Community Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32355 This STANDARD is not met as evidenced by: Based on interviews, video footage, and document review, the facility failed to comply with the Medicare provider agreement as defined in 489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS INCLUDE: 1. The facility failed to meet the following requirements under the EMTALA regulations: *Tag 2406: (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department, as defined in paragraph (b) of this section, the hospital must- (i)Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws rules and regulations and who meets the requirements of 482.55 of this chapter concerning emergency services personnel and direction; and by the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. *Based on interviews, video footage, and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. *Specifically, the facility failed to ensure a MSE was performed by a qualified medical professional (QMP) for one of one patients reviewed who presented to the emergency department (ED) with abdominal pain. (Patient #1). *Refer to C2406, findings 1 through 7.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 32355 Medicare State Operations Manual; Appendix V - Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases; A2406 MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. Based on interviews, video footage review, and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure an MSE was performed by a qualified medical professional (QMP) for one of one sampled patient (1) who presented to the emergency department (ED) with complaints of abdominal pain. Findings include: 1. Policy Review Review of the provider’s August 2017 revised and/or December 2022 EMTALA policy revealed: “Purpose: To ensure that all patients coming to [provider name] requesting emergency services receive an appropriate Medical Screening Examination as required by the Medical Treatment and Active Labor Act (EMTALA), ... Any patient who comes to [provider name] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists. EMTALA: Refers to Sections ... which obligates hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions... In general, when an individual comes by him or herself or with another person to the emergency department of the hospital, and a request is made on the individual’s behalf for a medical examination or treatment, the hospital must provide for an appropriate Medical Screening Examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists... When a Medical Screening Examination is required: If an individual arrives at the hospital and is not technically in the emergency department, but on Hospital Property or Premises (as defined under this policy) and requests emergency care, he or she must receive a Medical Screening Examination within the capabilities of the facility, or if necessary, execute an appropriate transfer according to the guidelines of EMTALA and these policies. The location in Which the Medical Screening Examination Should be Performed: The Medical Screening Examination and other emergency services need not to be provided in a location specifically identified as an emergency room or any emergency department. If an individual arrives at a facility and is not technically in the emergency department, but is on the premises of the hospital and requests emergency care, he or she is entitled to a medical screening examination... The hospital may use areas to deliver emergency services which are also used for other in-patient or out-patient services. Medical Screening Examinations or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the emergency department. The hospital is obligated to perform the Medical Screening Examination to determine if an emergency medical condition exists. It is not appropriate to merely “log in” a patient and not provide a Medical Screening Examination. Individuals coming to the Emergency Department must be provided a Medical Screening Examination beyond initial triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the “order” in which patients will be seen, not the presence or absence of an emergency medical condition. The hospital must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with the emergency medical conditions who come to the hospital for examination and treatment. -Medical Screening Examinations must be performed by individuals who are: Determined qualified by hospital medical staff bylaws, rules, and regulations which are approved by the hospital’s Board of Directors. ...1) the emergency department physician on duty is responsible for the general care of all patients presenting themselves to the emergency department... *Central Log: Purpose: To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. -The log must contain: The name of the individual seeking assistance, The disposition: patient refused treatment, was refused treatment by the facility, transferred, admitted and treated, stabilized and transferred, discharged. The log entry should be made at the first point of contact. This would normally take place at triage.” 2. ED video footage reviewed for 4/14/25 from 6:51 p.m. through 7:12 p.m. revealed: *At 6:59 p.m. 2 persons entered the ED through the ambulance entrance. Those persons were identified and Patient #1 and a non-family member. *At 7:03 p.m. Patient #1, accompanied by a non-family member, and ED Staff registered nurse (RN) F were observed entering room 121. -The room was designated as a waiting room for the ED and was located next to the ambulance entrance. *At 7:10 p.m. Patient #1, accompanied by a non-family member, were observed leaving the ED through the ambulance area. *There was no observation of a qualified medical professional or any other ED staff having entered the room to complete an MSE to determine an emergency medical condition existed or not. 3. Review of the provider’s 3/1/25 through 7/29/25 ED log revealed patient #1 presented to the ED on 4/15/25 at 8:49 a.m. with complaints of abdominal pain after she had been seen at the clinic. Diagnostic impressions supported the patient had a bowel obstruction and required a higher level of care than the critical access hospital (CAH) could provide. Patient #1 was discharged from the ED at 11:15 a.m. and was transferred to an acute care hospital by ground ambulance. There was no documentation to support the patient had presented to the ED on 4/14/25 at 6:59 p.m. with complaints of abdominal pain for the past two days and no relief from pain medications. 4. Review of patient #1’s first ED presentation and subsequent ED medical record review revealed: Patient #1 presented to the ED on 4/14/25 at 6:59 p.m., accompanied by a non-family member with complaints of increased abdominal pain for the past couple of days with no relief from pain medications. -ED Staff RN F obtained vital signs, listened to the patient’s bowel sounds over the patient’s clothing, and palpated patient’s stomach. Patient #1 left the ED without an MSE completed by a qualified medical professional. -The hospital was unable to provide a Medical Record for Patient #1 who presented to the ED on 4/14/25 at 6:59 p.m. furthermore, Patient #1 was not evident on the provider’s Central Log for 4/14/25. Subsequently Patient #1 presented to the ED for a second time on 4/15/25 at 8:49 a.m. after being seen at an on-campus clinic where the patient’s primary physician provided a diagnosis of bowel obstruction. -Patient #1 complained of increased abdominal pain, no bowel movement for several days, and recent nausea and vomiting of coffee ground emesis (vomiting); with no relief from pain medications or laxatives. -ED treatments were inclusive of intravenous (IV) fluids (for hydration), placement of a nasal gastric (NG) tube (flexible tube inserted through the nose and into the stomach), administration of pain and anti-nausea medications. -Patient #1’s ED condition was documented as serious. -Patient #1 was discharged from the ED on 4/15/25 at 11:15 a.m.., and transferred to hospital for higher level of care, where Patient #1 expired. 5. Interview on 7/29/25 at 2:08 p.m. with ED Staff RN F who was present on 4/14/25 when Patient #1 first presented to the ED revealed: *She confirmed patients who presented to the ED had to be screened and under no circumstances could they be denied treatment or an assessment. *Sometimes patients would present to the ED to have their stitches checked or blood pressure (b/P) taken. *She stated, “Obviously, the nurses cannot tell the patients if they should be seen or not.” *She stated, “We have to do a walk-in log now that is signed by two nurses ever since an incident and complaint occurred.” *She stated, “Before that, we just did a call-in log for those who called.” *The incident and complaint occurred a few months ago, and she had been involved with Patient #1 and the family friend who had presented to the ED through the ambulance door. *The family friend had done most of the talking and Patient #1 kept repeating she did not want to be there or seen. *Patient #1 had stated her friend drove her there and again, she did not want to be there. *ED Staff RN F had walked the patient and Patient #1’s family friend to a room for more privacy. -Both ED rooms had been occupied by other patients. *The family friend was a nurse. She had been concerned about Patient #1 because: -Patient #1 had a history of colon cancer with bowel obstructions in the past. -Patient #1’s abdomen had been more distended over the past two days, and the family friend did not have a stethoscope to listen for bowel tones. -Patient #1 had been having abdominal pain for the past two days and there was no relief from the pain medications. *The family friend had taken Patient #1 to the ED to have the someone listen to Patient #1’s abdomen to make sure they were present. *ED Staff RN F had: -Listened to the abdomen and heard bowel tones. -Completed soft palpitations (putting pressure on the stomach to check for pain with her hands) of the abdomen. The patient had no pain from palpitation during that assessment. -Told Patient #1 several times that she had the option to be seen by the practitioner since she was already there. *Several times the patient refused to be seen by the physician and stated and she wanted the least invasive treatment and that she would go to the clinic the next day. *ED Staff RN F stated, “The patient was adamant she did not want to be seen.” *They had discussed other options, such as taking Miramax (medication that helps promote a bowel movement). *Medical Doctor (MD) E: -Was in-house at the time of the incident, and ED Staff RN F had updated him on the status and situation of Patient #1. -Was provided the information of Patient #1’s courtesy screening results and the patient’s history of bowel obstructions greater than 5 years ago. -Had no instructions for Patient #1 and did not assess or complete an MSE. *ED Staff RN F stated, “[The practitioner] told me he felt I had done everything I could and there was nothing further they could do.” *ED Staff RN F was not able to diagnose or complete an MSE on the ED patients. -That had been the responsibility of the physicians and practitioners. *ED Staff RN F walked Patient #1 and the family friend out into the hallway and repeated three or four times “Are you sure you don’t want to be seen?” Patient #1 refused and again stated she wanted the least invasive treatment and would try Miralax at home. *ED Staff RN F recommended that Patient #1 be seen in the clinic the next day, in case there were further complications. *The ED nursing staff had recently been re-educated on their EMTALA policy after that incident and a walk-in log was initiated. Interview on 7/29/25 at 11:07 a.m. with ED Staff RN C revealed: *ED Staff RN C worked on the medical floor and in the ED when assigned. *ED Staff RN C could not refuse to triage anyone who presented to the ED. *If a patient refused to be seen, the ED staff were required to document that on the ED log. *Within the past month, the provider had implemented a walk-in log to be completed at the nurses’ station for those patients who presented to the ED but did not want to be seen by the physician. ED Staff RN C stated: -“Or they might just want a b/p checked because they were not feeling right or it felt high.” -“Or the clinic doctor told them to check their b/p over the weekend and they didn’t have a b/p cuff to do that so we would check it for them.” -“The clinic sometimes tells them to stop at the ED and have it [b/p] checked.” -“They might need help with changing a pain patch, something small like that.” *When patients presented to the ED for a b/p check they could have provided the patients with the results and recommendations, but could not tell them what to do from the results of their b/p check. *ED Staff RN C was not sure what the MSE was but she knew she could not have assessed the patients to determine if an emergency medical condition existed. -The physicians would have done that after she had completed her initial triage assessment to determine their chief complaint. Interview on 7/29/25 at 11:30 a.m. with ED Staff RN D revealed: *When a patient presented to the ED the staff could not refuse to triage the patient to determine if an emergency situation existed or not. *ED Staff RN D could not have given patients the option to not be seen or go to the clinic instead. *ED Staff RN D would have completed an initial triage assessment and then the physician would have completed the MSE to determine if an emergency situation existed. *If a patient presented to the ED and just wanted their b/p checked, they could have done that for patient. ED Staff RN D stated, “But we can’t tell them what to do with the results.” “If they want advice or some type of treatment I tell them they have to be seen in the ED.” *In the past, they would not have logged the b/p check anywhere. ED Staff RN D stated, “Sometimes a cardiologist tells them [the patients] they need their b/p checked and so they come to have us for [b/p] checking.” *A walk-in log had recently been initiated for those patients who presented to the ED and wanted a b/p check or something minor looked at. -If they refused to be seen by the physician when recommended, that now had to be charted on the walk-in log and signed by two nurses. *The completed walk-in and call-in logs had been placed in the director of nursing’s (DON) folder at the nurses’ station. -ED Staff RN D was not aware of what happened with those logs after that. *The call-in logs had been used to document those patients who called in requesting treatment recommendations. -They could have provided basic information for an infant or child who needed Tylenol (over-the-counter pain and fever-redoing medication) and the parent wants to confirm the dosage. *There was staff re-education provided on the EMTALA process within the past three months and the walk-in log was the only change in the provider’s processes for the ED. Interview on 7/29/25 at 2:26 p.m. with ED Staff medical doctor (MD) E who was present on 4/14/25 when Patient #1 first presented to the ED revealed: *ED Staff MD E recalled the evening when Patient #1 presented to the ED and had left without having an MSE completed. *ED Staff MD E was not concerned that an EMTALA occurred. *ED Staff MD E knew ED Staff RN F took Patient #1 to a room but could not hear the conversation taking place inside the room and was not aware of what ED Staff RN F had done. *ED Staff MD E had heard ED Staff RN F talking to Patient #1 as she was leaving the ED and telling Patient #1 that she had the option to be seen. *ED Staff RN F reported a courtesy screen was completed for Patient #1, bowel tones were noted, and the patient’s stomach was soft and non-tender. *ED Staff MD E stated, “I was fine with her going home. No, I did not see the patient, only when she was leaving.” -ED Staff MD E stated, “The patient did not seem upset and wanted to try something at home first. We can’t make them be seen, they have the option to leave. I did not talk to her at all.” Interview on 7/30/25 at 1:33 p.m. with RN I revealed: *She had been the quality and risk coordinator and sometimes worked in the ED. *Each department would determine the quality measures they wanted to monitor and reviewed them at the quality and risk meeting. *The ED had not been reviewed as a part of the quality meeting and RN I was unaware of any concerns or quality measures they had been monitoring independently. *RN I had questioned leadership staff if she needed to be asking about EMTALA concerns or address any ED measures in the meeting. -No one had responded to her question. -RN I had little to no guidance on what should have been discussed or reported to the quality meeting to review and address. *Any concerns RN I had heard about the ED had been through hearsay or casual conversations. *RN I had heard that a patient presented to the ED and was told she could wait until the clinic was open. -That patient had presented to the ED the next day, was discharged to a higher level of care and passed away days later. -It had not been discussed in the quality and risk meeting, and when she asked about it, there was no response to her question. *RN I stated most of the patients who presented to the ED were admitted, but there were times when a patient presented and they just wanted a b/p taken or something minor checked. *RN I agreed that when a nurse checks a patient’s b/p, listens to the abdomen for bowel tones or palpates for tenderness, those actions were considered nursing tasks and a type of screening should have been initiated. *RN I had not realized those nursing tasks or screenings had initiated the EMTALA process. *RN I agreed that when a patient left without an MSE being completed by the ED’s MD, that patient had left against medical advice (AMA). *There was the option available in the medical record for staff to initiate and complete a record for any patients leaving AMA. *A walk-in log had been initiated and was to be completed when patients presented to the ED for a courtesy screen and were not seen. -The walk-in log had recently been created shortly after the patient who presented to the ED was not screened, and passed away a couple of days later. -Two nurses had to sign the walk-in log for verification. *The last EMTALA training RN I recalled was completed as part of her annual training. -RN I had missed the provider’s June staff meeting but they recently started to record the staff meetings and send them to staff over email email. -RN I was unsure if there had been a deadline or a completion date assigned for her to have listened to the meetings or to have confirmed that she had read those emails. 6. Review of the provider’s 2025 Quarterly Quality report revealed there was no documentation to support the ED had been a part of the quality meetings. There were no quality measures in place for the ED to monitor to ensure all patients who presented to the ED had been properly triaged by the nurse and an MSE was completed by the MD or a practitioner to determine if an emergency medical condition existed. Review of the provider’s 1/14/25 Medical Staff By-Laws and Rules and Regulations revealed no documentation to support what the process and requirements had been for the completion of an MSE by the physicians or practitioners on all patients who had presented to the ED 7. Interview on 7/30/25 at 4:23 p.m. with director of nursing (DON) A and human resources (HR) B revealed: *It had been common practice for people from the community to come into the ED and request the staff to check non-emergent concerns and complete a courtesy screen. Such as: -Requesting a b/p to be taken because they were experiencing a headache or their b/p felt high. -Requesting to have stitches looked at to make sure they were not infected. *DON A and HR B agreed: -The ED was dedicated and required to assess, treat, and appropriately triage emergent situations. -That a patient could have presented anywhere on the hospital campus, and they had an obligation to treat them. -When a patient presented to the ED or on their campus, the patient had a concern that required them to be assessed and appropriately triaged. *DON A and HR B had not realized that: -As soon as the nurse started a courtesy screen, such as checking a patient’s b/p or listening to bowel tones, a service had been initiated by the staff and that had initiated the EMTALA process. -As a dedicated ED, they did not have the capability of completing non-emergent services such as checking a b/p, listening to bowel tones, or checking stitches to ensure they were not infected. -That every patient who presented to the ED was required to have an MSE completed by a competent medical personnel such as the physician or practitioner per their EMTALA policy. *DON A and HR B were aware the nursing staff initiated the triage process, but they did not have the capability to determine if an emergency medical situation existed. -Only qualified medical personnel, such as the physician or practitioner had the capability to do that. *DON A: -Was not sure an EMTALA concern was initiated the evening of 4/14/25 when Patient #1 presented to the ED. -Was not aware of the potential EMTALA until the administrator had received a call from a family member who was concerned about what occurred on 4/14/25 when Patient #1 presented to the ED. -Along with the administrator and HR B, had interviewed ED Staff RN F. ED Staff RN F had been directly involved with the incident involving Patient #1 on 4/14/25. -They felt ED Staff RN F had done everything to encourage Patient #1 to have an MSE completed but Patient #1 had refused and left the ED. -Stated Patient #1 refused to be seen and told ED Staff RN F that she wanted to do the least invasive thing. -Agreed that was considered AMA and the ED Staff had the capability to initiate a medical record for those situations when a patient would leave without being seen. -Interviewed ED Staff MD E who was present the evening of 4/14/25 when Patient #1 first presented to the ED. ED Staff MD E had not seen Patient #1 to complete an MSE and had stated “You can’t make a patient be seen.” -Had re-educated the ED nursing staff at their monthly meeting in May on EMTALA requirements. DON A would have left the meeting notes and education at the nurses’ station for those who had not attended to read/sign/date upon completion. DON A had not re-checked to make sure all of the staff who had not attended the meeting had completed the education. DON A had also emailed the education to the ED staff, but there was no process in place to ensure the ED staff had checked and read those emails. -Had not included the practitioners and physicians in the re-education of EMTALA requirements. DON A agreed they were a part of the ED and should have been included in that education to ensure they understood and were following those EMTALA and MSE requirements. -Had no monitoring process in place after the incident on 4/14/25 to ensure the ED staff had understood the EMTALA education and was implementing those requirements. -Had started a walk-in log for those patients who presented to the ED and requested the staff to complete a courtesy screen but refused to be admitted. -Had not considered the incident on 4/14/25 when Patient #1 presented to the ED and left without an MSE to have been an issue or to have created the potential for an EMTALA to occur. -Confirmed the ED was not reviewed or monitored through their quality and risk process to ensure they had met all of CMS requirements as a dedicated ED. DON A agreed it should have been.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 50715 Based on observation, interview, and policy review, the provider failed to ensure: *Outdated patient care supplies were not available and ready for patient use in three of three crash carts, one of one pediatric airway cart, and one of two ambulances. *Outdated patient care supplies were not available and ready for patient use in three of three emergency treatment rooms, one cardiac rehab room, one of one medication rooms, and one of one nurse aide storerooms. Findings include: 1. Observation on 5/19/25 at 2:30 p.m. in emergency department (ED) room 1 revealed: *One crash cart, one pediatric airway cart, and three large cabinets containing patient care supplies. *Outdated supplies included: -Three intravenous (IV) start kits with expiration dates of 11/30/22 and 3/31/25. -Multiple gauge needles with expiration dates ranging from 2022 through 2024. -One fiberoptic laryngoscope with an expiration date of 7/31/24. -One foley catheter kit with an expiration date of 8/2020. -Endotracheal kits containing laryngoscope blades with expiration dates ranging from 2019 through 2024. -One oxygen saturation probe with an expiration date of 2024. -Multiple three milliliters (ml) syringes with an expiration date of 3/23. -One lumbar puncture tray with an expiration date of 9/30/24. -One lumen central venous catheter kit with an expiration date of 5/31/24. -One quicktrach kit with an expiration date of 10/21/23. -Three pairs of #6 latex gloves with an expiration date of 8/31/23. -Two pairs of #6 ½ latex gloves with an expiration date of 4/30/24. -Two Yankauer suction devices with expiration dates of 10/24 and 1/28/23. -Two pediatric I-gel airways with expiration dates of 6/23 and 10/23. -19 huggable electrodes with an expiration date of 6/24. Interview on 5/19/25 at 2:45 p.m. with registered nurse (RN) A and RN B revealed: *Nurses had not checked the crash carts, pediatric airway cart, or supply cabinets for expired supplies. *Confirmed the supply chain departments were responsible for checking the supplies for items *RNs A and B confirmed they had never been told to check for outdates in the crash carts, pediatric cart, or cabinets in the ED rooms. *RN A had thought the supply chain staff were checking for outdated supplies monthly. 2. Observation on 5/19/25 at 3:15 p.m. in the ED triage room revealed outdated patient care supplies. Those supplies included: *Two #18 gauge (G) IV start needles that expired on 5/31/24. *One staple removal kit that expired on 4/30/25. *One chest tube tray that expired on 9/30/23. *Six huggable electrodes that expired on 6/24. *Multiple gauge needles located on a baby warmer that expired in 2022. 3. Observation and interview on 5/19/25 at 3:40 p.m. in the medication room with RNs A and B revealed: *Outdated supplies that included: -Three #20 G IV needles that expired on 7/31/23. -Two #18 G IV needles that expired on 12/31/24. -Four statlock IV device kits with expiration dates of 1/23 and 6/24. *RNs A and B confirmed nurses had been restocking the supplies in the medication room, but had been unaware of a process for checking for outdated supplies. 4. Observation and interview on 5/19/25 at 4:12 p.m. in ER room 2 with RNs A and B revealed: *One crash cart containing supplies with expiration dates ranging from 2022 through 2024 included: -Three IV start kits. -Four #20 G IV needles. -Four #18 G IV needles. -Multiple sterile gloves. -One bougie dilatator. -One I-gel airway. *RNs A and B confirmed the supplies had outdated and should have been discarded. *RN A stated, “I believe there is a miscommunication between nursing and central supply on who is responsible for checking outdates [expiration dates] on patient supplies.” 5. Interview on 5/20/25 at 9:15 a.m. with manager of materials management D revealed: *The provider had been following their policy for event-related shelf life and sterile storage of supplies. -She had thought it was acceptable to go six months to a year past the expiration date for supplies if their policy supported that practice. -She had been unaware in that had not applied to patient care items supplied by manufacturing companies. *She agreed expiration dates on patient care supplies set forth by the manufacturer needed to be followed and expired supplies needed to be discarded appropriately. *She confirmed both central supply staff and nurses should have been checking for product expiration dates on the nursing units as outlined in the provider’s policy. -Central supply staff had been checking for outdated supplies monthly and when restocking supplies. *She confirmed nurses were supposed to be checking expired supplies in the crash carts as outlined in the provider’s crash cart policy. *She confirmed the supplies found throughout the ED rooms and crash carts had expired and should have been removed. 6. Observation and interview on 5/20/25 at 10:15 a.m. in two of two ambulances with director of ambulance E revealed: *Outdated supplies in one ambulance included: -Three #22 G IV needles with an expiration date of 2024. -Four #20 G IV needles with an expiration date of 4/26/25. -Eight endotracheal tubes with an expiration date of 2024. *He confirmed he had been responsible for checking for outdated supplies monthly. *He confirmed the intubation supplies had been purchased as a kit and had not been checked for expiration dates. *He agreed staff should have been checking all patient care supplies for expiration monthly. 7. Observation on 5/20/25 at 1:45 p.m. in the nurse aide storeroom located by the nurses’ station revealed: *Outdated supplies included: -Five staple removal trays with an expiration date of 9/25/23. -Two staple removal trays with an expiration date of 3/4/25. 45683 8. Observation and interview on 5/21/25 at 10:45 a.m. in the cardiac rehabilitation room with RN K revealed: *In the crash cart drawer there were three sealed packages of five electrodes each that expired on 11/12/23. *She was not sure who monitored the crash cart for expired supplies. *She agreed there should be a checklist for the supplies in the crash cart to ensure that nothing had expired. *She confirmed the supplies should have been removed from the cart and replaced. 9. Interview on 5/21/25 at 10:00 a.m. with director of nursing (DON) C revealed she: *Had thought the supply chain staff had been responsible for checking the crash carts for outdated supplies. *Stated, “This is on me. I did not communicate with nursing staff that they were responsible for checking the crash carts for outdated supplies.” *Confirmed staff should have been discarding supplies that had expired as dated on the packaging per the manufacturer. *Would have expected nurses to check for expired supplies prior to patient use. *Would have expected staff to ensure outdated supplies were removed prior to restocking. Review of the provider’s January 2023 Emergency Crash Cart Protocol and Defibrillator Checks policy revealed: *”All crash carts will be checked monthly by the Pharmacy Department to check medications for outdates. *Nursing will check for outdated supplies. *Central supply will be notified of any nonpharmacy outdates for replacement purposes. *After each use, the supplies must be checked and replenished. *Nursing should replenish supplies after wiping off the crash cart.” Review of the provider’s April 2024 Event-Related Shelf Life & Sterile Storage policy revealed: *”Sterility of items will be event-related, but some commercially processed items will also be date-related. *These dates are monitored by CSR and the department and the items discarded when the date is reached. *An hourglass is sometimes used in manufacturing to mean expiration.” Review of the provider’s March 2025 Sterile Supplies policy revealed: *”It is the responsibility of the Central Supply Services and nursing when available in down time to check routinely for outdated supplies in the nursing units, exam rooms, and [the] emergency room. *Central Supply supplies are monitored for outdated supplies every month, those which are outdated or soon to be outdated before next check will be re-processed or destroyed. *In a department where CSR does not check outdates, it will be the responsibility of the Department Head to monitor outdates.” Review of the provider’s March 2025 Supplies (Ordering/Stocking) policy revealed: *”Nursing Unit Supplies: -CSR and Nursing when able is responsible to check daily for adequate supplies in ER, Triage, ICU, Exam Room and Nurses Aid Storeroom. -Product outdates will be checked monthly and removed as appropriate.””

“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: 50715 Based on observation, interview, equipment logs review, policy review, and manufacturer’s instruction for use (IFU) review, the provider failed to ensure: *The temperature of one of one fluid warmer machines located in the medication room had been monitored daily. *One of one Medivators Advantage Plus endoscope reprocessor machine’s (disinfects endoscopes) water and air filters had been changed every six months per the manufacturer’s IFU. Findings include: 1. Observation and interview on 5/19/25 at 3:40 p.m. with registered nurse A in the medication room revealed: *One fluid warmer contained three bags of lactated ringers solution. *No temperature readings had been recorded for May 4, 10, 11, 17, and 18 on the temperature log. *She stated the pharmacy staff was responsible for documenting the temperatures of the fluid warmer. *She had never been told to record the temperatures on the fluid warmer when pharmacy staff were not on-site. Interview on 5/20/25 at 3:10 p.m. with pharmacist coordinator J and pharmacy technician O revealed: *Confirmed pharmacy staff were responsible for monitoring and documenting the temperatures of the fluid warmers when pharmacy staff were on-site. *Pharmacy technician O stated, “Depends on who is working if the nurses will monitor the warmer when we are not here.” *Pharmacist coordinator J confirmed there had not been formal communication to the nursing staff about documenting the temperatures of the fluid warmers when pharmacy staff were unavailable. *Both agreed the temperatures of the fluid warmer should have been monitored and documented daily. Interview on 5/21/25 at 10:00 a.m. with director of nursing C revealed: *The fluid warmer temperatures had been monitored by pharmacy staff. *She was unaware the fluid warmers needed to be checked on the weekends or when the pharmacy staff had been unavailable. *She stated nursing staff could have assisted in documenting fluid warmer temperatures daily. Review of the provider’s May 2025 Bulk IV Fluid Warmers policy revealed: *”All bulk IV bag fluid warmers are to have a visible thermometer. *The temperature of the warmer is monitored daily by pharmacy and/or nursing staff if pharmacy is unavailable.” 2. Observation and interview on 5/20/25 at 8:35 a.m. with manager of materials management D in the endoscope reprocessing decontamination room revealed: *Three air filters on the wall had dates listed on each filter that read 6/24/24. *She -Confirmed maintenance was responsible for documenting the water and air filter logs. -Did not have the maintenance log for the filter changes in the decontamination room to reference. -Was unsure if maintenance kept a separate log of the filter change dates. -Would reach out to the director of maintenance to the confirm air and water filter changes of the Medivators Advantage Plus endoscope reprocessor. Interview on 5/20/25 at 1:30 p.m. with manager of materials management D of the reprocessor’s air and water filter logs revealed: *Documentation of the air filter changes had been completed in July 2024 by maintenance. -The reprocessor’s left and right air filters should have been changed every six months per the manufacturer’s IFU. *Documentation of the water filter changes had been completed in July 2024. -The water filters (1 micron, 0.4 micron, and 0.1 micron) should have been changed every six months per the manufacturer’s IFU. *She was unaware of when the manufacturer had changed the time frame for the air and water filters, as she thought it had been every year. Interview on 5/20/25 at 1:55 p.m. with director of plant operations F revealed: *He was unaware the reprocessor’s air and water filters needed to be changed every six months per the manufacturer’s IFU. *He confirmed maintenance had been changing the filters yearly, and that was last completed in June 2024. *He agreed the air and water filters should have been changed every six months according to the manufacturer’s IFU. Review of the Medivators 2020 Advantage Plus Endoscope Reprocessor Manufacturer’s IFU revealed: *”The Advantage Plus Reprocessor has four air filters. Each filter should be replaced every 6 months. *Water filters should be replaced at a minimum of every 6 months for the 1.0 micron and 0.4 micron filters. *0.1 micron minimum replacement schedule is 6 months.””

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 50715 Based on observation, interview, and policy review, the provider failed to ensure two of two syringes that had contained the medication Cimzia (medication used to treat inflammatory conditions) had been labeled with the medication name, strength, expiration date or time for one of one patient (28). Finding include: 1. Observation on 5/20/25 at 2:23 p.m. in treatment room 155 with registered nurse (RN) H and patient 28 revealed: *RN H: -Entered the room with two unlabeled syringes containing a clear solution that had been prepared in the medication room. -Had two empty vials of Cimzia 200 milligrams (mg)/1 milliliters (ml). -Laid the syringes down on the bedside table. -Verified the identity of patient 28. -Scanned each vial of Cimzia into the computerized medication record. -Administered each of the unlabeled syringes of solution separately into patient 28’s abdomen. Interview on 5/20/25 at 2:30 p.m. with RN H and RN G revealed: *Medications were labeled only if multiple different medications were drawn up at the same time. *Their practice had not been to label syringes if drawing up a single medication, or if drawing up the same medication into multiple syringes. *Confirmed medications were drawn up in the medication room and walked to the patient’s room for administration. *RN H and RN G confirmed they had not been aware a single medication or the same medication drawn up into multiple syringes needed to be labeled. Interview on 5/21/25 at 10:00 a.m. with director of nursing C revealed: *All medications required a label for proper identification. *Syringes containing medication should have been labeled with the medication name, strength, expiration date and time per the provider’s policy. Review of the provider’s June 2024 Medication Administration policy revealed: *”Medications are prepared, administered, labeled and recorded by personnel licensed to administer medications. *All medications that is not immediately administered must be labeled. Any medications that are transferred from the original packaging to another container must be labeled with: -Medication or solution name, -Strength, -Amount of medication (if not apparent from the container), -Diluent name and volume, -Expiration date or time. *Immediately discard any mislabeled products.””

“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: 50715 Based on observation, interview, policy review, and manufacturer’s instructions for use (IFU) review, the provider failed follow standard infection prevention practices by not having ensured one of one observed glucometer had been cleaned and disinfected properly prior to patient use. Findings include: 1. Observation and interview on 5/19/25 at 4:00 p.m. with registered nurse (RN) A and RN B revealed: *One glucometer that was docked and ready for patient use had a visible blood smear on top of the machine. *RNs A and B confirmed there was visible blood on the glucometer and it had not been cleaned properly prior to it being placed in the docking station. *RN A confirmed the procedure for cleaning the glucometer was to use a PDI disinfectant wipe after each patient use. *RN A removed the blood glucometer and used a PDI wipe to disinfect it. Interview on 5/21/25 at 10:00 a.m. with director of nursing (DON) C revealed: *Glucometer machines should have been cleaned with a PDI disinfectant wipe between each patient use. *Staff should have inspected the glucometer prior to placing it in the docking station to ensure it was appropriately cleaned. Review of the provider’s December 2024 NOVA Biomedical StatStrip Glucometer Hospital Meter policy revealed: *”Cleaning the meter: -The meter should never be immersed in any cleaning agent. -Always apply the cleaning agent to a soft cloth to wipe the meter surface. -The cloth should be damp NOT dripping. -Make sure that no solution is allowed to enter the strip port or the docking port.” Review of the provider’s November 2024 Equipment Cleaning policy revealed: *”For the safety and comfort of patients, all reusable “noncritical” patient care items will be cleaned, disinfected, and maintained in a safe manner between patient use. *Patient equipment will be disinfected immediately following patient use when the item has been contaminated with blood or other potentially infectious material (OPIM) or is visibly soiled. *All reusable patient care equipment removed from a patient room/procedure room is disinfected before use or another patient. *Disinfection recommendations: -Between each patient use (anything that touches a patient)-Some examples: -Glucose Meters.” Review of the 2024 StatStrip Glucose Meter instructions for use manual revealed: *”The StatStrip Glucose Hospital Meters should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patient and healthcare professionals. *1. Clean the Meter. -Remove a fresh germicidal wipe from the canister. -Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting bleach wipe. 2. Disinfect the Meter. -Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. -Gently wipe the surface area of the test strip port making sure that no fluid enters the port.””

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 40788 Based on record review, social service consultant reports review, interview, and policy review, the provider failed to ensure Case Manager/Social Services (CM/SS) Assessments (used to develop individualized discharge plans) were completed for four of four sampled swingbed patients (7, 8, 9, and 10). Findings include: 1. Review of patients 7, 8, 9, and 10’s electronic medical records (EMR) revealed: *There was no documentation to support a CM/SS Assessment had been completed for patients 7, 8, 9, and 10. -Information from the CM/SS Assessment was used to develop an individualized discharge plan for each patient. *That assessment would have included discharge-related information such as: -If the patient had a primary care physician. -The patient’s social/living circumstances. -Their post-discharge goal/treatment preferences. -Their anticipated discharge location. -The supports/resources the patient used prior to admission and the supports/resources the patient needed after discharge. -Transportation needs. -Durable medical equipment (DME) the patient used prior to admission and the DME the patient needed after discharge. -The patient’s ability/inability to pay for prescribed medications. -Their insurance information. Interview on 5/20/25 at 3:38 p.m. with director of nursing (DON) C regarding the completion of a CM/SS Assessment revealed: *She stated licensed clinical social worker (LCSW) consultant P had informed her an initial CM/SS Assessment did not need to be completed. -Other social service documentation including discharge planning notes and care conference notes were completed “at least weekly.” Telephone interview on 5/21/25 at 11:00 a.m. with LCSW consultant P revealed: *He consulted with DON C by telephone and he reviewed patients’ EMRs off-site. *His consultant reports were forwarded to chief executive officer (CEO) I and DON C upon completion. *A part of his consultation was the review of sampled swing bed patients’ EMRs for expected social service documentation. -That included completion of a CM/SS Assessment and CM/SS Discharge Planning notes. Continued interview and review of LCSW consultant P’s 6/12/24, 9/18/24, 12/10/24, and 3/20/25 consultant reports regarding the above social service documentation revealed: *CM/SS Discharge Planning notes were completed for the residents he had reviewed, but there was no documentation to support a CM/SS Assessments had been completed for those residents. -The 6/12/24 consultation documentation indicated: “I think it would be beneficial for staff to complete the Social Service Assessment Swing Bed form [a form comparable to the CM/SS Assessment] on each admission.” *The 9/18/24 consultation documentation indicated: “I did not find use of either the CM/SS Assessment [or the] Social Service Assessment Swing bed forms. I still think it would be beneficial for staff to at least complete the Social Service Assessment Swing bed Form on each admission.” *The 12/10/24 consultation documentation indicated: “I did not find use of the Social Service Assessment Swing Bed form.” “...I still think it would be beneficial for staff to complete this brief assessment with each swingbed admission.” *The 3/20/25 consultation documentation indicated: “Some (but not all) charts contained CM/SS Assessment entry.” “My recommendation is for staff to complete this assessment for each swing bed admission.” Interview on 5/21/25 at 1:30 p.m. with CEO I regarding LCSW consultant P’s above quarterly consultation reports revealed: *She confirmed DON C was LCSW consultant P’s primary contact for social service consultations. It was DON C’s responsibility to have reviewed the consultation reports and addressed the consultant’s recommendations with the staff and/or consultant as needed. *She had not known LCSW consultant P had repeatedly identified the same concerns regarding social service documentation. That pattern was indicative of a system failure that should have been brought to her attention for remediation. *Information obtained from the CM/SS Initial Discharge Assessment was used to direct a patient’s discharge plan. *The CM/SS Initial Discharge Assessment referred to in the provider’s policies was the same assessment LCSW consultant P had referred to as the CM/SS Assessment. -The expectations for completion of the CM/SS Initial Discharge Assessment had not been followed according to the provider’s policy. Review of the provider’s revised January 2020 Discharge Planning-Acute & Swing Bed policy revealed: *Patient Assessment: -“The admitting nurse will complete the CM/SS Initial Discharge Assessment.” Review of the provider’s revised May 2021 Swingbed Utilization Review Plan policy revealed: *V. Procedure for Discharge Planning: -“A. Planning is initiated on the CM/SS Initial Discharge Assessment on admission.””

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 25107 Based on observation, testing, and interview, the provider failed to maintain the positive latching feature of the door located in the two-hour separation between the clinic and the hospital during the business hours from 8:00 a.m. to 5:00 p.m. Findings include: 1. Observation, testing, and interview on 5/22/2025 at 2:45 p.mm with maintenance assistant Q of the two-hour separation between the hospital and the clinic revealed: *The ninety-minute fire-rated door between the clinic and the hospital was equipped with an electronic strike door latch. *During the business hours from 8:00 a.m. to 5:00 p.m. the door was programmed to release the electronic strike. *When the electronic strike was released the latching feature of the door was disabled. *Testing of the latching feature revealed the door could be pulled or pushed open without the need to turn the door handle proving the door was not positive latching. *It was unknow if the electronic strike would latch upon initiation of the fire alarm system. Follow up clarification regarding the latching of the electronic strike during initiation of the fire alarm system was requested by e-mail on 5/29/25 at 3:27 p.m. Director of maintenance R responded to request for clarification on 5/30/25 at 4:24 p.m. and verified the electronic strike would not latch during the initiation of the fire alarm system and confirmed the door was not positive latching.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider installed a lock on an egress/horizontal exit door in one randomly observed exit access corridor between the hospital and the clinic. Findings include: 1. Observation and interview on 5/22/2025 at 2:45 pm with maintenance assistant Q of a door between the hospital and the adjoining clinic, which serves as an egress/horizontal exit door for both occupancies, revealed the door has an electronic strike installed that is normally unlocked during the clinic’s hours of operation and is otherwise locked. Testing revealed that the door, when locked, stays locked during a fire drill. This is a deficiency as all egress doors and horizontal exit doors are required to be unlocked at all times. Interview with maintenance assistant Q confirmed the finding. He agreed it was a deficiency.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider failed to maintain the fire and/or smoke barrier for three randomly observed door assemblies. Findings include: 1. Observation and interview on 5/22/2025 at 10:20 am with maintenance assistant Q of a door between the laundry and the soiled linen room revealed the door was fitted with a closer but was being held open by a wooden wedge. When the wedge was removed, the door would not close due to interference with the frame. Also, the door was deconstructing (delaminating). The condition of the door compromises the door assembly’s ability to resist the passage of smoke as well as pathogens from the soiled linen room to the laundry. 2. Observation and interview on 5/22/2025 at 2:10 pm with maintenance assistant Q of an egress corridor double door assembly in the business center revealed the doors were unable to latch during testing due to interference with each other at the top interior edges. This compromises the door assembly’s ability to resist fire spread and the passage of smoke. 3. Observation and interview on 5/22/2025 at 2:25 pm with maintenance assistant Q of an egress (north) corridor double door assembly near room 180 revealed the south leaf of the door assembly was unable to consistently latch during testing. This compromises the door assembly’s ability to resist fire spread and the passage of smoke. Interview with maintenance assistant Q at the time of each observation confirmed the findings. He agreed they would not resist the passage of smoke.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider failed to maintain the fire and smoke barrier for one of four exit enclosures (stairway 10). Findings include: 1. Observation and interview on 5/22/2025 at 10:30 am with maintenance assistant Q revealed a nonlatching door in the basement level of stairway 10, thus compromising the door assembly’s ability to resist fire spread and the passage of smoke. Interview with maintenance assistant Q confirmed the finding. He agreed it would not resist fire spread or the passage of smoke.”

“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: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider created a hazardous area via the accumulation of combustible items within the air handler 1 room in the basement. The provider failed to protect this hazardous area as required, affecting one of six smoke compartments and an exit corridor. Findings include: 1. Observation and interview on 5/22/2025 at 10:50 am with maintenance assistant Q revealed three groupings of mixed combustibles (e.g., cardboard, plastics, fiberglass, adhesives) being stored under large metal forced-air ducts measuring approximately 5’ x 5’ in cross-section. The bottom of the ducts were approximately 5’ above the floor. The floor space occupied by the three combustibles groupings was approximately 5’ x 50’, 5’ x 25’, and 5’ x 15’ for a total area of approximately 450 square feet. This is larger than the 50 square feet of combustibles maximum for nonhazardous areas. Therefore, this area requires hazardous area protections. The area is sprinklered. However, the combustibles are shielded by the metal ducting immediately above, thus compromising the effectiveness of the sprinklers. Sprinklered hazardous areas must have smoke resisting partitions. However, the door to the air handler 1 room (from the fire alarm room) was propped open with a wedge. When tested, the door would not close on its own due to interference with a foam safety protector installed on the corner of a nearby metal duct fitting. The adjacent fire alarm room, into which the smoke from the hazardous area would enter in a fire event, had a compromised smoke resisting partition between it and the lay-in ceiling above the adjacent exit corridor (two rectangular holes in the wall measuring approximately 4” (inches) x 12” serving as pipe and cable conduits and one approximately 2” circular penetration containing a pipe without fire caulking near the fire alarm room ceiling). Random observation of ceiling tiles in the exit corridor lay-in ceiling near the fire alarm room door revealed three instances of broken tiles that would not resist the passage of smoke. Interview with maintenance assistant Q confirmed the above findings.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider failed to maintain the smoke barrier for one randomly observed patient sleeping room (140). Findings include: 1. Observation and interview on 5/22/2025 at 3:20 pm with maintenance assistant Q revealed a gap at the top of the corridor door assembly for room 140 between the top of the door and the door frame stop (latch side) of approximately 1/4” (one-quarter inch) thus compromising the door assembly’s ability to resist the passage of smoke. Interview with maintenance assistant Q confirmed the finding. He agreed it would not resist the passage of smoke.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 25107 52836 This STANDARD is not met as evidenced by: Based on observation and interview, the provider failed to protect medical gas storage as required in the oxygen cylinder storage room (sprinklered) affecting one of six smoke compartments. Findings include: 1. Observation and interview on 5/22/2025 at 1:30 pm with maintenance assistant Q revealed 13 full “E” size oxygen cylinders (approximately 312 cubic feet) colocated with a spray can of highly flammable glass cleaner, approximately 14 cardboard boxes and other combustibles within 5 feet of the cylinders, and a key-making machine with a grinding wheel which could generate sparks. Each of these observations represent deficiencies. Interview with maintenance assistant Q confirmed the above findings.”