Penn Highlands Connellsville

“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: 44386 Based on observation and interview, it was determined the facility failed to maintain a clear and unobstructed egress path within an exit in two instances, affecting two of 12 emergency exits. Findings include: 1. Observation on February 3, 2026, revealed the following means of egress deficiencies: a) 11:00 a.m., revealed the Stairwell 2 exit to the outside was obstructed with snow and ice; b) 11:15 a.m., the exit pathway through Stairwell 1 was unsafe due to paint chips left on the floor going down the stairwell. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the paths of egress were not continuously maintained to be free of all obstructions and ready for full use.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 50030 Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in two instances, affecting two of 14 smoke compartments. Findings include: 1. Observation on February 3, 2026, revealed the following vertical opening deficiencies: a) 9:55 a.m., there were multiple unsealed penetrations through the concrete block wall of the Elevator 2 shaft, above the ceiling on 3 West; b) 10:25 a.m., there was an unsealed penetration in the stairwell/elevator shaft, above the ceiling next to the stairwell on 3 West. Interview with the Chief Nursing Officer (CNO) and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the listed vertical opening deficiencies.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 44386 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of 14 smoke compartments. Findings include: 1. Observation on February 3, 2026, at 10:51 a.m., revealed the door to the dirty utility room in the second floor walk in clinic failed to latch when tested. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the door failed to latch at the time of the survey.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 39523 Based on observation and interview, it was determined the facility failed to maintain the fire alarm system in four instances, affecting four of fourteen smoke compartments. Findings Include: 1. Observation on February 2, 2026, revealed the following fire alarm deficiencies: a) 9:30 a.m., there was an unsealed ceiling penetration in the men’s locker room in the basement, which would allow the passage of smoke and affect operation of the fire alarm system; b) 9:50 a.m., there were multiple unsealed ceiling penetrations in the telephone room in the basement; c) 10:00 a.m., there was an unsealed penetration in the ceiling of the switch gear room in the basement. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the fire alarm system deficiencies. 2. Observation on February 3, 2026, at 9:10 a.m., reveled a large penetration in the ceiling of Room 0215. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the fire alarm system deficiencies.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 39523 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility. Findings include: 1. Observation on February 2, 2026, at 10:10 a.m., revealed the automatic sprinkler gauges in the basement were dated 2019 and the facility could not provide documentation that the gauges had been changed or recalibrated within the last five years. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the automatic sprinkler system deficiency.”

“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: 52584 Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting one of fourteen smoke compartments. Findings Include: 1. Observation on February 3, 2026, at 10:30 a.m., revealed a fire extinguisher cabinet door would not open on 3rd Floor West, outside of the surgery suite. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the fire extinguisher cabinet door would not easily open without excessive force.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 44386 Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of 14 smoke compartments. Findings include: 1. Observation on February 3, 2026, at 11:15 a.m., revealed a gap greater than 1/8” in the smoke doors of the Behavioral Unit when they were closed. Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed excessive gap in the smoke barrier doors.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 44386 Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of 14 smoke compartments. Findings include: 1. Observation on February 3, 2026, at 10:50 a.m., revealed an electrical outlet within six feet of a sink, in the second floor walk in clinic dirty utility room, was not GFCI protected Interview with the Chief Nursing Officer and Maintenance Director on February 3, 2026, at 12:30 p.m., confirmed the electrical receptacle was not GFCI protected.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 45574 This condition was not met as evidenced by failure of the facility to maintain current and relevant policies and procedures; failure to conduct a review and evaluation of contracted services; and failure to assure orientation of a Board member. Findings include: On January 20, 2026, a review of the “Amended and Restated Bylaws of Highlands Hospital; d/b/a Penn Highlands Connellsville” (Last Approved: August 4, 2025: Last Amended: June 2, 2025) was completed and revealed the following: “Article VI: Committees- Section 6.5 (a) Board Quality Oversight: ... The functions of the Committee, which shall be monitored by the PHH Quality Oversight Committee, shall be to provide oversight and make recommendations to the Board concerning: (b)Patient Safety and Risk Management...(d) Compliance with Department of Health Regulations and Medicare Conditions of Participation, and (e) Policy review, as appropriate. Section VIII: Quality Assurance- Section 8.2 Delegation to Administration and to the Medical Staff: ... (b) To the Medical Staff: The Board delegates to the medical staff and holds it accountable for conducting specific activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided by the Corporation. These activities include: ...(2) Ongoing monitoring of critical aspects of care...8.3 Documentation and Oversight: The Board, through the Board Quality and Oversight Committee and/or Executive Committee shall require, receive, consider and act upon the findings and recommendations emanating from the activities required by Section 8.2 of these Bylaws...” ________ On January 22, 2026, review of the current Nursing Policies located in the Integrated Nursing Unit policy book (Last Approved by the Medical Director: 12/10/2025) was completed and revealed policies for the administration of the following medications: Amiodarone, Adenosine, Dobutamine, IV Nitroglycerin, Versed Drip, Alteplase, Nipride, Procainamide, IV Neosynephrine, as well as a policy for Care of a Patient on a Mechanical Ventilator. On January 22, 2026, review of the Criteria for Admission to the Integrated Care Unit, was completed and revealed, “Patients with acute medical or surgical issues may be admitted upon acceptance by the attending physician”. During an interview on January 22, 2026, at approximately 12:15 PM, EMP2 confirmed that the critical care policies are not part of the scope of practice, and should not have been available to staff. _______________________ On January 23, 2026, a review of Case Management policy, “Discharge Planning” was completed and revealed, “Discharge Planning for continuity of care after hospitalization is an interdisciplinary service made available to patients of Penn Highlands Dubios and Penn Highlands Clearfield ... Interventions per Unit: Penn Highlands DuBois: Behavioral Health ... NICU ... Maternity ... Pediatrics ... Acute Care/Neuro ICU/CVICU ... Short Stay Unit ... Emergency Room ... Penn Highlands Clearfield: Medical Surgical ... Short Stay ... Emergency Room ... “ There is no evidence that this policy is intended for Penn Highlands Connellsville. On January 23, 2026, a review of Case Management Policy, “Delivery of Important Message from Medicare - FFS Medicare and Medicare Advantage Enrollees” revealed, “PH Dubois (PHD) Registration Staff or Case Management; or at PH Clearfield (PHC), Nursing or Case Management staff, are responsible to deliver the “Important Message from Medicare” (IM) to all Medicare and Medicare Advantage beneficiaries ... PH Dubois Registration Staff or Case Management; or at PH Clearfield, Nursing or Case Management staff, will issue an admission Important Message from Medicare (IM) notification ... PHD Case Management staff, or at PHC, Nursing or Case Management staff, will ensure that this initial notice is provided within 2 calendar days ...” There is no evidence that this policy is intended for Penn Highlands Connellsville. On January 23, 2026, a review of Case Management policy, “Coverage, Case Management” was completed and revealed, “Daily Coverage hours (PH Mon Valley): Monday through Saturday: 0700-1530, Sunday: 0700-1530 (Director on-call), Emergency Department (ED): Monday through Friday: 0700-1530 ... “ Penn Highlands Connellsville case management coverage hours are absent from this policy. There is no evidence that this policy is intended for Penn Highlands Connellsville. _______________________ On January 22, 2026, a review of the current Respiratory Therapy Policy Manual (Last Approved by the Medical Executive Committee: 1/14/2026) was completed and revealed the following: “Pediatric Cardiac Arrest (Code Alert)- Section II: Any nursing unit that admits a pediatric patient weighing less than 30 kg. will notify cardiopulmonary. They will then bring a pediatric crash cart to be kept on the unit until the patient is discharged.” On January 23, 2026, at approximately 10:15 AM, both EMP2 and EMP24 confirmed that the facility did not admit pediatric patients to the hospital. On January 22, 2026, a review of the “Policy on Supervision” was completed and revealed the following: “The therapist may contact the Cardiopulmonary Manager at home... 3. Problems of a technical nature involving department equipment or procedures. (Arterial Blood Gas, Respiratory Equipment, PFT’s, etc.)” On January 23, 2026, at 10:26 AM, EMP24 confirmed that EMP24 was a Registered Nurse and would have no knowledge regarding technical issues with arterial blood gasses, respiratory equipment, or PFT’s. ____________________ Based on a review of facility documents and employee interview (EMP) it was determined that the organization failed to assure that the Market President (Southwest Region) received orientation to the Governing Board. Findings Include: On January 20, 2026, a review of the “Amended and Restated Bylaws of Highlands Hospital: d/b/a Penn Highlands Connellsville” (Last Approved: August 24, 2025) was completed and revealed the following: Section 3.2 (e)- Orientation: Newly elected directors shall participate in PHH’s new director orientation program. PHH shall be responsible for developing, implementing, and overseeing compliance with the Board orientation program.” On January 21, 2026, a copy of the Market President’s Board Orientation was requested. On January 22, 2026, at 9:45 AM, EMP1 confirmed that verification of Board Orientation was not available. Cross Reference: 482.12 (e)”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 45574 Based on a review of facility documents and employee interview, it was determined that the facility failed to evaluate the performance of contracted services. Findings include: On January 20, 2026, a review of the Governing Body Bylaws, was completed and revealed the following: Section 6.5: The Board Quality Oversight Committee shall not exceed 12 members...The functions of the Committee, which shall be monitored by the PHH Board Quality Oversight Committee, shall be to provide oversight and make recommendations to the Board concerning: (a) Clinical Quality; (b) Patient Safety and Risk Management; (c) Quality implement initiatives; (d) Compliance with Department of Health regulations and Medicare conditions of participation; and (e) Policy review, as appropriate. On January 21, 2026, a review of 2025 Governing Body Minutes was completed and revealed no evidence of evaluation of contracted services. On January 21, 2026, a review of the 2025 Quality Board Oversight Committee Minutes was completed and revealed no evidence of evaluation of contracted services. On January 22, 2026, at 10:26 AM, EMP1 confirmed that the no evaluation of contract services had gone to the Quality Oversight Committee of the Governing Body.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 50900 Based on a review of facility policy, observational tour, medical record review (MR) and employee interview (EMP), it was determined that the facility failed to protect patient health information by not storing medical records in a locked / secure location in two of three outpatient locations toured, and not properly disposing of expired medical records in one of three locations toured. Findings include: On January 21, 2026, a review of facility policy, “Record Retention / Storage / Destruction”, not dated, revealed the following: “PURPOSE: ... To ensure that records are properly identified, stored in a safe and secure location (long-term off-site), maintained until required retention times have expired and destroyed using an approved method for the type of document and media. .... DEFINITIONS: Medical Records: The legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization. ... The legal health record contains individually identifiable data, stored in any medium used in documenting healthcare or health-status. ... Healthcare Records: Include all patient documents containing Protected Health Information (“PHI”) that are a part of the designated record set. Claims submitted for payment, patient bills, remittance advice forms and other payer correspondence are examples of Healthcare records. ... POLICY: [The facility] will maintain and retain all medical, healthcare, ... records, regardless of format, for the period of time defined in state and/or federal regulations. ... This includes all healthcare records created and stored by ... physician practices. ... When the retention period expires, the records are destroyed. ... Maintaining healthcare records beyond the required period exposes the facility to unnecessary risks of liability, disclosure and breaches. ... PROCEDURE: Healthcare Records Storage Guidelines ... Minor children records are stored in boxes separate from adult records. ... Penn Highlands Healthcare’s Record Retention Guide | Record Type: Diagnostic Images (such as x-ray films) (Adults) Retention Period: seven years | Record Type: Diagnostic Images (such as x-ray films) (minors) Retention Period: Age of majority plus seven years ...” On January 21, 2026, at 9:15 AM, a tour of the facility, “Open MRI of Connellsville”, was completed and revealed an unlocked, unsecured storage room which contained cleaning equipment and approximately three to four open shelving racks which were filled with protected patient health information. On January 21, 2026, at 9:35 AM, three medical record files were randomly selected for closer review: Review of MR30, dated January 29, 2007, was completed and revealed the patient’s full name, birthdate, medical record number, and scanned area “Orbits FU MRI” written on the exterior of the file. The interior of this file contained the associated diagnostic films. According to facility policy, this PHI should have been destroyed in 2014. Review of MR31, dated June 15, 2006, was completed and revealed the patient’s full name, birthdate, medical record number, and scanned area “LT Foot” written on the exterior of the file. The interior of this file contained the associated diagnostic films. MR31 was revealed to be a pediatric file. Based on the patient’s birth year of 1995, this PHI should have been destroyed in 2020, per facility policy. Review of MR32, dated January 30, 2007, was completed and revealed the patient’s full name, birth date, medical record number, and scanned area “Mammogram” written on the exterior of the file. The interior of this file contained the associated diagnostic films. According to facility policy, this PHI should have been destroyed in 2014. The above findings were confirmed by EMP14 on January 21, 2026, at 9:41 AM. ------------- On January 21, 2026, at 11:00 AM, tour of the facility, “Highlands Hospital Health Stop”, revealed that (at minimum) three non-laboratory employees have keyed access to this location, including the owner of the building, specimen courier(s), and the biohazard waste removal company, who visits the facility during off-hours. During tour of the facility, an unlocked, unsecured milk crate was observed on a small table beside the patient check-in desk, which appeared to contain patient information. EMP22 confirmed the milk crate contained records of patients who have “standing orders”. On January 21, 2026, at 11:10 AM, three medical record files were randomly selected for closer review: Review of MR33, dated April 4, 2025, was completed and revealed the patient’s full name, birthdate, medical payment information, order date and time, and the referring provider’s prescription for lab work to be completed. Review of MR34, dated November 10, 2025, was completed and revealed the patient’s full name, birthdate, medical payment information, order date and time, and the referring provider’s prescription for lab work to be completed. Review of MR35, dated October 2, 2025, was completed and revealed the patient’s full name, birthdate, medical payment information, order date and time, and the referring provider’s prescription for lab work to be completed. On January 21, 2026, at 11:15 AM, during employee interview, EMP22 confirmed the files are stored in this location and remain there during hours of closure. The above finding was confirmed by EMP21 on January 21, 2026, at 11:15 AM.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 45574 Based on a review of facility documents and employee interview (EMP) it was determined that the facility failed complete a performance improvement project in 2025. Findings include: On January 21, 2026, a review of the “Quality Assessment & Performance Improvement (QAPI) Plan” was completed and revealed the following: “Quality and Safety Department: ...Facilitating Performance improvement teams drawing on their expert knowledge of team dynamics, the PDSA Process, DMAIC Process, use of QAPI Tools and Measurement. Performance Improvement Models: ...The underlying performance improvement philosophy is driven by tools and concepts based on the Six Sigma Methodology. Data is collected to assess performance, outcomes, and identify opportunities for improvement.” On January 21, 2026, during an interview with EMP1, EMP2, EMP7 and EMP35, EMP1 was asked how the risk reports were used for tracking and trending. EMP1 replied that that there were no facility trends and trending was “very difficult.” EMP1 stated there were no addtional performance improvement teams/ projects identified or completed in the last year.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 45574 Based on a review of facility documents and employee interview (EMP), it was determined that the facility failed to include all hospital departments in the facility Quality Assurance/ Performance Improvement Plan. Findings Include: On January 21, 2026, a review of the facility “QAPI Plan” was completed and revealed the following: “Nursing Leadership Council (NLC): The NLC is comprised of the Chief Nursing Officer and Nursing Management. This leadership council is responsible for: Defining key nurse sensitive measures and setting targets for expected performance... Developing, implementing, and monitoring plans to address QAPI improvement opportunities... Reviewing events for patterns and trends including the impact of staffing effectiveness... Review results of the Nursing Quality Excellence dashboard, QAPI Teams such as, Safe Patient Handling and designated sub teams , RCA, FMEA results etc..: Quality and Safety Department: The Quality and Safety Department serves as an organizational resource, whose main purpose is to advance the quality and safety of patient care. In collaboration with Executive/Senior Management, Organizational Excellence Council. Quality, Safety and Service Excellence Steering Committees and the Board, the Quality and Safety Department is responsible for: ... Facilitating performance improvement teams drawing on their expert knowledge of team dynamics, the PDSA [Plan/Do/Study/Act] Process, DMAIC [Define/Measure/Analyze//Improve/Control] Process, use of QAPI Tools, and Measurement.; Assuring ongoing measurement and data review to monitor the organization’s current performance and effectiveness of the QAPI Plan in meeting QAPI Goals and other opportunities identified for improvement.” On January 21, 2026, a review of the faciltiy’s “Quality Excellence Reporting Matrix” was completed and revealed that there was no expectation for facilties management, medical records or nursing to report to the Quality Excellence Committee. On January 21, 2026, during an interview with EMP1, EMP2, EMP7 and EMP35, EMP1 confirmed facilties management, medical records or nursing departments were missing from the “Quality Excellence Reporting Matrix.” at 12:56 PM. On January 21, 2026, during an interview with EMP1, EMP2, EMP7 and EMP35, the group was asked for the minutes of the Nursing Leadership Council Meeting. At 1:17 PM, EMP2 stated that the Nursing Leadership Council “has not met for a long time.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46390 Based on review of facility polices, personnel files (PF), and interview with facility staff (EMP), it was determined that the facility failed to ensure that registered nurses had the competencies to care for the patients on the inpatient nursing unit as per current hospital policies and procedures. Findings include: On January 22, 2026, review of the current Nursing Policies located in the Integrated Nursing Unit policy book, last approved 12/10/2025, revealed policies for the administration of the following medications: Amiodarone, Adenosine, Dobutamine, IV Nitroglycerin, Versed Drip, Alteplase, Nipride, Procainamide, IV Neosynephrine, as well as a policy for Care of a Patient on a Mechanical Ventilator. During an interview on January 22, 2026, at approximately 12:15 PM, EMP2 confirmed that the critical care policies are not part of the scope of practice, and should not have been available to staff. On January 22, 2026, a review of personnel files for the third floor integrated care unit revealed that there are two Registered Nurses, PF16 hired in 1987, and PF17 hired in 2023, who have been hired to be able to perform critical care competencies on this unit. Review of PF16, revealed that most recent the critical care competencies were completed in 2016. Review of PF17, revealed that no critical care competencies were present in the file. During an interview on January 22, 2026, at approximately 12:00 PM, EMP2 confirmed that there are no current critical care competencies for the registered nurses to care for critical care patients, and the above polices should have been retired.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 42809 Based on review of facility documents, medical records (MR),and staff interview (EMP), it was determined the facility failed to ensure medical records were properly filed and retained per facility policy for three of three pediatric medical records reviewed that are still within the required record retention period (MR3, MR4, MR7) Review on January 21, 2026, of facility policy “Record Retention/Storage/Destruction”, last approved 10/27/2025, revealed: “ ... Short-term storage areas must be dry, secure, no entry windows, and locked at all times. ... Table 1 Penn Highlands Healthcare’s Record Retention Guide ... Record Type ... Patient health/medical records (minors) ... Age of majority plus 7 years ...” On January 21, 2026, at 10:50 AM, a tour of the basement storage room, which is located about 100 feet from the entrance to the cafeteria, was conducted. During the tour, several cardboard boxes containing medical records were observed on shelves in the basement storage room. The storage room did not have a working light. Moisture, which appeared to be from condensation, was noted on the shelving where these boxes were stored. In addition, steam was noted being emitted from a pipe connected to the boiler near the ceiling of this room. Further review of the contents of two boxes revealed several medical records, including the following: 1) A record of hospitalization for MR3, who was admitted on November 17, 2005 and discharged on November 19, 2005, for fever, vomiting and leukocytosis. Review of MR3 revealed the patient’s birth month and year as May, 2002. 2) A record of hospitalization for MR4, who was admitted on October 18, 2005 and discharged on October 20, 2005, for pneumonia. Review of MR4 revealed the patient’s birth month and year as October, 2001. 3) A record of hospitalization for MR7, who was admitted on May 14, 2005 and discharged on May 15, 2005, with a diagnosis of right upper lobe pneumonia. Review of MR7 revealed the patient’s birth month and year as July, 2002. On January 21, 2026, at approximately 11:00 AM, EMP6 confirmed the basement storage room conditions noted above. In addition, EMP6 confirmed that the above medical records are still within the required medical records retention period per facility policy for pediatric patients (age of majority plus 7 years).”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 42809 Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure medical records were complete per facility policy, for three of three pediatric medical records reviewed that are still within the required record retention period (MR3, MR4, MR7). Review on January 22, 2026, at 10:00 AM of facility policy “Scanning Charts”, last reviewed 11/25, revealed: “ ... PURPOSE: The Health Information Management Department’s primary purpose is to contribute to the quality of patient care through the development and maintenance of a comprehensive medical record system. This includes ensuring that medical records are processed and completed properly. ... PROCEDURE: 1. Access charts from medical/behavioral health/SPU/ER unit after discharge. ... 5. Chart goes through scanner and pages are saved into the correct account number. ... 8 At the completion of the scanning process, charts are then checked for accuracy. ...” During interview with EMP6 on January 21, 2026, at approximately 10:00 AM, EMP6 explained that after patient discharge, hard copy documents are scanned into the electronic medical record and checked for accuracy, to ensure the electronic medical record is complete. The hard copy documents are ultimately shredded, after it is confirmed that the electronic file is complete and contains all medical information. On January 21, 2026, at approximately 10:30 AM, when asked how long the facility has been using its current electronic medical recordkeeping system, EMP2 confirmed that the electronic medical recordkeeping system has been utilized since 2003. On January 21, 2026, between 11:30 AM and 12:00 PM, the following hard copy medical records were compared to the electronic medical record to determine whether the electronic records were complete: 1) A record of hospitalization for MR3, who was admitted on November 17, 2005 and discharged on November 19, 2005, for fever, vomiting and leukocytosis. Review of MR3 revealed the patient’s birth month and year as May, 2002. Further review of the electronic medical record for this patient encounter revealed that the physician orders and progress notes had not been scanned into the electronic medical record. 2) A record of hospitalization for MR4, who was admitted on October 18, 2005 and discharged on October 20, 2005, for pneumonia. Review of MR4 revealed the patient’s birth month and year as October, 2001. Further review of the electronic medical record for this patient encounter revealed that the physician orders and progress notes had not been scanned into the electronic medical record. 3) A record of hospitalization for MR7, who was admitted on May 14, 2005 and discharged on May 15, 2005, with a diagnosis of right upper lobe pneumonia. Review of MR7 revealed the patient’s birth month and year as July, 2002. Further review of the electronic medical record for this patient encounter revealed that the physician orders and progress notes had not been scanned into the electronic medical record. On January 21, 2026, between 11:30 AM and 12:00 PM, the above missing scanned documents were confirmed with EMP8 during review of the electronic medical.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50899 Based on a review of facility documents, facility tour, and interview with staff (EMP), it was determined the hospital failed to maintain the physical environment of the hospital to ensure the safety and well-being of patients, staff, and visitors. Findings: A tour of the main hospital campus on January 20, 2026, at 11:10 AM, revealed: The main supply storeroom had copious amounts of dust and debris on the windowsills, floor, and high elevated surfaces. Multiple large cobwebs were visible hanging from the ceiling. The storage room in the service hallway near the main supply storeroom, currently being used as overflow storage contained copious amounts of dust and debris on the floor and supplies. This room has an exterior window that was ajar approximately 2 inches without a screen covering. This window also had a thick layer of ice on the interior of the window prohibiting closure. In a locked area adjacent to the service hallway revealed a storage room and adjoining corridor containing boxed records. In the storage room there were approximately 150 to 200 banker boxes filled with billing documents containing personal identifiable information (PII). The boxes were stacked on the floor, many of which had fallen over covering the entirety of the floor. Staff cleared a path to allow proper inspection which revealed an area approximately 10x13 feet with water damaged boxes below a section of drop ceiling which had collapsed due to water infiltration. In the corridor leading to the storage room approximately ten banker boxes of pediatric medical records were found. The corridor was unlit, had water dripping from the ceiling and pressurized steam escaping from a boiler pipe on the ceiling. Hallway light fixtures on unit two west contained dirt and debris. The equipment storage room on unit three central contained ceiling water damage with ceiling tile staining. The men’s room adjacent to the cafeteria entrance contained a worn, partially unsealed concrete floor, debris buildup on the floor in the rear right corner, a 3x3 inch area of chipping paint, and eight holes in the wall above the paper towel dispenser. The above findings were confirmed with EMP1, EMP2, EMP3, and EMP27, on January 23, 2026, at 11:30 AM. ------------- On January 20, 2026, at 11:00 AM, a tour of the nutritional services department was completed and revealed: The outpatient cafeteria service line revealed a leaking faucet beside the prepared food warmer. This finding was confirmed by EMP15 at 11:20 AM. The area surrounding the dishwasher revealed approximately ten metal-grate ceiling tiles which were covered in rust-like color and texture. During employee interview with EMP15, it was revealed that the facility does not currently monitor the temperature or humidity of the general spaces within the department. This finding was confirmed with EMP15 at 11:35 AM. The dishwasher hood contained a lightbulb encasement which was fully cracked in two locations, dividing the light cover into three separate pieces. The light cover contained debris and was held in place with duct tape. The duct tape had become dry to the touch and was flaking. A sink beside the dishwasher was leaking brown-tinted fluid into a plastic bin placed underneath the sink. These findings were confirmed by EMP15 at approximately 11:40 AM. The walk-in beverage refrigerator revealed a square shaped section on the ceiling which appeared to have rust-colored staining, some type of exudate/growth, and lifting of the sealant/paint. This finding was confirmed by EMP15 at 11:55 AM. The walk-in produce refrigerator revealed a hole in the ceiling with rust-colored areas surrounding and peeling away from the ceiling-surface. Beneath this hole was a cart of filled styrofoam cups which were intended to be for delivery to the patient floor. This finding was confirmed by EMP15 at 12:00 PM. Beside the oven area, a gas pipe which supplies energy to the oven was emerging from the wall and did not have any type of sealant surrounding its entry/exit point from the wall. This pipe was revealed to be the location of the emergency on/off control for gas supply to this location. This finding was confirmed by EMP15 at approximately 12:10 PM. On January 20, 2026, following tour of the nutritional services department, copies of the following maintenance orders were provided by the facility, in correlation to the above findings: 1) Department: Dietary. Description of work to be performed: “Light on dishwasher fix or remove (and no duct tape)” Signed EMP15, 01/07/2026 2) Department: Dietary. Description of work to be performed: “Pop cooler clean bacterial growth and paint” Signed EMP15, 01/07/2026 3) Department: Dietary. Description of work to be performed: “Produce cooler (seal hole) in ceiling.” Signed EMP15, 01/07/2026. 4) Department: Dietary. Description of work to be performed: “Need green tape on floor around gas shut off fix hole around it” Signed EMP15, 01/19/2026. At the time of survey, zero of four work order requests were completed by maintenance staff. This finding was confirmed by EMP15 on January 20, 2026, at 12:30 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46390 Intakes: PA00072325 This condition is not met as evidenced by: Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for patients as evidence by: psychiatric patients who eloped from the hospital (A0144), and failing to follow the restraint policy for restraint orders (A0167). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients. Cross reference: 482.13(c)(2) Patient Rights: Care in Safe Setting 482.13(e)(4)(ii) Patient Rights: Restraint Or Seclusion”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46390 This condition is not met as evidenced by: Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to provide supervised nursing services by a registered nurse as evidence by: failure to ensure that all licensed nurses adhered to the policies and procedures of the hospital (A0398), and failure to provide the ordered dosage of medication (A0405). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients. Cross reference: 482.23(b)(6) Supervision of Contracted Staff 482.23 (c)(1), (c)(1)(i), (c)(2) Administration of Drugs”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients who eloped from the hospital for three of twenty two medical records reviewed (MR1, MR21 and MR22). Findings include: A review on May 15, 2024, at 10:45, of the facility’s policy, “Assessment and Reassessment of Patients” (Last Revised: 3/2023): “Policy: 1. A registered nurse completes the initial assessment or triage. The scope of the nursing assessment is driven by the chief complaint of the patient and is completed at bedside. Anu incidental findings are assessed as they arise. Triage is documented in Notes under ER Nursing Triage ...5. Reassessment of patients occurs when there is a change in patient condition, a change in diagnosis, following any treatment measures and in accordance with policy regarding the taking of vital signs ... All patient reassessments, treatments, medications, and/or procedures are documented in Notes under ER Nursing Note ...”. A review on May 15, 2024, at 11:25, of the facility’s policy, “Securing the Safety and Care of Behavioral Health Patients in the Emergency Department” (Issued: 10/2001; Last Revised: 02/2023): “Policy: Penn Highlands Connellsville takes extra measures when caring for behavioral health patients in the Emergency Department to provide for a safer environment for the patients, staff and visitors. Procedure: 4. Patients are medically cleared by the Emergency Department physician. Once medically cleared, mental health is notified for evaluation. Documentation of blood alcohol below the current legal limit is required prior to mental health evaluation when patient has presented with alcohol intoxication ...6. If behavioral health patient is here for a 302 commitment, all attempts including physical restraint must be utilized to prevent patient elopement ...”. On May 15, 2024, a review of MR1 revealed that on May 10, 2024, at 23:07, the patient presented to the hospital via ambulance accompanied by police. According to the medical record the patient stated that they wanted to not be alive. Additionally, the patient injected eight insulin pens and called 911 because the patient changed their mind and wanted to go to the hospital. Upon arrival to the hospital, police were completing a involuntary commitment (302) paperwork and MR1 told the nurse they wanted to be a 302 because they wanted to not be alive. At 01:00, MR1 eloped from the emergency department and the police were called. Additionally, three staff members followed the patient out the door. Further documentation revealed that on May 11, 2024, at 01:04, the patient was found about a block away from the facility. The patient was escorted back to the facility at 01:11. At 01:15 the 302 was granted and at 01:18 Thorazine was given. At 02:45 the patient was found unresponsive, code blue called. At 03:00 the patient was intubated and at 03:15 pronounced dead. On May 23, 2024, a review of MR21 revealed that on May 15, 2024, MR21 was admitted through the emergency department as Suicidal with Anxiety, Depression and with a plan to overdose. The patient requested help with medication and was admitted to the behavioral health unit (BHU) as a voluntary psyciatric admission (201). On the BHU, MR21 was ordered every 15 minute observation. Further review of MR21 revealed that on May 19, 2024, at 14:35, MR21 eloped from the BHU by following a staff member out of the door. However, the Patient Observation Form continued to be completed by staff which indicated that the patient was in their room at 14:45 and 15:00. Additionally, the faciltiy searched but was unable to locate the psychiatric patient to date. On May 23, 2024, a review of MR22 revealed that on may May 22, 2024, MR22 arrived at 08:52, in the emergency department accompanied by police threatening too kill herself at home. The 302 was already granted and documentation revealed a negative elopement risk. The patient talked about microphones in their stomach and being Bipolar with suicidal thoughts. At 10:10, MR22 ran to the door, pushed the door open and exited the building. 911 was called and at 10:30, MR22 was returned to the hospital. At 11:17, MR22 was admitted to the BHU. During an interview on May 23, 2024, at approximately 12:15, EMP2 confirmed the above for MR1, MR21 and MR22.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to follow the restraint policy for restraint orders in one of two medical records reviewed (MR1). Findings include: On May 15, 2024, a review of the restraint policy “Non Behavioral, Behavioral and Seclusion Policy” (Last Revised: 9/2023), revealed, “Chemical Restraint: A medication used to restrict the patient’s freedom of movement or used for the specific and exclusive purpose of controlling an acute or episodic behavior by the patient. The drug is not standard treatment for the patient’s medical or psychiatric condition. A physician order is required. Guidelines: 7. In the event a chemical restraint is ordered to be give aster [sic] the initial dose, the patient must be seen face-to-face by a physician at least once every 12 hours while chemical restraint is being utilized. If the medication is incorporated into the plan of care, it ceases to be considered a chemical restraint. Documentation in the medical record should indicate this incorporation. ...Restraints may only be used when less restrictive interventions have been determined ineffective to protect the patient, staff member or others from harm. The type of technique of restraint used must be the least restrictive intervention that will he effective to protect the patient, staff member or others forrn harm...A written physician order is obtained including: a) Reason for restraint, b) Clinical justification for use of device...”. On May 15, 2024, a review of the medication administration list for MR1 revealed an order on 05/11/2024 at 01:18 for chlorpromazine (Thorazine) injection (50 milligrams per 2 milliliters) for 12.5 milligrams IM (intramuscularly) times one. It was noted on the medication administration list that MR1 received 50 milligrams of Thorazine at 01:18. On May 15, 2024, at 12:38, EMP6 confirmed the above. On May 15, 2024, a review of MR1 revealed that MR1 was ordered soft restraints, as a verbal order, on May 11, 2024 at 02:00. Soft wrist restraints were applied. There is no evidence of the required physician signature in the chart. On May 15, 2024, at 13:55, EMP1 confirmed the above.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46390 Based on review of facility polices and medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that all licensed nurses adhered to the policies and procedures of the hospital for one of 22 medical records reviewed (MR21). Findings include: On May 23, 2024, review of “Code Green Policy” (Issue Date: 10/2000; Last Revised: 6/2022) revealed, “Policy: Penn Highlands Connellsville will have an efficient and effective method to handle elopements involving patients who are attempting to leave the hospital and are in danger to themselves and others. Procedure: Bullet 1: Any employee that observes a patient fleeing the hospital should immediately dial “2222” from an in house telephone and instruct the switchboard operator to call a “Code Green ...”Bullet 2: Upon hearing the announcement of “Code Green,” all available employees on duty should proceed to that area ... Bullet 4: If a patient attempts to flee and appears to be a threat to himself/herself or others, i.e., intoxicated, under the influence of drugs, etc., staff may be instructed to prevent that patient from leaving for their own protection or the protection of others in the community. Physical restraint may be necessary for their protection and the protection of others ...”. On May 23, 2024, review of hospital policy “Behavioral Health Observation of Patients (Connellsville)” (last revised 1/7/2023) revealed, “PURPOSE: To ensure the safety of patients by providing an adequate level of nursing observation at all times ...Individuals entering the program are assessed for their degree of risk during the admission assessment process Routine observation of patients will be conducted by staff to assure patient safety ...all patients are placed on 15 minute observations. Observation type is determined either by a physicians or nursing order. Nursing may place the patient on closer observation than that ordered by a physician if deemed necessary. ... Staff summarize their observations of behavior or verbalizations of assigned patients and interventions and record these in the medical record ...Description of Observation Levels.· Routine 15-minute checks:1. The patient is placed under staff observation every fifteen (15) minutes. The patient is visibly observed by a staff member every fifteen (15) minutes. The patient’s location at the time of the check is documented on the Observation Log. Constant Visual Observation: The patient is to remain visible to a staff member. The patient’s location is documented on the observation log every fifteen (15) minutes... “. On May 23, 2024, a review of MR21’s Patient Observation Form dated May 19, 2024, revealed that the patient eloped at 14:35. The Patient Observation Form continued to be completed by staff which indicated that the patient was in their room at 14:45 and 15:00, which was incorrect. Additionally, Code Green was never initiated, as per policy. During an interview on May 23, 2024, at approximately 10:30 AM, EMP2 confirmed the above.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to provide the ordered dosage of medication for one of 22 medical records reviewed (MR1). Findings include: On May 15, 2024, a review of “Medication Administration, Scanning, and Documentation” (Last Revised: 04/26/2023) was completed and revealed the following: “Policy: Medications are administered per the order of licensed practitioners with clinical privileges granted in accordance with the Medical Staff Bylaws or Rules and Regulations. Licensed staff may administer medications in accordance with hospital policy, procedure, applicable state laws and practice acts, and governmental rules and regulations ... Bullet 8: Computerized Provider Order Entry (CPOE) sets a standard for all medication orders to be placed by the ordering provider directly into the EMR. Verbal/telephone orders can be accepted only by a registered/graduate nurse (RN/GN) and the read back and verify process must be completed between the RN/GN and provider and documented in the order entry ... Documenting of Medication Administration- Each dose of medication administered is documented on the individual patient record at the time the medication is administered ...”. On May 15, 2024, a review of the medication administration list for MR1 revealed an order on May 11, 2024, at 01:18 for chlorpromazine (Thorazine) injection (50 milligrams per 2 milliliters) for 12.5 milligrams IM (intramuscularly) times one. It was noted on the medication administration list that MR1 received 50 milligrams of Thorazine at 01:18, not 12.5 mg as ordered. On May 15, 2024, at 12:38, during an interview EMP6 confirmed the above.”