrective Action Taken. The log entries for the dates were handwritten and pre-dated for the following: “6/27/24 ... 7/4/24 ... 7/11/24 ... 7/18/25 ... [and] 7/25/24”. Although the information for the other columns was blank, the pre-dating created a risk that checks might be done on different dates, i.e. if a date was missed, and the log would not reflect the actual date the staff person conducted the check. * Two scrub sinks in the operating room suite were stained pink. Rust was visibly present around both drains. One sink had two dark patches that were pink and brown, ~ 3-4 inches in diameter. * Patient care items, such as “Skinaffix” had a hospital printed label applied to the package which covered the item’s expiration date information which required the user to peel back the hospital label in order to verify the expiration date prior to patient use. * A housekeeping closet in the operating room suite and directly right of the entrance to the alcove of the two adjoining operating rooms contained a large, cut out rectangular hole in the wall. The hole was ~ 12 inches x 24 inches and approximately 4 inches from a functional sink. Electrical wires were exposed and the drywall from the next room was visible. Packages of microfiber mop heads were stacked in the sink and 7 mop handles were stacked throughout the small closet. A bucket of mop water was on the floor near the sink. The SSM was asked how long the hole had been there and they stated since the ADU had been installed “last year some time.” They also stated that “we only use it for storage” and they had not used the sink for approximately 1 year. When asked how often the facility flushed that sink as part of its water management program, the IPD stated, “We don’t have a water management program.” Additionally, there was peeling paint near one of two electrical panels and just outside the housekeeping closet was a damaged corner edge where a large eye bolt had been screwed into the wall. * On the counter outside the decontamination room used for processing endoscopes was a pile of uncovered cotton washcloths that were used to wipe down the endoscopes after HLD processing. * Cabinets on the clean side of the sterile processing area that used to store sterilized equipment for patient use contained a mixture of outdated equipment, books, office supplies, and employee personal items such as “Emergen - C” vitamin supplements and a knitted cap were intermingled and disorganized. The cabinets were blocked by a long metal table on wheels that contained biohazard containers marked “Dunes” as well as a stack of papers, an uncovered tray of surgical instruments, and two packages of wrapping paper for sterilization use. It was unclear whether the biohazard containers were “clean” as there were no “clean” labels affixed. There was no clear separation from clean, and dirty items. An unlaminated, and uncleanable photo was taped to the outside of the cabinets. * The sterile storage area contained approximately seven pieces of equipment that were not tagged or otherwise identified as clean. A plastic cart contained 8 sterilized packages and next to those was a box of disposable cannulas. * Items in the anesthesia rooms were in unmarked Ziploc bags and 2 packages of “i-gel” were expired. The observed expiration dates were “2024-2” and “2023-9”. A disposable plastic wash basin was stored under the sink in the anesthesia room and a variety of items such as a feeding tube and bandage wrap. Damages to the walls were visible such as peeling drywall and gauges. 12.b. The SSM and the IPD acknowledged those findings during interview at the time of the observation. 13.a. During a tour of EVS on 06/26/2024 with the EVS Lead and the IPD beginning at 11:30, the following was observed: * The hospital’s linens for patient care were stored on open shelving located below ~ 6-8 water/drainage pipes that were ~ 4-6 inches in diameter and were running across the length of the room near the ceiling. Some of the linens were encased in plastic wrap, however, the majority of linens, including hospital gowns, blankets, and towels, were uncovered and open to airborne contamination, unregulated humidity and other contagions. The ceiling had open holes, an electrical wire hung down from a junction box, and other electrical lines crossed through and over the pipes. A layer of dust was visible on the pipes and top shelves; one pipe was labeled “Steam” and other pipes had wheel valves or lever type valves attached. There were gray, black and brown patches visible near pipe and hose wall and ceiling entries where the finishes were cracked and warped. It was unclear whether the discoloration, cracks and warping were caused by water damage or whether mold was present; neither the IPD nor the EVS staff had clearly visualized or evaluated those areas for IC risks. Cardboard boxes with visible dark residue on the the bottoms and sides were stored on the top shelves above the patient care linen and contained other housekeeping items such as “Disinfectant Cleaner Concentrate” and “Old Curtain Panels”. Some of the open areas surrounding pipes were filled with foam and other open areas, such as anchor screws in the ceiling, were left open, creating an entry point for rodents and insects. * A housekeeping closet had a stained floor sink with hoses hanging from the disinfectant dispenser into the sink and coiled near the drain. Near the floor sink was a cardboard box with visible moisture damage in which housekeeping items such as a large black plastic bag and 5 mops/brooms were stored. 13.b. In an email received on 07/08/2024 at 0823 the CSC wrote that the hospital had “No policy” for the storage of patient care supplies and “No policy” for the storage of equipment for patient care, clean or soiled. 14.a. During a tour of EVS maintained areas on 06/26/2024 with the EVS Lead and the IPD beginning at 11:30, the following was observed: * Throughout the hospital several plastic bottles filled with cleaning solution were visualized by more than one surveyor. Bottles were undated and unlabeled. Per the EVS Lead at the time of the observation, those bottles were cleaned and “changed out every Sunday, except if bottles were in a “locked” room. 14.b. During interview at the time of the observation the EVS Lead and the IPD confirmed those findings. Additionally, the EVS Lead confirmed there was no written protocol on how those secondary bottles of cleaning solution were labeled, dated, tracked, refilled or replaced prior to the expiration date or “Use By” date. 15.a. During tour of the ED on 06/25/2024 beginning at 1525 with the AC/ED NM, observations included: * At 1640, an ice machine was observed on a counter top next to a sink. The ice machine had white stains on the stainless steel backsplash below the ice chute. Rust and white grime was observed on the drain pan grill. A clear, flexible PVC drainage tube extended from the back of the ice machine through a hole in the counter into the cupboard space below the sink. The cupboard was opened and the ice machine drainage tube was connected to a sink drain pipe. The inside surface of the drainage tube section that was under the sink was discolored brown with darker brown and black speckled areas. 15.b. The observations related to the ED were confirmed with the AC/ED NM on 06/25/2024 during interview at the time of the observation. The AC/ED NM stated the ice machine was used to provide ice to patients and they did not know who was responsible for cleaning the ice machine. 16.a. Observations of the soiled utility room near inpatient Room 112 on 06/26/2024 beginning at 1400 with the AC/ED NM present revealed it was disorganized, cluttered, crowded, dirty and in disrepair. Examples included but were not limited to: * A visibly dusty, disorganized EVS cart with a sticker on it that read “Philips Cart” was observed. Items on the cart included a hand towel next to a dirty wadded up, knotted garbage bag, a dirty mop and other dirty floor cleaning supplies, two clear plastic containers that looked like “to go” food containers, a spray bottle laying on its side, and other items. * An electric wheelchair plugged into an outlet crowded between the EVS cart and metal counter and lower cupboards. * The metal counter was disorganized and cluttered with items that included a transfer board, foam pad with blue plastic cover, reacher/grabber tool, large battery, a “Home & Garden Sprayer” box, items that looked like wheelchair parts, and a tote that contained a wadded up yellow PPE gown, rubber mat, inflated cushion, and other items. * Below the metal counter, one of the lower cupboards had been removed leaving a large space exposing the wall and floor underneath the counter. Four wheelchair wheels were observed inside this space. The wall, which was shared between the “Soiled Utility Room” and adjacent “Clean Utility Storage” room, was in disrepair with areas of rough wall patch and caulking that had crumbled onto the tile floor. The wall had a large, unfinished jagged hole approximately 24x18 inches. The back of a metal door that had been installed on the wall inside the “Clean Utility Storage” could be seen through the hole. The metal door was not fully closed leaving a gap between the “Soiled Utility Room” and “Clean Utility Storage” room. * A hopper with yellowish-tan water in the bowl was observed with a folded up walker next to it on one side and other equipment wedged between it and the wall on the other side. * A sink and sink counter was observed with items cluttered and piled up on top including a folded up cardboard box, red rubber items in plastic bags, pink wash basin, splint parts, two IV poles, a portable oxygen stand, two garbage cans and other items. * Upper cupboards and shelves were observed with items inside and on top piled and arranged precariously and included but were not limited to cardboard boxes, sharps container, at least five large, round floor cleaning pads, a large foam positioning piece, a black garbage bag with fabric items inside, and other items and equipment. 16.b. Observations of the clean utility room near inpatient Room 112 on 06/26/2024 beginning at 1400 with the AC/ED NM present revealed it was disorganized, cluttered, dirty and in disrepair. Examples included but were not limited to: * An ice machine with a round, plastic wash basin on the floor behind it. The wash basin had dirt and whitish liquid stains inside and the purpose of the wash basin was not clear. Two drainage lines from the back of the ice machine fed into a rigid black pipe that led to an exposed floor drain. Water marks were observed on the floor at various places on the side and back of the ice machine near the pipe. It was not clear if the pipe had leaked, was leaking, or other water spilling or splashing had caused the water marks. A five-gallon bucket with thick brown grime inside it was observed between the ice machine and corner of the room. A metal door was observed in the wall near this corner. The wall was shared with the soiled utility room described in Finding 16.a. The surface surrounding the metal door had areas of uneven wall patch. The metal door was not fully closed leaving a gap between the clean utility room and the soiled utiltiy room. * Closets containing items that included a crumpled brown paper grocery bag labeled “Kids Clothing”, cardboard box overflowing with clothing items, crumpled up clothing items, cardboard boxes labeled “Free books”, boxes of BP monitors and scales, three boxes containing packages Abbott Covid-19 Ag Card rapid tests with one box containing packages with expiration date 11/16/2023, and seasonal items. It was unclear if items in the closets were clean or dirty. * Piles of disorganized, cluttered patient care equipment including IV pole parts, medical bed parts, crutches and other patient equipment and accessories. * On the handwashing sink counter, a container of Purell Advanced Hand Sanitizer with expiration “03/2023”. A shelf above the handwashing sink revealed two clear, plastic containers containing ground coffee with illegible handwritten labels on pieces of masking and painters tape that read “Decaf Coffee Opened [illegible, scribbled over date]” and “Reg Coffee [illegible date]”, a package of Rituals House Blend Decaffeinated Coffee, coffee filters partially covered with plastic, and a cooking thermometer. It was unclear if these items were clean or dirty. The cupboard under the handwashing sink was opened and the bottom surface had tan liquid marks, dark brown round and circular stains, and a spray bottle of Hepastat 256 Ready-To-Use disinfectant cleaner with no expiration date. A broom was observed leaning against the handwashing sink counter with a dust pan on the floor next to it. * Crumpled up white paper or tissue on the floor next to garbage can. * Dirty vinyl-like floor tiles and baseboard moulding. * A dirty ceiling vent. 16.c. The observations related to the soiled and clean utility rooms were confirmed with the AC/ED NM on 06/26/2024 during interview at the time of those observations. The AC/ED NM stated that some of the items in the clean utility room belonged to “Aidan Senior Living” who leases another part of the building. 17.a. Observations in OP Wound on 06/26/2024 at 1035 with the AC/ED NM and an RN present revealed a lack of clear separation between clean and dirty areas. Examples included: * Observations of an adjoined patient bathroom with shower revealed a 4-tier metal wire shelving unit with a vinyl, zipper-closure cover next to the right side of the toilet. There was no barrier between the toilet and shelving unit and the shelving unit cover was fully unzipped with the front of the cover draped over the top and back of the unit so that the front of the shelves and contents were fully exposed. The inside of the shelving unit had two cardboard boxes and approximately 19 shoe-box size plastic containers that contained dressing supplies for individual patients. Fabric incontinent pads and a pillow were stacked on top of the shelving unit. A red dust pan and hand-held broom were observed on the floor under the shelving unit. A folded brown grocery type bag and two cardboard boxes were observed next to the shelving unit between the shelving unit and the wall. The boxes had frayed edges and holes at the corners. One of the cardboard boxes was directly on the floor and the other box was on top of it. The cardboard boxes contained patient care items that were available for use including multiple individual boxes of Hollister ostomy supplies. A vertical shower bracket with three plastic clothing hangers hanging from it was observed on the wall to the left side of the toilet. It was not clear whether this space and items were clean or dirty. These cumulative observations reflected a lack of clear separation between clean and dirty spaces and patient items. 17.b. During an interview on 06/26/2024 at the time of those observations the RN who was present during the observations stated the supplies in the cardboard boxes were expired and needed to be “sent back” or disposed of. 18.a. Observations in OP Infusion on 06/26/2024 beginning at 1055 with AC/ED NM present revealed: * On the handwashing sink counter, a container of Purell Hand Sanitizer with expiration “03/2023”. * Near the entry door, a wall mounted hand hygiene dispenser with hand hygiene product inside that had expired “01/2024”. 18.b. The observations in OP Infusion were confirmed with AC/ED NM on 06/26/2024 during interview at the time of the observations. 19.a. Observations in OP Wound patient bathroom on 06/26/2024 at 1035 with AC/ED NM revealed: * A spray bottle with a manufacturer label that read “Secondary Container Label” and indicated it contained Hepastat 256 Cleaner was observed inside a cupboard above the toilet. There was no initial fill date, refill date, or expiration date on the bottle. * A spray bottle with a manufacturer label that read “Secondary Container Label” and indicated it contained Micro-Kill NQ5 One-Step Disinfectant was observed hanging on a grab bar next to the toilet. There was no initial fill date, refill date, or expiration date on the bottle. 19.b. The observations in OP Wound were confirmed during an interview with the AC/ED NM on 06/26/2024 at the time of the observations. The AC/ED NM stated the CAH did not have a process for dating secondary containers. 20. During tour of the Outpatient Rehabilitation Department on 06/25/2024 beginning at 1030 observations included: * A container of “Biofreeze” gel located on a counter had an expiration date of “01/2021.” * A container of “Aquasonic 100 Ultrasound Transmission Gel” located on a counter had an expiration date of 06/18/2024. * A bottle of “Purell Hand Sanitizer” on the counter in an OT treatment room had an expiration date of “08/2023.” * A container of “Avagard Instant Hand Antiseptic” was observed on an open shelf in the hallway just outside the outpatient “Therapy Services Check-In” door. It had an expiration date of 12/04/2022. The expiration date was clearly marked and evident on the front of the label. * A jar of “CeraVe Itch Relief Moisturizing Cream” in the Rehabilitation Department wound care room had an expiration date of “05/2024.” * Two bottles of liquid solution with “Micro-Kill NQ5 One-Step Disinfectant” labels had no lot numbers or expiration dates. * A bottle of solution with a label that contained the following information was on the counter in the Rehabilitation Department wound care room : “Hepastat 256 Secondary Container Label Disinfectant Solution.” There was no lot number or expiration date evident on the label or the bottle. * The OT treatment room counters and open cabinet shelves were disorganized and cluttered with a mixture of items that included: patient care supplies, food, eating utensils, mouthwash, a bottle of “Nutri-Calm Nervous System Support ... Dietary Supplement ... Tablets,” beverages, a plastic container full of white rice with a “Rice Bin” label on it, games, books, toys. It was unclear what items were clean and what items were dirty, and whether all of those items were for patient use or whether it was a mixture of staff and patient use items. Those conditions rendered those spaces and the patient use items not readily cleanable. Another counter had an unlabeled plastic container with an unidentified pill/tablet in it. 21. During tour of the Respiratory Therapy Department on 06/25/2024 beginning at 1220 observations included: * A bottle of household “Dawn” dishwashing liquid and a bottle of “Lavender & Kakadu Plum Hand Wash” were located at the handwash sink in the department. It was unclear if those had been approved by the IP and the IPC for use in the hospital. * The shelves in a storage closet in the department were cluttered and disorganized with a mixture of patient care supplies and non-patient care supplies that included holiday decorations, a sewing kit, a household coffee maker, and more. There was no separation of clean patient care supplies and the misc. household items, and the shelving was not readily cleanable. 22. During tour of the Imaging Department on 06/25/2024 beginning at 1510 observations included: * A bottle of liquid solution with “Micro-Kill NQ5 One-Step Disinfectant” labels had no lot numbers or expiration dates. * Cabinet shelves above the counters in the X-Ray room were cluttered and disorganized with patient care supplies and other items including an “Arthrogram 22GX3.5 Spinal” kit, a wicker basket, and an actual large animal extremity bone with a significant length and diameter and with evidence of discoloration and decay. Those conditions rendered those spaces not readily cleanable and did not ensure the integrity of the patient care supplies. * A wide and deep open space was observed under the sink in the X-Ray room. Evident only when the surveyor and staff bent down or crouched over to look into the space under the skin was observed an open box labeled “Coban” that had another open box labeled “Coban” inside of it. Inside of that box was a pink, single-patient use wash basin inside of which was a round, blue plastic bucket. The surfaces of the wash basin and bucket in particular were covered with a film of discolored dust and debris. Most significant was that over the bottom surface of the bucket was observed a thick, wet, semi-liquid substance or matter that was was grayish green in color with darker areas throughout. In addition another container pulled out from the space under the sink had a number of folded white towels, some which had become a beige color. * On the countertop next to the sink in the X-Ray room were observed long wedges for patient positioning. One of the wedges was not contained in the blue vinyl covering that others were. The gray, porous, rubber/foam type material had numerous areas of damage and degrading, and was not readily cleanable. 23.a. During a tour of the Dietary Department on 06/25/2024 with the DNSM, RD and NM beginning at 0940, the following was observed: * An employee coffee drink was on the same counter where patient food was prepped. * A plastic spray bottle containing a blue liquid and a masking tape label that reflected “Freezer Floor Cleaner”. When the DNSM was asked to identify the chemical in the bottle, the DNSM stated that the bottle was not correctly labeled and that it was “Windex.” There was no chemical name, open date, refill date or expiration date on the bottle. The DNSM later stated that the chemical was not Windex. * A plastic rectangular container in the food prep area contained several opened packages of undated gravy packets along with an unknown food item for use in patient food preparation. The container had visible residue and a metal clip on the bottom of the container where the gravy packets were being stored. It was unclear when the packets had been opened and no “Use By” date was noted. For example, one gravy packet reflected an opened date of “OP 06/20” and the unknown food item reflected “Open 12/15.” Both lacked the year. * An intermingling of food prep items and office supplies in a plastic rectangular container in the food prep area that contained labels, note pads, pens and other labeling supplies along with paper muffin liners for use in patient food preparation. * Next to the plastic rectangular container was a polished rock. Both were located on a shelf above the food prep area, posing a concern for the rock falling onto prepped patient food when the container with labels was moved from the shelf. * Two bottles of chemical test strips were next to a sink with an expiration date of “August 2023.” When the DNSM was asked what was tested with those strips, the DNSM stated they were used in the manual dish washing processes. * Several items were stored under the “steamer” approximately 4.5-5 inches above the ground. Items included: vinegar, Worcester sauce, honey and molasses. All of the containers were covered with a palpable layer of grease and grit. A 5 lb container of honey had a worn label containing the “Use By” date which was 80% illegible and a handwritten date of “OP 3/8”. There a second handwritten date of “2/19” on the honey container. The molasses container had a handwritten date of “R-10/19” and a manufacturer “Best By: 01/24/24” date. * The ovens and several other pieces of equipment below waist level had a visible and palpable layer of grease and grit. * The dry storage area contained several food items stored in the cardboard boxes in which the items had been shipped with visible residue on the outside of the boxes. * Dates on boxes and other food items, including refrigerated items, reflected a 2-digit date and it was not clear when food items were received, opened or whether the “Use By” date had passed. For example, a plastic container labeled “Panco” reflected “Date: 4/22” and “Use By: 10/22”. It was unclear whether these dates reflected “April 2022” and “October 2022” or whether the dates were meant to reflect “04/22/2024” and “10/22/2024”. * A temperature log near the dishwasher reflected “Required Wash Temp: 115 ... Required Rinse Temp: 120”. Recorded on the “Breakfast” temperature log for “June 2024” under “Wash Temp” (and 2 “Rinse” temps) for the following days in June were: - June “2 ...100” - June “3 ...100” - June “4 ...110” - June “7 ...100” - June “9 ...100 ... 115” - June “13 ...100” - June “14 ...110” - June “15 ...100” - June “16 ...100” - June “18 ...90” - June “19 ...90 ... 110” - June “20 ... [this was blank]” - June “21 ...100” - June “23 ... [this was blank]” - June “24 ...100” - June “28 ...100” (Three days after the date of the observation.) 23.b. During interview at the time of those observations the DNSM confirmed the findings. In regard to the dishwasher temperatures they were asked what the protocol was when the “Wash” temperature and the “Rinse” temperature were out of range. The DNSM stated that the temperature log form was out of date, and that the temperature requirements listed were for “a three sink manual dishwashing”. An updated copy of the dishwasher log was provided during the survey. It contained the same instructions and information. 23.c. Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness. Refer to Tag C-1231, Dietary policies on food storage, dating and labeling. 23.d. In an email received on 07/08/2024 at 0823 the CSC wrote that the hospital had “No policy” for staff food in patient care areas; “No policy” for dishwashing procedures or food temperatures; and “No policy” for cleaning patient food storage or prep areas. 24.a. During tour of the Med/Surg Unit on 06/26/2024 beginning at 1330 with the AC/ED NM, an upright refrigerator/freezer in the medication room containing patient food and beverages was observed and included: * Three clear plastic bags, each containing ~ 20-25 single use Gold-n-Sweet vegetable oil whipped spread, mayonnaise and ketchup packets with no evidence of expiration dates for those. * A single serving size container of butter pecan Magic dessert with a smudged, illegible expiration date. * Four ham and cheese sandwiches wrapped in clear plastic wrap with labels on each. The labels had spaces for recording “Item”; “Date”, “Time” and “AM” or “PM”; “Use By”, “Date”, “Time” and “AM” or “PM”; “Shelf Life”; “M T W TH F SA SU”; and “Emp.” and “Mgr:” It was not clear when the sandwiches should be used by and when discarded as the “Use By” and other information on the labels was incomplete and unclear. For example, labels on at least two of the sandwiches reflected: - “Item” followed by “Ham Cheese” - “Date” followed by incomplete date, “6/25” and no time. - “Use By” followed by incomplete date, “6/28” and no time. - None of the other information on the labels was filled out. - There was no other information that reflected when the sandwiches should be used by or discarded. * A partially opened brown cardboard food container had the same label as sandwiches above. The label on the container reflected: - “Item” followed by “Chix Salad” - “Date” followed by incomplete date, “6/24” and no time. - “Use By” followed by incomplete date, “6/27” and no time. - None of the other information on the label was filled out. - There was no other information that reflected when the contents of the container should be used by or discarded. 24.b. The observations related to food storage on the Med/Surg Unit were confirmed during interview with the AC/ED NM on 06/26/2024 at the time of the observations. 25.a. During tour of outpatient Reedsport Medical Clinic on 06/25/2024 at 1440 with the CM and MA, observations in a utility room revealed: * A corner handwashing sink was observed. The sink had a countertop on the left side that was approximately 3 feet long that extended from the left side of the sink to a wall, and a countertop on the right side of the sink that extended approximately 1 foot from the right side of the sink. * A small piece of blue paper was affixed to the wall with “Dirty” handwritten on it. Below the blue paper, a gray tote was observed inside a second tote that was clear with a clear lid and red hazardous waste symbol on the lid. The gray tote contained various instruments of which all were not in the open position. For example, a pair of forceps or scissors with black handles were in the closed position. There was no information on the tote or surrounding area that indicated when the instruments had been put into the tote, nor when or if they had been sprayed with enzymatic in accordance with the posted instructions and procedures described below at Findings 25.b. and 25.d. * An open push cart with patient care supplies on the top and bottom sections of the cart that included a box of Ortho-Glass splints and other items was observed in front of the counter where the “Dirty” paper was posted. It was not clear if those items were clean or dirty as it was unclear whether the “DIRTY” area included the countertop just below the blue “Dirty” paper, or other surrounding areas in the room. * Behind the sink basin on the left side of the sink rim, a spray bottle of Prepzyme Forever Wet Instrument pre-cleaner was observed. * On the counter behind the sink, an open blue caddy was observed with a liquid nitrogen dispenser and other items inside. It was not clear whether those items were clean or dirty and the items were directly behind the sink faucet creating the risk for splashing when the sink was in use. * On the right side of the sink, a small piece of green paper with “CLEAN” printed on it was affixed to the backsplash above the counter. * On the floor below and near the green “CLEAN” paper, a gray tank with a blue top was observed with an orange 8x11 piece of paper posted on a cabinet next to it that read “Warning! Liquid Nitrogen Please Do Not Touch”. A tan-colored, metal container with “BIOHAZARD” and a biohazard symbol on the lid was observed next to the tank. It was not clear if those items were clean or dirty as it was unclear whether the “CLEAN” area included the countertop just below the green “CLEAN” paper, or other surrounding areas in the room. 25.b. A document on hospital letterhead titled “Instrument Cleaning Instructions,” # 60100-003/0422 was observed taped to a cupboard above and to the left of the sink. It read, “Wipe off gross debris from instruments at point-of-use with 4x4 gauze. Do not soak ... Place contaminated instrument(s) from exam or procedure into bio hazard transport container with lid. Assure all instruments are ‘open’ when place [sic] in container to allow enzyme spray to touch all parts of the instrument ... spray Forever Wet on the contaminated instrument ... Reapply Forever Wet each time a contaminated instrument is placed in the transport bin ... Keep instrument(s) moist until transport to Central Sterile decontamination ... Dirty instruments should be taken to Central Sterile decontamination each day ...” 25.c. During interviews on 06/25/2024 at the time of the observations in the utility room the CM and MA provided the following information: * The CM and MA confirmed the instruments in the gray tote had been used and were contaminated. * The CM and MA stated they did not know how long the instruments had been in the gray tote. * The CM stated the instruments had been in the gray tote for “at least five days” because that was when the last procedure occurred. * The CM stated instruments that have been used are supposed to be taken to SPD daily. * The MA stated the instruments in the gray tote should have been taken to SPD the day they were used. * The CM and MA acknowledged the instruments in the gray tote were not taken to SPD timely after they were used as they should have been. 25.d. The P&P titled “Central Service - Sterilization - Scope of Services Provided” dated last revised 05/02/2023 reflected “Central Service is responsible for the processing, sterilization and quality control of all sterile supplies and equipment used in Lower Umpqua Hospital District.” Regarding outpatient Reedsport Medical Clinic, the P&P reflected “Individual departments will bring items to Central Service for processing ... All instruments, single packaged instruments and trays and other patient care items that must be sterilized prior to use, will be sterilized by Central Service ... Clinic staff will wipe gross debris off instruments at point of use with 4x4 gauze ... Clinic staff will spray dirty instruments with approved enzymatic spray ... Instruments should remain moist until they are transported to Central Service for sterile processing ...” The P&P was not fully developed as it did not specify when, after being used, instruments should be transported to Central Service for processing. 26. During tour of the outpatient Reedsport Medical Clinic on 06/25/2024 beginning at 1130 with the CM and MA, observations included: * At 1225, in the medication room a wall mounted hand hygiene dispenser containing Purell Hand Sanitizer Foam with expiration date “11/2014”. * At 1300, a container of Clorox Healthcare VersaSure Cleaner Disinfectant wipes with expiration date 06/16/2024. * A clear plastic E-kit with zip tie closures contained emergency medications. The E-kit was on the countertop approximately four inches from the handwashing sink and there was no barrier between the sink and E-kit creating the risk of splashing onto the E-kit when the sink was used. 27.a. Observations during tour of the outpatient Reedsport Medical Clinic on 06/25/2024 beginning at 1220 in the medication room revealed: * An open “Single Dose Vial” Bupivacaine HCl injection 10 mL with a small amount clear liquid inside was observed available for use in a cupboard above the handwashing sink. The manufacturer label stipulated, “Discard unused portion after initial use.” The vial had “5/30” handwritten in ink on it. There were no initials or other information regarding who had written “5/30” on the vial or who had opened the vial. The handwritten date was unclear as there was no information that reflected what the date meant. Further, the date was incomplete as there was no year. * An open “Single-use Vial” 4.2% Sodium Bicarbonate injection 5 mL with a small amount clear liquid inside was observed available for use in the same cupboard. The manufacturer label stipulated, “Discard unused portion.” There were illegible ink marks on the vial that looked like handwriting of which most had rubbed off. There was no date, initials or other information that reflected who had opened the vial or when it had been opened. * An open “Multiple Dose Vial” Xylocaine 1% injection 20 mL that was approximately half filled with clear liquid inside was observed available for use in the same cupboard. The label had “Exp 25” handwritten with Sharpie marker. There were no initials or other information that reflected who had made the handwritten entry and it was unclear what the entry meant, for example, expiration 2025 without a specified day/month, expiration on the 25th without a specified month/year, or other. There were no initials that identified the person who had opened or labeled the multi-dose vial and no BUD in accordance with the CAH P&P in Finding 27.c. below. 27.b. During an interview on 06/25/2024 at the time of those observations the MA provided the following information: * Regarding the single-dose vials of Bupivacaine HCl and 4.2% Sodium Bicarbonate, the MA confirmed the handwritten information was incomplete and illegible. The MA stated both vials were used during a procedure on 05/30/2024 and should have been thrown away after they were used. * Regarding the multi-dose vial of Xylocaine, the MA confirmed that the vial had been opened. The MA stated the handwritten entry “Exp 25” on the vial meant the Xylocaine expired “August 2025” and confirmed that date was not clear. The MA stated the date the vial was opened should be on the label and confirmed it was not. 27.c. Review of the P&P titled “Single-Dose and Multiple-Dose Vials/Containers,” dated effective 07/13/2022 reflected: * Regarding single-dose vials, the P&P reflected “Single dose vials and ampules used outside of an ISO Class 5 (Pharmacy IV hood) environment are only entered and used one time ... Open single dose vials are not stored for future use.” * Regarding multiple-dose vials, the P&P reflected: - “When used, MDVs are controlled in a manner that assures their sterility, chemical stability, and quality.” - “Open MDVs may be used up to the BUD ... The BUD for an opened or entered, i.e., needle-punctured MDV with antimicrobial preservatives is 28 days, unless otherwise specified by the manufacturer.” - “Label the container with the BUD based on 28 days from the date the vial is opened, the manufacturer’s expiration date ... whichever is shorter ... The initials of staff person opening and labeling the vial are included on the label.” 28.a. In regard to contracted laundry services a “Subordinate Agreement For Laundry Processing And Rental Services” dated as “Effective” 04/05/2022 was reviewed. Language in the agreement included: “Laundry Quality, Quality Assurance, and Specifications ... Supplier must maintain service levels and adequate Laundry quality that is: (a) reflective of high quality operations; (b) legally compliant in any state or local health and safety code grading survey and (c) meets Customer’s quality standards ... Quality Assurance. Supplier must ensure that the Laundry is processed in accordance with customer’s quality requirements ... Laundry Specifications. Supplier must perform the Services in accordance with the following standards: (a) Supplier must comply with all applicable federal, state and local laws, codes and regulations, with [TJC] requirements and must at a minimum comply with the recommended standards of the Textile Rental Services Association ... Supplier Processing Facility Inspections. Customer’s infection control representative, laundry contract administrator or hospital licensing or accreditation officials may conduct inspections of Supplier’s processing facility, delivery vehicles and Laundry Equipment to ensure that infection control and housekeeping practices are satisfactory ... Processing Guidelines. Supplier must process all Laundry in accordance with guidelines specified by [TJC], OSHA, the Centers for Disease Control and any other state or local regulations. If requested by Customer, Supplier must provide documentation of compliance with guidelines ... Monthly Inspections. Organize with Customer and conduct with Customer monthly inspection. Supplier must provide a report to Customer detailing the results of the monthly inspection ... Joint Review Committee. Supplier’s management staff will join Customer’s representative to form the Joint Review Committee. The Joint Review Committee will meet at a frequency required by Customer, and will review the monthly inspection reports Supplier provides to Customer. At each Joint Review Committee meeting, Supplier must take the minutes and provide them to Customer ... Laundry Program. Supplier’s management staff will work jointly with Customer’s representative to develop, implement and maintain a Laundry program which complies with all [TJC] standards.” 28.b. It was not evident what the “Customer’s quality standards” and “customer’s quality requirements” were, nor were the “guidelines specified by” the stated organizations delineated, referenced, or attached to identify all aspects of laundry processing and ensure compliance with the hospital CoP for Infection Prevention. During interview on 06/27/2024 beginning at 1015 at the time of review of services furnished under contract, arrangement or agreement with staff that included the CEO, CNO, and DQRM, the CEO indicated that evaluations of services furnished under contract, arrangement or agreement varied based on the type of service. Staff stated that the laundry services were evaluated by staff “recalculation of linen pounds and items returned” against the charges for the processing. They further confirmed there was no system in place at the time of the SA survey for inspections of the laundry processing facilities or other methods for evaluation of those services to ensure appropriate infection prevention practices but that a process was being developed. 28.c. Refer to Finding 1.b., the IPD statement that they had not reviewed the contract nor conducted an on-site Risk Assessment. 29.a. During interview with the Rehabilitation Director on 06/25/2024 beginning at 1030 they stated that pool therapy was provided for hospital outpatients at the local, public “Highland Swimming Pool.” The pool was located at the Highland Elementary School. A “Memorandum of Understanding” dated 12/16/2008 between Highland swimming pool operators and LUH was signed by a prior LUH Administrator. Review of the MOU reflected it contained no information related to pool inspections for water quality, infection prevention, or safety purposes. 29.b. During interview on 06/27/2024 beginning at 1015 at the time of review of services furnished under contract, arrangement or agreement with staff that included the CEO, CNO, and DQRM, staff stated the pool was inspected by a State agency but the hospital did not have documentation of that or of a system to ensure appropriate infection prevention and patient safety. 29.c. Refer to Finding 1.b., the IPD statement that they had not reviewed the contract nor conducted an on-site Risk Assessment.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 29708 44104 Based on observations, interview, review of infection control P&Ps, and other documentation, it was determined that the CAH failed to fully develop and implement infection prevention P&Ps hospital wide. Policies did not adhere to manufacturer’s instructions or nationally recognized standards in the following areas: * Dietary and Nutrition Services policy regarding the storage of patient food. * Policies regarding animals in the hospital were not fully developed or implemented and lacked key stakeholder input. * Hospital wide policies regarding the labeling of refilled chemical bottles were not clearly written. * TB Exposure and Control policies were not fully developed or implemented and were unclear. * Surgical Services policies regarding the disinfection of endoscopes and continuing education were not fully developed or implemented and were unclear. Findings included: 1. The policy titled “Labeling, dating [sic] & Storage” with “Effective Date: 5/28/2018” and last “Revised: [this was blank]” was reviewed and reflected: * “Approved By: [name of] CDM CFPP” * “Purpose To ensure the ... Nutrition Department is following all federal and local government guid lines [sic] on food safety.” * “Labeling and Dating ... All items must be marked with a received date to ensure proper food rotation ... All items that are removed from the original package must be marked with the received date and expiration date ... All food items that are made need a date of when it was made and a use by date ... Use by date must be 4 days after date it was made. The first day is the day it was made. (example Potato salad made on 6/26/2024 the use by day would be 6/29/2024.} [sic] ... All items that are open must have an open date and must be secured tightly.” * “When product must be received at appropriate times and at the recommended temperature [sic] ... Frozen products must be put away within 2 hours of of receiving it ... Dry goods must be put away with in [sic] 3 hours after delivery ... All items must be marked with a received date to ensure proper food rotation ... When putting away product you must follow FIFO9First in First out) [sic]”. * “All food items must be stored at least 6in about [sic] the ground ... Chemicals cannot be stored with food items ... All chemicals must be stored off the ground ... All products must be rotated by using FIFO.” * No references noted. The policy was unclear and not fully developed. For example, the policy lacked references and therefore it was unclear whether the policy was based on nationally recognized standards. Although the policy stated that food items “must be marked with a received date ... must be marked with a receive date and expiration date ... need a date of when it was made and a use by date ... must have an open date ... “, the policy did not specify a date format. The hospital did not fully implement its labeling and dating policy as food items were observed undated and stored less that 6 inches above the ground. Refer to Tag C-1208, Findings 23, that reflects observations noted during the Dietary and Nutrition Services tour and confirmation that Dietary and Nutrition policies had not been fully developed or implemented. 2.a. The policy titled “Animal Assisted Interventions” with “Effective Date: 08/18/2021” and “Review Date: (No Revisions)” was reviewed and reflected: * “Approved By: [unknown employee name & no corresponding title or credentials]” * Objective: To provide guidelines to ensure that animals allowed in the Lower Umpqua Hospital ... meet infection prevention and animal safety guidelines.” * “Definitions: Animal-Assisted Therapy (AAT) Dog: A dog that has been trained and evaluated to safely interact with individuals for a goal directed benefit in the use of therapy. Therapy dogs are required to ... pass a yearly review of skills and veterinary exams.” * “Animal Assisted Intervention Requirements and Eligibility ... Pass yearly veterinary exams ... Pass a yearly review of skills ... “ * “References: Adopted and revised from Banner Health Therapy Dog Program and Pet Visitation (2012) ... “A Protocol for Animal Assisted Therapy in a Midwestern Hospital” (2015) ... Occupational Therapy Capstones ... “ The policy was unclear and not fully developed. For example, the policy lacked infection control references, did not reflect whether the hospital considered recommendations by other professional sources such as the CDC, APIC or SHEA and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, whether the policy was consistent with other similar policies, or whether the policy had been evaluated by an interdisciplinary team of personnel involved in the use of AAT or animal visitations. The policy failed to describe who would be responsible for documenting, monitoring and tracking for compliance the “Animal Assisted Intervention Requirements and Eligibility”. Refer to Finding 2.c., competencies for the AAT dog did not reflect yearly skills review per policy. It was unclear who had approved the policy, including whether leadership had reviewed and approved all aspects of the process. 2.b. The policy titled “Pet Visitation” with “Effective Date: 05/02/2018” and last “Revised: 08/11/2022” was reviewed and reflected: * “Approved By ... Director Infection Control [and] ... Chief Nursing Officer” * Lower Umpqua Hospital .. acknowledges the virtue and importance of patient-pet contact in a healthcare setting and promotes an environment supportive of the patient’s needs while complying with Center [sic] for Disease Control ... guidelines on animals in health care facilities, to provide direction and guidelines for staff including required assessment, identification and restrictions to ensure compliance with Americans with Disabilities Act ... for animal visitation.” * “Definitions ... Therapy dog - A therapy dog has been through a formal training program with its owner for the purpose of visiting healthcare facilities and providing structured interaction with patients.” * Sixteen references were listed including: ADA.gov; CDC; and APIC. The policy failed to reflect key stakeholders, such as the Infection Control Committee, to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment, that the policy was consistent with other similar policies, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use animal visitation or AAT. It was unclear whether leadership had reviewed and approved all aspects of the process. 2.c. An undated document titled “Classes/exams taken with [AAT dog] and Handler [name]” was reviewed and reflected: * “Puppy behavior and management ... September 11, 2017 - October 9 [sic] 2017 ... Coastal Canine Center in Coos Bay”. * “Agility training and commands ... September 14, 2019 - Oct 19, 2019 ... Coastal Canine Center in Coos Bay”. * “Advanced handling for agility ... January 18th, 2020 - February 22, 2020 ... Coastal Canine Center in Coos Bay”. * “Canine Good Citizen Test ... May 25th, 2019 ... The American Kennel Club”. The information provided lacked documentation of the hospital’s AAT animal’s yearly reviews of skills for 2021, 2022, 2023 or 2024. It was unclear whether the AAT animal present in the hospital met all required yearly competencies for a therapy dog as described in policy, “Therapy dogs are required to ... pass a yearly review of skills ... “ 3.a. The policy titled “Employee Notification of Chemical Management and Application” with “Effective Date: 05-22-2019” and “Review Date (No Revisions)” was reviewed and reflected, in it’s entirety: * “Approved By: [unknown employee name & no corresponding title or credentials]” * “Purpose: To ensure the safety and well-being of Lower Umpqua Hospital District’s patients, employees, volunteers, and visitors when using new products, chemical, and pesticides.” * “Policy: - When a new product, chemical, or pesticide is used in an area of work, all employees need to be aware of the application of said chemical. - It will be the responsibility of the department manager to notify their staff of the usage of said materials. - The SDS (Safety Data Sheet) on said material will be immediately available in the work area. - The manager will go over the SDS sheets with staff to ensure staff know the physical and health hazards of the material being utilized in the work area. - It is the responsibility of staff members to notify their manager if they feel they have health issue [sic] with any product, chemical, or pesticide. All staff members can access our SDS in various ways including: Phone Number (see yellow SDS stickers in your department): [two phone numbers listed] Online SDS that can be accessed on all employee computer desktops Hard copies of the SDS sheets are located in admitting in the copy room.” The policy failed to describe labeling requirements for the transfer and filling of chemicals from its primary container to a secondary container and lacked written protocol on how those secondary bottles of chemicals were labeled, dated, tracked, refilled or replaced prior to expiration date or “Use By” date. 3.b. The policy titled “Hazard Communication Program” with “Effective Date: 05/22/2019” and last “Revised: 06/26/2024” [the second day of the survey] was reviewed and reflected: * “Approved By: [signature of CEO]” No title accompanied the signature. * “Objective: To ensure all affected employees understand the information concerning the dangers of all known hazardous chemicals used by LUHD and to protect LUHD employees and contractors who may come in contact with hazardous chemicals wile performing there job duties.” * “The written Hazard Communication Program ... will include ... Methods used to ensure that all containers ... are labeled, tagged or marked properly... Methods used to inform the employees of other employers of the labeling system used in the workplace.” * “The Hazard Communication Program will identify the following ... Workplace labeling system.” * “Responsibilities ... Ensure all containers are labeled, tagged or marked properly ... Material Manager is responsible for ... Contacting chemical manufacturers and/or distributors to obtain SDS and secondary labels for hazardous chemicals used or stored in the workplace ... Department Managers are responsible for ... Ensuring all chemicals in the departments are labeled properly, including secondary containers ... Employees are responsible for ... Becoming familiar with container labels ... Notifying the supervisor of torn, damaged or illegible labels or of unlabeled containers ... “ * “Labels and other forms of warning ... Chemicals transferred to secondary containers in the workplace must also be appropriately labeled ... When a chemical is transferred from the original container to a portable or secondary container, the container will be labeled, tagged or marked with a GHS label containing the following information: product identifier, signal word, hazard statement(s), pictograms(s), precautionary statement(s), and the name, address and telephone number of the chemical manufacturer, importer or other responsible party. *Include the lot number ad expiration date of chemical on the secondary container.” * “References: Approved by LUHD Board of Directors, June 26, 2024” 3.c. During an interview with the CNO on 06/26/2024, they stated that the phrase “*Include the lot number ad expiration date of chemical on the secondary container” was added to the policy just prior to the governing board meeting on 06/26/2024. The previously revised policy failed to include specific information about the need for an expiration date on secondary containers. 4. Refer to Tag C-1208, Findings 4.a., 4.b., and 4.c., that reflects TB screening policies were not consistent with nationally recognized standards. Employee screening policies were not fully implemented. A TB Risk Assessment upon which the hospital’s TB screening policies, and a TB Exposure and Control Plan should have been based, was not fully developed or implemented; a final hospital-wide Risk Determination had not been determined per CDC recommendations and nationally recognized standards. The hospital stated that a TB Exposure and Control Plan, per CDC recommendations and nationally recognized standards, had not been developed or implemented. 5. Refer to Tag C-1208, Findings 6 through 12, that reflects Surgical Services policies that were not fully developed, were unclear, and not fully implemented in accordance with manufacturer’s instructions and nationally recognized standards.”

“DISCHARGE PLANNING EVALUATION CFR(s): (2) A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-CAH services, including, but not limited to, hospice care services, post- CAH extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 08621 Based on interview, review of 1 of 1 medical record reviewed for discharge planning (Patient 18), and review of the DP P&P, it was determined the discharge planning evaluation and efforts were not complete, coordinated and effective, and did not incorporate consideration of this houseless patient’s complex discharge planning needs for caregiver supports and resources in their temporary place of residence in the community. Findings include: 1. Review of the findings that follow from Patient 18’s medical records reflected that discharge planning for this patient was a complex and challenging process. The patient primarily self-directed their discharge planning, had a strong desire to be in setting where they could self-direct their activities and life, and was opposed to facilities for reasons that included they would not allow smoking. The patient did not have a permanent residence, did not have family support in the area, and did not have a guardian or legally appointed representative. The hospital’s DP worked extensively on the patient’s discharge plans and had actively attempted to locate a facility residence for Patient 18 but none would accept the patient. However, it was not clear that efforts were exhaustive and coordinated effectively with the State/local APD CM, and it was not clear what the patient’s actual financial, State insurance/benefits, VA benefits, and other related resources were to provide for their access to services for housing, living, and care. Although the patient had expressed to a physician on 10/24/2022 that they were “interested in caregivers,” there was no indication in physician notes or discharge planning notes for these hospitalizations that staff had approached the patient or the State/local APD CM with the idea of discharge back to a hotel/motel, an apartment type residence, residential living, or low-cost housing, with the services of non-skilled in-home care services or other community and caregiver supports. 2.a. Review of Patient 18’s medical record reflected that on 10/20/2022 Patient 18 was brought to the ED by ambulance from a hotel/motel where they were living, and was in observation status until 10/24/2022 on which day they were admitted as an inpatient. They had a primary diagnosis of Failure to Thrive and were discharged to a shelter on 10/28/2022. 2.b. Physician notes and documentation included: *The ED physician note reflected “Patient brought in by ambulance from a hotel where [they were] living, found to be sitting in [their] own diarrhea for unknown amount of time ... patient recently signed [themselves] out of [SNF/NF] despite recommendations against this. [They have] been living in a hotel since that time ... 80-year-old ... with a history of CKD, coronary artery disease, peripheral vascular disease, alcohol abuse brought in by ambulance from [their] hotel room ... On exam, [the patient] is nontoxic-appearing but is in distress. [They have] severely excoriated skin of [their genitalia] and buttocks ... patient was previously living at [SNF/NF] but left against advice of providers choosing instead to stay in a hotel room ... Patient has admitted today that [they are] unable to care for [themselves] and does need to be placed. [They] requested [they] be admitted back to [SNF/NF] but [was] declined as the patient apparently was quite difficult and even smoked alcohol [sic] into the facility which puts [them] at risk of losing their license. Our discharge navigator is aware of the situation and states that arrangements are attempting to be made for placement of this patient ...” * The observation H&P dated 10/20/2022 reflected the physician’s “Assessment and Plan” to include “Failure to thrive in adult ... admit to observation, discharge planning. PT, OT eval.” * Physician notes dated 10/21/2022 reflected “Moderate agitation ... Nursing reports that [Patient 18] refuses care and medications from time to time. Physical therapy reports that [the patient] was able to transfer safely but refuses to use walker ... Reluctantly working with staff. Difficult social situation as patient left AGAINST MEDICAL ADVICE from rehab center and is living in a motel but unable to care for [themselves] including getting back and forth from the bathroom.” * Physician notes dated 10/22/2022 reflected “Behavior bit better today. Not refusing [their] many medications and treatments ... We will continue [patient] as observation with goal of returning back to motel under self-care.” * Physician notes dated 10/23/2022 reflected “Making slow and steady improvement as anticipated. Tolerating Bactrim for UTI ... Behavior is generally improved ... Doing well in supported system here in the hospital. We will have discharge planning and Adult Protective Services continue to work with [them] to see if [they] would ever consent and find a bed at an assisted living care facility or foster home type setting.” * Physician notes dated 10/24/2022 reflected “... pain from [patient’s] back seems to be persistent and moderate to severe. [They give] history of all fall [sic] in [their] motel room. Concerned that [the patient] may have a fracture. Will obtain CT scan of lumbar spine and make further determinations pending results ... Patient continues to be bedbound. Has difficulties with transfers and ambulation. Physical therapy and Occupational Therapy should work with patient again today. We will see if [they have] any more rehab potential since [they have] been on antibiotics for urinary tract infection. Also improving mentation. Consider adjusting to inpatient.” * The inpatient admission H&P dated 10/24/2022 reflected the physician’s “Assessment and Plan” to include “Failure to thrive in adult ... The patient was unable to care for [themselves] in the face of fall with worsening back pain and diarrhea. Per [SNF/NF] was fairly independent with a scooter, and would be most appropriate in assisted living facility. [Patient] is interested in caregivers. Currently [patient] resides in a hotel where ... cannot use toilet because [their] scooter will not fit into the bathroom. The plan is to improve [patient’s] mobility to where [they are] again independent with [their] transfers. Will bring scooter from [hotel room].” * Physician notes dated 10/25/2022 included “... Discharge planning pursuing assisted living placement ... Extensive imaging negative for any acute fractures ... Encourage mobilization, out of bed to scooter for all meals. Placement pending.” * Physician notes dated 10/26/2022 reflected “Patient is frustrated with [their] living situation. [SNF/NF] believes [patient] needs assisted living facility. The patient tried living independently but learned a [hard way] that [they need] assist.[sic] [They are] agreeable to go to assisted living facility. [They are] tired of being in the hospital. [They were] not allowed to go out and smoke which is somewhat frustrating to [them]. [Patient] does not want nicotine patch.” * Physician notes dated 10/27/2022 reflected “[Patient] was slow to improve with [their] pain and mobility ... was started on antidepressants/ antianxiety medications with risperidone and Effexor and subsequent labs showed significant hyponatremia 124. Sodium level quickly improved with gentle IV fluids and free water restriction. The new psych meds felt to contribute and were discontinued. [Patient] is now transferring independently out of bed to [their] scooter ... Patient however is not very happy ... is grumpy and frustrated about [their] situation ... awaiting placement to a assisted living facility. No other new complaints.” * The physician Discharge Summary dated 10/28/2022 reflected “Plan: The patient is awaiting for assisted living facility placement. [They] will have to follow-up with [their] [APD CM]. In the meantime ... is being discharged to gospel mission [shelter]. Hospital Course: This is 80-year-old [patient] with extensive past medical history, prior long-term resident of [SNF/NF] until about 3 weeks ago when [they] decided to try living independently and moved to a hotel. [They] left [SNF/NF] without adequate support/assist, and moved into a hotel room with no access to a toilet on [their] scooter ... was admitted with acute on chronic low back pain, after reported fall complaining of diarrhea and severe skin rash/burn in perineal area ... was given gentle IV fluids and extra painkillers ... was slow to improve with [their] pain and mobility ... was started on antidepressants/antianxiety medications with risperidone and Effexor and subsequent labs showed significant hyponatremia at 124. Sodium level quickly improved with gentle IV fluids and free water restriction. The new psych medications felt to contribute and were discontinued. The past couple of days the patient is doing well ... eating very well ... able to independently transfer to [their] scooter ... has been a bit upset-feels like a prisoner because ... is not allowed to go outside to smoke ... appears at [their] functional baseline. [SNF/NF] recommended assisted living facility. Referrals were sent but there is no immediate opening. Patient has no further indications to justify hospital stay ... was given couple of options with local hotels, but with limited budget ... chose to go to the [shelter]. This is suboptimal situation, and the patient is at high risk for readmission ... will need a close follow-up from [their APD CM] as an outpatient for ongoing assistance with placement. I asked our discharge planner to alert them about the discharge. [Patient] is mentating well, and appears to be able to make [their] own decisions. [They] will be discharged with all necessary medications. Follow-up appointment is arranged with [their] PCP in about 2 weeks.” 2.c. The hospital’s DP notes and documentation included the following: * On 10/20/2022 at 1545 the DP documented that “Patient presented to ER. It is reported that [they] recently checked [themselves] out of [SNF/NF] a few weeks ago. Called [SNF/NF] and confirmed, the declined accepting [them] back. Call to Roseburg APD ... It was requested that I call back and speak with [APD CM]. [They report] that they are aware and that there is a plan in place, [APD CM] will give further details.” * On 10/20/2022 at 1553 the DP documented that “Call to [APD CM], left voicemail requesting return call and if unable to reach this RN to call ER and speak with nursing. Will provide nursing a report.” * On 10/21/2022 at 1008 the DP documented that “Call to [APD CM] with the Roseburg office who is interim until a permanent CM is hired and assigned for the local area. If the Roseburg office is called, you will be directed to the CM of the day, so [they recommended] calling [the] direct line ... [They reported] that patient left AMA from [SNF/NF] on 10/8/22 and paid for 1 month at motel. [Out of area family member] is [patient’s] financial rep and manages [their] Income Cap Trust, it is reported [they make] a significant amount of income. [Family member] has an ill spouse and is unable/willing to assume any further responsibilities and if the case closes will remove [themselves] from providing further assistance. [APD CM] was having difficulty making contact, [they] reached out to the [family member] to encourage patient to talk .... regarding care. [Their] initial contact was on 10/10/22 and reports during this exchange [they] “sounded reasonable”, refused care giving, refused placement and further services so a form was mailed for [them] to sign to close the case. Initial contact to APS documented on 10/14 and again on 10/19. [APD CM] called [family member] and requested [them] to encourage patient to allow for a visit on 10/20 to discuss care option. [APD CM] reports that [they] and a trainee arrived at the motel at approximately 12:07. [They were] yelled at for waking [the patient] up ... reports that [they] opened the door, [patient] was dressed and In [their] chair, opened the door and wheeled [themselves] by with a cigarette to the smoking section. [Patient] reported that [they] had not yet signed the form closing the case [and] reported being “angry” with [SNF/NF]. [They] reported intention to continue to stay at the motel but the worker reported to [them] that motel will not be allowing [them] to extend [their] stay. At this point [they were] agreeable to go back to [SNF/NF]. At the time of my call yesterday [they] had not had a chance to reach out to [SNF/NF] about the possibility, updated [them] that they decline to accept [them] back. [APD CM] reports patient refuses to move out of the area although [they don’t] have any family or natural supports in the area with [their] only tie being [their] PCP. [APD CM] offers to call Timber Town in Sutherlin to inquire about availability; although reports last week they did not have any and is not certain [patient] meets all specifications for this facility. [APD CM] reports that [patient] is ‘probably not completely cognitively intact’. [They] will discuss this case with APS and discuss consideration for public guardianship but is unsure if there is enough to support a case for this ... reports plan to request case aides to start making calls to facilities regarding availability and requests and to be notified of discharge.” * On 10/25/2022 at 1129 the DP documented that “Met with patient who is alert and oriented x’s 3 ... is pleasant and cooperative ... reports leaving [SNF/NF] and moving to Fir Groove so [they can] do [their] own cooking ... was placed in a room at Fir Groove that had a microwave, hot plate and air fryer ... reports that [they were] ‘doing fine’ until [they] sustained a fall out of ... wheel chair which led to an ER visit and discharged back to the motel according to [their] report. [Patient] reports then having incontinence of loose stool which [they] could not independently manage and ... was unable to access the bathroom in [their] room. [Patient] reports prior to the incontinence, [they were] utilizing the restroom of the restaurant across the street daily for BM’s and then urinals in [their] room. It is reported that the Motel is unwilling to allow [patient] to return, patient reports that [they are] aware. When asked [their] plan for discharge, [they state] ‘I want to leave, gather [my] things and figure out my next steps’. Instructed on discharge placement options available with [their] LTC Medicaid benefit. [They are] willing to consider ALF’s, plan to call regarding availability. [They report] being told that Budget Inn by Safeway has kitchenettes and is ADA accessible, but has not called to verify. Discussed options to retrieving [their] power chair, [patient] suggests dial a ride, will call today. [Patient] instructs ... will need [their] cell phone charger and ... TENS unit controller. [Motel manager] from Fir Groove Motel calls regarding what to do with [patient’s] belongings. Asked [motel manager] what do they typically do with residents belongings, [who] reports they store them for up to 90 days. Instructed that [patient] is in need of [their] charger, TENS controller and power chair. [Motel manager] goes into room and is able to locate phone charger and TENS controller, this RN agrees to retrieve these items on behalf of the patient from the front desk. Upon arrival to the Fir Groove front desk, items are placed into a clear plastic bag. [Motel manager] includes a sealed envelope with patient refund which [they have] labeled with refund amount of $150.00 ... Upon return, notified [first name] RN. We brought contents of the bag to the patient room, cell phone charger, TENS controller and signed sealed envelope ... Items will be placed in the safe for keeping until discharge. Call placed to [APD CM] and left voicemail requesting a call back. Patient has had multiple staff visitors from [SNF/NF], it may be worth discussing barriers to readmission and to see if they are willing to reconsider.” * On 10/25/2022 at 1325 the DP documented that “Assisted patient in calling Mast Bros. to arrange for electric wheel chair to be brought to LUH. Patient self paid for this service. Call to [motel manager] and notified [them], [they] will have chair ready for pickup in addition to charging cord. Notified nursing, security and registration department.” * On 10/25/2022 at 1356 the DP documented that “Call from [APD CM]. [They report] having reached out to the following facilities and left voicemails and awaiting responses: Regency, Life Care, Avamere CB. Avamere New Port does not have beds available. Instructed that patient would be appropriate for an ALF. [They report] leaving a voice mail with Ocean Ridge. This RN left voice mail at the following ALF Bay Side Terrace. Inland Point does not have any Medicaid rooms available. Pacific View in Bandon does not have rooms today but will have later this week and is willing to review packet.” * On 10/25/2022 at 1452 the DP documented that “Faxed referral to Pacific View for review.” * On 10/26/2022 at 0946 the DP documented that “Call to Budget Inn x 3, no answer. Call to City Center Motel, no answer.” * On 10/26/2022 at 1232 the DP documented that “Nursing notifies this RN that there is a [person] who reports [they have] collected patient’s items from the motel and is inquiring what [they] should do with them ... Inquired regarding the amount of items, [they report] fills up the back of [the] van. Instructed [them] that I spoke with the motel yesterday, and that they reported they were required to hold on to the belongings for 90 days ... we are unable to store all [the patient’s] belongings and that other arrangements will need to be made ... met with [first name] Quality and Safety RN and provided report ... to patient room so they may work on a plan. Patient requests to speak with [MD] who allows patient to go out to van to retrieve personal items. This RN accompanies patient and ensures the amount and appropriateness of items selected.” * On 10/26/2022 at 1528 the DP documented that “Voice mail left for Pacific View ALF admissions.” * On 10/27/2022 at 1214 the DP documented that they “Called the following facilities: Shore wood senior living - this is independent living and do not accept Medicaid Spruce Point- No Medicaid rooms available Inland Point- No Medicaid rooms available Bayside Terrace - Referral faxed ... Ocean Ridge - Referral secured email marketing@oceanridgeseniorliving.com Pacific View - declined Budget Inn called and the bathrooms are not ADA accessible ...” * On 10/27/2022 at 1818 the DP documented that “Bayside Terrace called and declined due to level of care.” * On 10/28/2022 at 0946 the DP documented that “Updated clinicals faxed to Bayside Terrace. Call to Timber Ridge Independent Living Apartments and left a voicemail with inquiry on availability. Call to Ocean Ridge and left message requesting a return call.” * On 10/28/2022 at 1241 the DP documented that “Met with patient who is alert and oriented. Discussed discharge today. Provided options of Gospel Mission or Motel. Instructed that a bed at the Mission is not guaranteed, [they have] to arrive by 4 and complete an assessment. Provided information that regarding [their] transportation benefit through [their] OHP, will give [them] a brochure. [Patient] requests contact information for [their] state case manager, will provide [their] name and phone #. Call to the Mission, they request [they] call them directly, will provide [them] the phone # for [them] to call.” * On 10/28/2022 at 1305 the DP documented that “Handed off the following patient information to [their] discharging primary RN: brochure Ridesource brochure, copy of [their] trillium card, list of Reedsport/Coos Bay/[North Bend] hotels, Resource guide and [their] APD CM contact information. Went to follow up with patient if [they] called the Mission, currently [they are] on the phone with Roseburg DHS office.” * On 10/28/2022 at 1420 the DP documented that “Call from ... Roseburg APD. Provided report and anticipated discharge today with disposition pending patient’s decision. [They report] a new [APD CM] has been assigned ... Will provide this contact to patient.” 2.d. The patient signed their post hospital discharge instructions on 10/28/2022 at 1300. 3.a. On 11/04/2022 Patient 18 was brought to the ED by ambulance from a hotel/motel where they were living. On 11/05/2022 they were admitted as an inpatient. They had a primary diagnosis of “prostatic abcess” and were discharged to a hotel/motel on 11/10/2022. 3.b. Physician notes included: * The ED note dated 11/04/2024 reflected the patient presented with a primary complaints of constipation and anal “burning.” The physician wrote that the patient “resides at hotel and has been kicked out not welcome to come back, [they have] a motorized scooter apparently it is [only hotel] that will accomodate ... [they] will have to go someplace else such as Coos Bay or Eugene to find a hotel that will accept a scooter ... patient is awake alert conversant moves all extremities [they are] wheelchair-bound no acute gross focal deficits ... somewhat ‘grumpy’ which is the reason [they were] expelled from a hotel. But is independent and does attend to ][their] daily needs independently ... no acute psychiatric process identified.” * The inpatient H&P dated 11/05/2022 reflected “... homeless [person] who is wheelchair dependent and chronically incontinent of urine and stool for many years (unknown reasons per pt report). [They have] most recently been living at the Best Western Hotel but ... reports that [they were] ‘kicked out’ but cannot say why [they were] asked to leave ... reports that [they have] ‘plenty of money’ and has been paying [their] bill ... states that [they are] not welcome at the [shelter] due to being incontinent ... presented to the ED with c/o rectal and lower abdominal pain ... was found to be constipated and was manually disimpacted and given enemas which resulted in stool evacuation but ... continued to have pain and discomfort in the rectal area ... also c/o chills and subjective fever prior to admission ... underwent a CT abdomen/ pelvis and was found to have a prostatic abscess of 3 x 2.3cm ... has been admitted for antibiotic coverage. Pt reports [they haven’t] been hungry for about one day ... denies n/v ... refused to eat here today ... has had a subjective fever and pain when trying to have a BM ... denies dysuria or hematuria ... denies flank pain. Denies soa or cough over baseline ... does have chronic DOE and cough productive of gray sputum ... is a smoker x many years and currently smokes about 10 cigarettes daily ... has a hx of heavy alcohol abuse and reports [they] still [drink] ‘when I can get it’ ... is not forthright when [their] last drink was. Denies any problems with alcohol withdrawal syndrome, shakiness or seizures. Denies any use of illicit drugs. Denies headaches, sore throat, change in vision. Denies chest pain or pleurisy. Pt is somewhat irritable and has a hostile attitude ... reports ‘I’ve answered all of these questions before, I’m hurting and need some pain medicine’ ... Will ask discharge planning to see [patient] to help with disposition when [they recover].” * Physician notes dated 11/07/2022 reflected that “Patient reports that [they] ‘hurts all over’ ... is asking for [their] norco to be increased to 10mg q 4hrs ... reports that [they have] had significant back pain plus incontinence for many years following a lumbar fusion surgery ... wants to go live at [SNF/NF] again but they refuse to take [patient] due to ... alcoholism and combative behavior ... has been staying at the local Best Western but now ... reports if [they return] there [hotel] will have [them] arrested for trespassing [because they were] yelling at the housekeeping staff for not helping [them] clean up after [they] had some incontinence. No n/v. No f/c. Reports soa and cough are at baseline. Denies chest pain or pleurisy. Denies dysuria or hematuria. PT has been consulted but they have not yet seen [them] today ... Pt appears to be doing well ... does not appear septic and is afebrile here ... leukocytosis has improved ... is tolerating po and is taking oral cipro. I am concerned about [their] compliance if [they discharge] ... apparently is homeless and there is no good option at this point for long term care or an assisted living situation ... apparently is abusive and none of the local facilities will take [them]. I placed a call to [MD] in Medford--[their]facilities are short staffed and cannot take [patient]. Also placed a call to [another MD] who is medical director of several long term care facilities--await a call back. Will reach out to [their] APS social worker to see if there are any further options * Physician notes dated 11/08/2022 reflected that “Patient is scooter dependent at baseline ... is at [their] baseline level of functioning per PT report ... is being considered for placement at two facilities in Medford ... reports [they are] willing to move there for long term care in assisted living.” * Physician notes dated 11/09/2022 reflected that “Patient reports that [they are] feeling well today ... abdominal pain resolved after [they] had a large BM ... ate well today. Reports [they plan] to go live in a hotel again tomorrow [because] none of the assisted livings in the area will take [them].” * The physician Discharge Summary dated 11/10/2022 reflected 80 year old homeless [patient] who is scooter dependent and chronically incontinent of urine and stool for many years due to a previous lumbar injury and surgery. [Patient] has chronic back pain and has a spinal stimulator in place. [They] also [have] a history of heavy alcohol abuse and has been belligerent and abusive to others which has caused [them] to be unable to be admitted to any of the local care facilities ([they] did live at [SNF/NF] previuosly [sic] but is unable to be readmitted there due to [their] verbal abuse of staff members) ... presented back to the ED c/o of rectal pain. [Patient] was found to be constipated and was disimpacted but continued to have ongoing pain and CT scan revealed a prostatic abscess. The pt was admitted for ongoing management. The pt was initially started on iv antibiotics. [Patient] did well without signs of sepsis or severe infection ... was able to be transitioned to po antibiotics ... was eating and transferring to [their] scooter at [their] baseline. [DP] did attempt to help [them] secure a new living situation but due to [their] previous abusive behavior, this was unable to be accomplished. [Patient] was discharged in good condition and the [DP] helped [them] secure transport to a hotel in Coos Bay. [Patient] is asked to f/u with [their] PCP within 1-2 weeks and [their] antibiotics were electronically sent to the pharmacy downstairs at LUH to enable [them] to easily pick them up. 3.c. Discharge Planner notes included: * On 11/08/2022 at 0948 the DP documented “Call to Roseburg VA, spoke with [staff] in eligibility who reports patient is not located in the system which looks nationally. Voicemail left for [APD CM] requesting a return call.” * On 11/08/2022 at 1249 the DP documented: “Referrals sent: Bayside Terrace [Phone and Fax numbers] New Friends ALF [Phone and Fax numbers] Ridge View/Medford [Phone and Fax numbers] Laurel Pines [Phone and Fax numbers] Patient is agreeable to any ALF.” * On 11/09/2022 at 0950 the DP documented “Call from New Friends Florence, unable to accept.” * On 11/09/2022 at 1230 the DP documented “Voice mail left for [APD CM] x’s 2. Call to Laurel Pines ALF, no answer or ability to leave a VM x’s 4. Call to Ridgeview ALF and spoke with [staff]. [They report] plan to reach out to [staff] in admission for decision and someone will call this RN back. Bayside Terrace called and they currently do not have any Medicaid availability. Met with patient to discuss ... plan and update on status of referrals to ALF. [Patient] is interested in going to [North Bend/Coos Bay] to seek a hotel, provided [them] a list of hotels for the area. [Patient] inquires regarding transportation; instructed that ... Ridesource provided information that if patient is being transported from Reedsport to another city they could arrange wheel chair [sic] transportation. [Patient] inquires if that benefit will work for [their] upcoming MD appointment, call to Ridesource and confirmed that service from out of the area to Reedsport will be covered. Call to Ridgeview ALF, left message. Another call to Laurel Pines left message requesting a return call.” * On 11/09/2022 at 1641 the DP documented “Contacted Lone Oak ALF, they currently do not have Medicaid availability.” * On 11/10/2022 at 1535 the DP documented “Met with patient who is alert and oriented. [Patient] has secured a room at the City Center Motel. Transportation arranged through Ridesource for pickup at 1pm. Transportation for [their] DFHC f/u appt on Monday arranged with Ridesource for 8:30-9am pickup at the motel. They will provide return transportation. In large print typed out Monday’s ride information to include p/u time and the phone # [they] can call Sunday to confirm. Notified patient, provided typed ride info and scanned copy into chart. Printed off VA eligibility application and form to request discharge paperwork. Called the phone # on the application that indicates they provide support if the veteran requires assistance for inquiry. There is not a physical location to go for assistance. They can assist over the phone. [They] recommended the patient reach out to any veteran service organization with inquiry if they provide support. Partially filled out the application. Assessed if patient would like to complete the application with my assistance, [patient] declined ... reports plan to come and see me on Monday. Provided a handout for VA Homeless support. Spoke with [APD CM] and provided update on plan. [They report] that [they have] reached out to 25 facilities and no acceptance. [APD CM] reports that the case has been escalated to the complex care coordinator. APD will continue to seek placement opportunities.” * After the patient’s discharge, on 12/02/2022 at 1607 the DP wrote that “Spoke with [Person’s name] with Senior Service who reports making contact with the patient yesterday. [They were] able to provide the patient with [their] APD CM’s contact information and was present while [patient] called [them]. [They] reviewed the APD notes and they indicate that [patient] was still residing at the City Center Hotel until at least 11/16/22. [They report] that [patient] states [they] left because [they] ‘hated that place.’ [Person with Senior Service] reports plan on making an APS report. [Person with Senior Service] went to follow up with the patient today at approximately 2pm in front of Safeway where [patient] was sleeping. [They] inquired if [they were] ready to ‘look at somewhere to go to get out of the weather’? [Patient’s] response was telling [them] to ‘leave [me] alone and to go away!’” 4. Review of the one and one-half page “Discharge Planning” P&P in effect in 2022 revealed that it was generic and broad in nature. It primarily referenced “planning for the home care environment.” It lacked reference to evaluation of what the patients’ post-hospitalization location might be, including what “home care environment” might mean for a houseless individual or someone with no permanent residence. It lacked lacked reference to evaluation of patient’s financial resources and governmental/insurance benefits and supports. It lacked reference to coordination of efforts with governmental/insurance agencies/companies. It lacked reference to evaluation of patients’ needs for services of both skilled and non-skilled post-hospitalization providers and community organiziations and agencies. The only post-hospital service it referenced was for medical equipement. It lacked reference to management of complex and complicated discharge plannning situations. 5. During interview with staff that included the DQRM, NM and DP on 07/01/2024 beginning at 1400 at the time of the review of Patient 18’s medical record, they stated that the DP at the time of Patient 18’s hospitalizations was no longer employed with LUH, and that DP assessments were not complete.”

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 08621 Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient’s rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights delineated above in this CFR 485.645(d)(1). Findings include: 1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights. 2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights.”

“ADMISSION, TRANSFER, & DISCHARGE RIGHTS CFR(s): Admission, Transfer and Discharge Rights (§483.5 definition of transfer & discharge, §483.15(c)(1), (c)(2), (c)(3), (c)(4), (c)(5), (c)(7), (c)(8), and (c)(9) of this chapter). “ §483.5 definition of transfer & discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. “ §483.15(c)(1) Transfer and discharge-(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. “ §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident (B) Resident representative information including contact information. (C) Advance Directive information. (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals, (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2), as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. “ §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii)Include in the notice the items described in paragraph (c)(5) of this section. “ §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii)Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. “ §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. “ §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. “ §483.15(c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.70(l). “ §483.15(c)(9) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5) are subject to the requirements of §483.10(e)(7) and must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part’s locations. This Standard is not met as evidenced by: 08621 Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient’s rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights related to admission, transfer and discharge delineated above in this CFR 485.645(d)(2). Findings include: 1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights. 2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights. 44104”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 08621 Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient’s rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights related to freedom from abuse, neglect and exploitation delineated above in this CFR 485.645(d)(3). Findings include: 1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights. 2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights. 44104”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (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 at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)). Findings include: On 6/25/2024, during record review between 9:00 am and 10:30 am, the facility failed to develop and implement EP policies and procedures, based on the risks identified in the Hazards Vulnerability Assessment (HVA). Emergency Management staff indicated they coordinated the Emergency Plan with county officials and it was a high level overview and did not include detailed policies and procedures for all identified risks on the HVA as required by CMS. Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.”

“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: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(1)). Findings include: On 6/25/2024, during record review between 9:00 am and 10:15 am, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff. Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(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:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[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. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 42986 Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator Emergency Management Staff that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(2)). Findings include: On 6/25/20224, during record review between 9:00 am and 10:15 am, the facility failed to provide a defined system to track the location of on-duty staff during an emergency. Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Emergency Management that the facility failed to comply with Federal, State and local Emergency Preparedness (EP) requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(d)(2)). Findings include:: On 6/25/2024, during record review between 9:00 am and 10:15 am, during interviews Emergency Management staff indicated facility testing exercises (drills) were provided to leadership and all staff did not participate in the exercises. Surveyor was accompanied by the Facility Administrator and Emergency Management Staff who acknowledged the existence of these conditions.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 38637 Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections unless modified by 19.2.2 through 19.2.11 for 1 of the sampled corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 19.2.1, 7.1.10.1). Findings include: On 06/25/2024, at 12:30 p.m., the egress corridor leading from the pharmacy to the exit discharge was obstructed by chairs placed in the corridor on both sides, reducing the clear width to less than 48 inches. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.”

“Anesthetizing Locations CFR(s): NFPA 101 Anesthetizing Locations Areas designated for administration of general anesthesia (i.e., inhalation anesthetics) are in accordance with 8.7 and NFPA 99. Zone valves are: located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Area alarm panels are provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems. Panels are at locations that provide for surveillance, indicate medical gas pressure decreases of 20 percent and vacuum decreases of 12 inch gauge HgV, and provide visual and audible indication. Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone box valve assemblies. The EES critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits, and EES equipment system supplies power to ventilation system. Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer’s instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 19.3.2.3 (LSC) 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 38637 Based on record review, observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures. Findings include: On 06/25/2024, during record review of the facility’s humidity policies and procedures dated 07/20/2017 and documentation of humidity records it was noted by the surveyor that the policy had a stated range of 30%-60%. Record review identified the following recorded humidity recorded below the established range in OR1 and OR2: January 2024, OR1, had humidity levels documented at below 30% on the 15th, 16th and 20th. OR2 had humidity levels documented at below 30% on the 14th, 15th, 16th and 20th. February 2024, OR1, had humidity levels documented at below 30% on the 4th. March, OR1, had humidity levels documented at below 30% on the 1st, 2nd, 3rd, 4th and 7th. OR2 had humidity levels documented at below 30% on the 7th. April, OR1, had humidity levels documented at below 30% on the 17th and 18th. Surveyor requested a copy of the Risk Assessment for the equipment used within the OR’s to ensure they can operate safely in the lower humidity range. The facility could not produce the Risk Assessment or other documentation to show compliance. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 38637 Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install/maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 19.3.2.5.1 – 19.3.2.5.4, 19.3.2.5.1 – 19.3.2.5.5, 9.2.3, NFPA 96, TIA 12-2, UL300). Findings include: On 06/25/2024, at 12:42 p.m., it was observed by the surveyor that a 2-burner cooking appliance was being used for cooking in the kitchen. This cooking appliance was brought in due to the existing burners not working, however the suppression heads for the cooking hood did not cover the new 2-burner appliance. The suppression system and head locations were designed and installed for the commercial cooking appliances and not the replacement 2-burner appliance. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of the following conditions.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 38637 Based on the observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers in areas that are not protected by sprinklers within the building. This resulted in the potential for injury to residents/patients and staff (LSC 39.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30). Findings include: On 06/25/2024, at 2:30 p.m., there were ABHR dispensers located throughout the facility that were placed over carpeted areas. The facility was not equipped with a fire sprinkler system. ABHR dispensers are not allowed to be located over carpeted floors in buildings that do not have sprinkler coverage. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 38637 Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for 3 of the extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10). Findings include: 1. On 06/24/2024, at 3:43 p.m., there was a fire extinguisher located in the generator room that did not have the required monthly inspection performed by evidence of missing documentation on tag. 2. On 06/24/2024, at 3:45 p.m., there was a fire extinguisher located in the elevator mechanical room that did not have the required monthly inspection performed by evidence of missing documentation on tag. 3. On 06/24/2024, at 3:54 p.m., there was a designated smoking area that did not have an accessible fire extinguisher located in the area or within 75 foot travel distance. 4. On 06/25/2024, at 9:05 a.m., there was a fire extinguisher located in the surgical suite that did not have the required monthly inspection performed by evidence of missing documentation on tag. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 38637 Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 39.7.1.4 - 39.7.1.7). Findings include: 1. On 06/25/2024, during record review between 9:15 a.m. and 11:00 a.m., facility fire drill documentation for the main hospital showed missing fire drills in quarters 1 of 2024, 3 of 2023 and 4 of 2023 for night shift and quarters 1 and 3 for swing shift. 2. On 06/25/2024, during record review between 11:00 a.m. and 11:30 a.m., fire drill documentation requested for review for the satellite business office could not be provided. According to staff, fire drills were not being performed at that location. Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.”