Avera St Benedict Health Center - Cah

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 50715 Based on observation, record review, interview, manufacturer’s instructions for use (IFU) review, policy review, and Association for the Advancement of Medical Instrumentation (AAMI), the provider failed to ensure: *Fourteen of thirty surgical instruments wrapped with surgical tape were free from cracks, rips, tears, and discoloration. *Fourteen of thirty surgical instruments had surgical tape wrapped one and one-half (1.5) times around the instrument, applied flat, and without gaps per the manufacturer’s IFU. *Three of twenty observed surgical instruments were free of rust and corrosion. *Three of twenty observed surgical instruments were not etched with lettering. *Three of twenty peel packs (disposable packages used to hold instruments during sterilization) containing surgical instruments were free of rust and brown discoloration within the sterilized package. *Ten of twenty peel packs were positioned so that the packaging was not crushed, bent, or compressed. *A bottle of Rapicide PA (disinfectant used for high-level disinfection) test strips was dated with an opened date according to the manufacturer’s IFU. *Rapicide PA was tested with a test strip to determine effectiveness according to the manufacturer’s IFU. Findings include: 1. Observation on 1/13/26 at 10:53 a.m. in the Emergency Department (ED) rooms revealed: *In the emergency ear, nose, and throat cart, trauma cart, and instrument carts, 13 peel packs containing sterilized surgical instruments (scissors, clamps, tweezers, forceps, and specula’s), ready for patient use, had surgical tape on the instrument that: -Was not wrapped 1.5 times around the instrument according to the manufacturer’s IFU. -Was not laid flat without gaps. -Had visible cracks, tears, and brownish discoloration. Interview on 1/13/26 at 11:20 a.m. with registered nurse (RN) A regarding the surgical instruments revealed: *She was not aware of the above issues regarding the surgical tape on the sterilized instruments. *She stated all instruments were taped and reprocessed by the sterile processing department. *She stated the staff were taught to ensure the packages were not opened, to look at the dates of when the instruments were reprocessed, and to ensure the instruments were ready for patient use. *She agreed that the tape on the instruments had gaps and discoloration, needed to be replaced, and those instruments should not have been used on patients. Interview on 1/13/26 at 11:28 a.m. with surgical technician (ST) B revealed: *Surgical instruments were taped so when they were reprocessed, she would know what department or cart they were to be returned to. *Surgical instruments containing tape were to be inspected before sterilization to ensure the tape was not cracked, frayed, discolored, or placed incorrectly. *Her process was to wrap the surgical tape one and three-fourths times around the instrument. *The provider followed AAMI guidelines to guide their practice. *She agreed that the surgical instruments found in those carts needed to be retaped due to peeling, gaps, and discoloration, as they created the potential for bacteria to remain on the surgical instruments and that could potentially infect the patient, and lead to serious complications. Observation on 1/13/26 at 11:45 a.m. in the procedure room, there was one anesthesia cart that revealed: *One of two magil forceps (surgical tool used in airway management), ready for patient use, had surgical tape on the instrument that: -Was not wrapped 1.5 times around the instrument according to the manufacturer’s IFU. -Was not laid flat without gaps. -Had visible cracks. Observation on 1/14/26 at 11:15 a.m. in operating room (OR) 1 revealed: *Two large cabinets containing multiple sterilized instruments. *Of the 20 observed peel packs: -Three instruments contained rust and corrosion. --Inside the packaging of those three peel packs, sterilized in 2011 and 2014, were noted to have rust and a brown/yellowish discoloration. -Three instruments were engraved with lettering. -Ten peel packs had been positioned in bins where the packaging was bent, folded over, and compressed. Interview on 1/14/26 at 11:45 a.m. with chief executive officer (CEO) C regarding the above findings revealed she: *Agreed that the instruments contained rust and corrosion. *Was unaware that some of the instruments were etched. *Agreed that the packaging of the instruments contained rust and brown/yellowish discoloration, which was bent and folded over, and could have affected the sterility of the instruments. *She agreed that the instruments should not have been used on patients or be ready for patient use. Interview on 1/14/26 at 12:05 p.m. with ST B revealed: *She had worked with the provider for over 16 years, and felt that they did not etch any instruments, but was aware that there are many surgical instruments had etching on them. *She agreed that instruments that were etched did not follow the manufacturer’s IFU and could harbor bacteria. *She agreed that the instruments and packaging contained rust and corrosion. *She agreed the packaging was bent, folded, and compressed effecting the sterility. *She stated that many of the instruments were no longer used and should be reviewed more frequently to ensure the integrity of the packaging is intact, and that the instruments and packaging were free of rust and corrosion. Review of the provider’s 1/7/2025 Instrument Care for Cleaning policy revealed: *”If a surgical instrument begins to pit or corrode from age or misuse it no longer can be sterilized and needs to be replaced. *Pitting or corrosion can occur when blood or bioburdens come in contact with instruments. *Report any damage to instruments to Central Supply.” Review of the provider’s 9/2025 Surgical Instrument, Cleaning of OR and OB policy revealed, “Manufacturers’ written instructions will be followed for the detergent selection, and the proper use, care, and handling of instruments, powered equipment, and reusable supplies. Review of the provider’s 10/27/2025 Contaminated Instrument: Pre-cleaning, Prep for Transport, Disinfection, and Deliver to CSP Department education revealed: “If you notice any instrument having a flaw, damage, corrosion, or any issue of concern, please place a note on container lid for SPD [Sterile Processing Department] to check [the] instrument before sterilization.” Review of the provider’s 9/2025 Monthly inspections policy revealed, “All supplies with damaged packaging will be brought to Central Supply to be repackaged and resterilized.” Review of the manufacturer’s revised 2024 Key Surgical Identification Tape IFU revealed: *”Firmly apply tape; do not stretch. Tape should be applied to the nonworking end of the instrument. *Wrap tape 1.5 times on a stainless-steel instrument. Tape should lay flat without gaps. *Inspect tape prior to each use. Identification tape is not intended as a permanent mark and will discolor, break, chip, or flake over time. *Replace as soon as these are noticed.” Review of the 2017 AAMI-ST 79 guidelines, pg. 40 revealed: *”Instruments should be carefully inspected for flaws, damage, debris, detergent residue, and completeness, then dried. *Instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed, check them for wear according to the IFU of the product used, and replace them as often as needed.” Review of the 2017 AAMI-ST 79 guidelines, pg. 66 revealed: *Sterile items should be: -Positioned so that packaging is not crushed, bent, compressed, or punctured and so that their sterility is not positioned so that packaging is not crushed, bent, compressed, or punctured and so that their sterility is not otherwise compromised. *Rationale: -Compression of packages can force air and microorganisms into the package contents, cause seals to burst, or puncture the packaging, all of which lead to contamination.” 2. Observation and interview on 1/14/26 at 10:00 a.m. in the sterile processing room with ST B revealed: *One Advantage Plus Endoscope Reprocessor (machine used to disinfect endoscopes and colonoscopes) that used Rapicide PA as the disinfectant. *She stated that to ensure the effectiveness of the Rapicide PA, the solution was to be tested with a test strip after the reprocessor has completed its cycle. *ST B removed a test strip from an undated bottle of Rapicide PA test strips, filled a medication cup to ten milliliters with the disinfectant, and then dropped the strip into the disinfectant. -She confirmed the test strip bottle should have been dated with an open date, as it would have expired in four months according to the manufacturer’s IFU. *She stated the test strip was to stay in the solution for 30 seconds, and then the strip was to be read to determine a pass or fail of the effectiveness of the Rapacide PA. -Per the Rapacide PA’s manufacturer’s IFU, the test strip should have been dipped in the disinfectant for one second, immediately removed, gently shaken to remove the excess solution, and then read after 30 seconds. *She was unaware that she was supposed to test the disinfectant by that process. *She agreed that leaving the test strip in the disinfectant for over the recommended time could have caused an error in determining a pass or fail result. 3. Interview on 1/16/26 at 11:19 a.m. with RN, Infection Prevention and Control D revealed: *She was not aware that surgical instruments were taped. *She expected the staff to inspect the surgical tape on instruments and replace it as needed according to the manufacturer’s IFU. *She performed rounds in the OR but did not notice any issues with packaging or rust on instruments, and stated, “I don’t look at all [of the] instruments, just a sample.” *She was not aware that surgical instruments were etched and were still being used. *She agreed etching of instruments created the potential for bacteria to remain on surgical instruments. *She was not trained to perform high-level disinfection, but yearly she used a checklist to confirm the competency of the staff who operated the endoscope reprocessor. *She was not aware that staff were performing the testing of the disinfectant of Rapicide PA incorrectly and not as instructed by the manufacturer’s IFU. Review of the provider’s 1/2026 Endoscope Reprocessing policy revealed, “Test sterilant solution with processing every scope by protocol; test strip sitting time into a med cup for 30 seconds with remaining water from sterilizer of that scope.” Review of the 2018 Rapicide PA test strips manufacturer’s IFU revealed: *”Shelf life is one year unopened and four months once opened. *For the ADVANTAGE PLUS AER [Automated Endoscope Reprocessor] - Use the sampling cups to collect the solution sample from the reprocessor. Dip the test strip indicator pad into the solution in the sampling cup for one second and immediately remove. Gently shake off excess solution. *Wait 30 seconds and then compare the test strip color with the color chart located on the side of the test strip bottle to determine peracetic acid ppm is above MRC [Minimum Required Concentration].””

“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: 50915 Based on observation, interview, record review, and policy review, the provider failed to ensure that two of two defibrillator (a device that delivers an electrical shock to correct life-threatening heart rhythms) and code carts (a wheeled cabinet with essential medications and equipment used during life-threatening emergencies) were checked daily for proper function according to provider’s daily checklist. Findings include: 1. Review of the 2019 Physio-Control LifePak 15 Monitor/Defibrillator Operation Instructions revealed: *User Tests “The User Test is a functional test of the LIFEPAK 15 monitor/defibrillator. The User Test should be performed only as a test and not while using the defibrillator during patient care. Perform the User Test as part of completing the daily Operator’s Checklist.” 2. Observation and record review on 1/13/26 at 11:15 a.m. in the emergency department (ED) revealed the January 2026 Defibrillator/Code Cart/Lucas Checklist had not been completed from January 1, 2026 to January 13, 2026. 3. Interview on 1/13/26 at 11:20 a.m. with registered nurse (RN) A revealed that if the ED Defibrillator/Code Cart/Lucas Checklist was completed, it was not documented, but should have been. 4. Observation and record review on 1/13/26 at 11:45 a.m. in the procedure room revealed the January 2026 Defibrillator/Code Cart/Lucas Checklist had not been completed on the 1st, 5th, and 9th days of January 2026. 5. Interview on 1/13/26 at 12:54 p.m. with director of patient care F regarding checking the defibrillators revealed she: *Confirmed the defibrillators were to be checked daily. *She expected the staff to document those checks as completed on the checklists daily.”

“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, and manufacturer’s instruction for use (IFU) review, the provider failed to ensure: *One of one Advantage Plus Endoscope Reprocessor (machine used to disinfect endoscopes and colonoscopes), water and air filters was changed every six months according to the manufacturer’s IFU. *One of one Advantage Plus Endoscope Reprocessor machine’s waterline was disinfected weekly according to the manufacturer’s IFU. Findings include: 1. Observation and interview on 11/14/26 at 10:00 a.m. in the sterile processing room with surgical technician (ST) B revealed: *One Advantage Plus Endoscope Reprocessor. *On the wall were three water filters (1 micron, 0.4 micron, and 0.1 micron). *She stated that the maintenance staff were responsible for changing the water and air filters, but she would have to remind them when the filters were due to be changed. *She was aware that the filters had not been changed every six months. *Documentation of the air filter changes was completed in May 2024, January 2025, and November 2025. -That indicated there was a nine-month gap and a ten-month gap between documented air filter changes. -The reprocessor’s left and right air filters should have been changed every six months according to the manufacturer’s IFU. *Documentation of the water filter changes were completed in May 2024, January 2025, and November 2025. -There was a nine-month gap and a 10-month gap between documented water filter changes. -The water filters (1 micron, 0.4 micron, and 0.1 micron) should have been changed every six months according to the manufacturer’s IFU. *She was responsible for completing the waterline disinfection. *Documentation of the waterline disinfection indicated it was completed monthly, dating back to August 2022. -The waterline disinfection was to be performed every week, and every time the 0.1 micron filter was changed. *She stated, “I did not realize it was supposed to be done weekly instead of monthly.” *On the wall were laminated guides to guide the staff in operating the Advantage Plus Endoscope Reprocessor, and she confirmed that it stated to run a waterline disinfection weekly. Interview on 1/15/26 at 1:35 p.m. with director of plant operations E revealed he: *Was unaware that the reprocessor’s air and water filters needed to be changed every six months according to the manufacturer’s IFU. *Stated, “I change the filters for the reprocessor upon request.” *Confirmed the air and water filters were not on any type of calendar or reminder. ST B would remind him when they are due to be changed. *Stated that sometimes, when the filters are old, the water pressure to the reprocessor will decrease, causing the machine to not work properly, and he would then change the filters. *Agreed that the air and water filters should have been changed every six months according to the manufacturer’s IFU. Review of the 2020 Medivator’s 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. *Weekly Maintenance: Water Line Disinfect: -In order to ensure the required water quality standards are met, the water line disinfection must be performed weekly.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 45683 Based on South Dakota Department of Health (SD DOH) complaint report, record review, interview, registered nurse (RN) III job description review, and RN orientation core curriculum, the provider failed to ensure physician’s orders for strict bed rest were followed for one of one sampled patient (16) who had increased pain in her left femur (thigh bone). Findings include: 1. Review of the SD DOH complaint report revealed: *Patient 16 was admitted on 4/5/25 at 12:00 p.m. from the nursing home. *Initial diagnosis was increased pain in her left femur due to a lesion. *The plan was to manage her pain and offer a hospice consultation. *Physician’s orders placed on 4/5/25 at 12:08 p.m. included: -“Chair TID [three times a day] with food.” -“Vital signs [measurements of the body’s basic functions, such as temperature, blood pressure, pulse, and respiration rate] QID [four times a day].”” -Ambulation [walking or moving around] TID as tolerated with assistance.” -“Tylenol, Dilaudid, Neurontin for pain.” -“DNR/DNI [do not resuscitate/do not intubate].” -“Hospice consult.” *At 1:42 p.m. a strict bed rest order was ordered. -Registered nurse (RN) M acknowledged that order at 1:50 p.m. -The nursing staff followed that order and documented the patient was on bedrest with repositioning efforts from 4/4/25 through 4/7/25. *On 4/8/25 at 12:42 a.m. RN I documented “Found the patient [16] sitting on the edge of her bed trying to standup asking, “Can’t I just sit in that chair.” She is assisted with 2 [by two staff members] to sit in the chair and elevated her legs. Note: her left femur is swollen, she c/o [complains of] increased pain, and her left foot is turned inward.” *On 4/8/25 at 1:03 a.m. RN I documented, “[Patient 16] Stood with 3 [staff members’ assistance] and gait belt and pivoted back to bed. Left femur is swollen, she is unable to move leg independently. She has severe pain with moving her leg. Repositioned with pillow until she reported less pain. Ice pack to femur.” *A physician’s order on 4/8/25 at 7:09 a.m. indicated to X-ray the femur with a left 2V (view) for possible femur fracture. *An x-ray of the left femur revealed a “pathologic fracture in the area of the infiltrative lesion involving the mid diaphysis (middle part of the long part of a bone) of the left femur.” *An order placed on 4/8/25 at 8:59 a.m.: -Left NWB (non-weight bearing). -Right NWB. *An order placed on 4/8/25 at 12:13 p.m. L(left)leg 10 bucks traction (temporary form of skin traction most often used for hip or femur injuries to keep the leg aligned). *Physician K’s progress notes on 4/8/25 at 9:00 a.m. stated that patient 16 “Suffered a fracture on the left femur at site of lesion last night. X-ray confirming displacement. Planning to place in traction today. She is strict non-weight bearing.” *Physician K’s progress note on 4/9/25 at 10:35 a.m. stated “During a transfer, [patient 16] developed worsening pain and subsequent pathologic fracture. Orthopedics was consulted and recommended traction, non-weight bearing. Due to the traction, unable to discharge [the patient] back to [the] nursing home.” *Patient 16 was discharged to inpatient hospice care at the hospital on 4/9/25 at 10:44 a.m. 2. Review of patient 16’s electronic medical record (EMR) revealed: *She had a diagnoses of: -Metastatic (spread from one part of the body to another) bone tumor. - Urothelial carcinoma (bladder cancer). -Stage III chronic kidney disease (moderaate kidney damage). -Closed left femoral fracture on 4/8/25. -UTI (urinary tract infection). -Memory impairment. *Review of nurse’s notes 4/5/25 through 4/8/25 regarding patient 16 revealed: -On 4/5/25: --At 12:54 p.m. no edema (swelling) noted. --At 2:00 p.m. bedrest, extensive assistance of 2 people. --At 3:47 p.m. hospice consult. --At 4:00 p.m. bedrest, extensive assistance of 2 people. --At 6:00 p.m. bedrest, extensive assistance of 2 people. --At 8:56 p.m. bedrest, extensive assistance of 2 people. --At9:46 p.m. resting in bed comfortably. --At 11:30 p.m., the patient’s daughter agreed on letting the patient rest until 2:00 a.m. -On 4/6/25: --At 3:11 a.m. patient resting comfortably in bed at this time, will continue to monitor. --At 6:20 a.m. reposition, extensive assistance, 2 people. --At 8:00 a.m. sleeping, on bedrest. --At 9:34 a.m. physical assessment completed, alert, confused, cooperative, at rest, no edema --At 12:00 p.m. bedrest --At 2:22 p.m. PRN (as needed) medication reassessment, effective opioid induced sedation, sleep. --At 4:00 p.m. reposition, extensive assistance, 2 people --At 5:54 p.m. reposition, extensive assistance, 2 people --At 9:05 p.m. patient on bedrest --AT 11:20 p.m. patient resting comfortably at this time -On 4/7/25: --At 3:12 a.m. patient resting comfortably. --At 5:13 a.m. reposition extensive assistance, 2 people . --At 6:17 a.m. pain controlled. --At 10:00 a.m. reposition extensive assistance, 2 people. --At 12:00 p.m. bedrest --At 1:17 p.m. physical assessment completed, awake, confused, drowsy cooperative, no edema --At 1:25 p.m. reposition, 2 people. --At 4:30 p.m. reposition, 2 people left side. --At 5:57 p.m. bedrest --At 8:00 p.m. RN I wrote: “Found her sitting on the edge of her bed trying to stand up, asking “can’t I just sit in that chair”. Staff assisted with 2 to sit in the chair and elevated legs. Note that her (L) femur is swollen, she c/o increased pain and her left foot is turned inward.” --10:30 p.m. RN I wrote: “Stood with 3 and gait belt and pivoted back to bed. (L) femur is swollen, she is unable to move leg independently. She has severe leg pain with moving her leg. Positioned with pillows until she reported less pain. Ice pack to her femur. Pain assessment 7 out of 10 --10:30 p.m. physical assessment completed, awake, appropriate for patient, tearful, non-pitting (no indentation left in skin) edema noted. -On 4/8/25: --At 12:00 a.m. Bedrest/reposition. --At 2:00 a.m. Bedrest/reposition. --At 3:30 a.m. PRN medication reassessment, she remains awake but is calmer. --At 6:13 a.m. Full leg immobilizer applied to her (L) leg to try to keep her leg immobilized due to pain. --At 8:00 a.m. Bedrest/supine with pillow. --At 10:00 a.m. Reposition total assistance, 2 people. --At 11:32 a.m. PRN medication reassessment patient slightly drowsy, less anxious, medication was effective. --AT 12:10 p.m. pain assessment 3 out of 10, patient placed in bucks traction. --At 1:15 p.m. pain assessment 0 out of 10, controlled. --At 3:25 p.m. note by certified nurse practitioner (CNP) J “Upon arrival to shift patient has a possible fracture of left femur. While in her bed she set off her bed alarm. RN and aide immediately presented to room finding her trying to stand out her bed. She was transferred to her chair last evening via stand-pivot transfer with assist of 2. RN assessed patient noting leg was misaligned, concerning for fracture of left femur. Patient transferred back to bed. She did not suffer a fall. RN placed patient in an immobilizer. Her pain was controlled with scheduled Oxycodone [pain medication, PO Roxanol [pain medication], and Ativan Intensol [a concentrated oral solution used primarily to treat anxiety disorders]” *The two transfers on the evening of 4/7/25 went against the physician’s orders for strict bed rest. 3. Interview on 1/14/26 at 10:15 a.m. with physician K revealed: *She recalled patient 16 being admitted for pain control. *Patient 16 had advanced dementia. *She expected the nursing staff to follow all physician orders. *X-rays confirmed a lesion on her left femur. *A hospice services referral was made. 4. Interview on 1/14/26 at 11:00 a.m. with CNP J revealed: *Patient 16 was admitted for pain control issues. *Patient 16 had a lesion on her left femur. *CNP J was notified by RN I that patient 16 had a possible left femur fracture when she arrived on 4/8/25. *She ordered x-rays for the possible femur fracture. *The x-rays confirmed a left femur fracture. *She stated with the lesion on the femur the fracture could have occured when patient 16 sat on the edge of the bed or when she was transferred to the chair. 5. Interview on 1/14/26 at 1:45 p.m. with RN I revealed: *After the nursing report, patient 16 was sitting on the edge of her bed, requesting to sit in the recliner. *She did not have time to review orders for patient. *She and another staff member used a pivot transfer to move patient 16 to the recliner. *She put patient 16’s feet up and recognized left leg swelling. *At 10:45 p.m., patient 16 was transferred back to bed and repositioned until she was comfortable, swelling was still noted in her left leg. *She stated patient 16 had calmed down and was resting, so she did not need to notify the provider until the next morning for rounds. *On 4/8/25 at 7:00 a.m. she notified CNP J about patient 16’s leg swelling. 6. Interview on 1/14/26 at 2:30 p.m. with RN, quality assurance L revealed: *She was aware of the 4/8/25 incident regarding patient 16. *The fracture was considered a pathological fracture and was not related to a fall, so it was not a reportable incident. *Staff were made aware of patient activities at shift change. 7. Interview on 1/15/26 at 10:15 a.m. with RN M revealed: *She confirmed she was the day shift charge nurse on 4/7/25. *Patient 16 was in the hospital at that time for pain control. *She knew that patient 16 had an order for strict bed rest. *Patients’ activity status were discussed at shift change report and written on the report sheet. *Patient activity status was also written on the whiteboard in each patient’s room. 8. Interview on 1/15/26 at 1:30 p.m. with chief executive officer (CEO) C and director of patient care F revealed: *Nursing reports were shared during shift change at 7:00 a.m. and 7:00 p.m. *Report sheets were updated and communicated with patient information. *All pertinent patient information was expected to be shared at that time. *They expected that the staff would follow the physician’s orders. 9. Observation on 115/26 at 1:45 p.m. of patient rooms revealed that patients’ ambulation and transfer status were written on the white boards in the rooms to notify staff. 10. Observation and interview on 1/15/26 at 1:55 p.m. with licensed practical nurse (LPN) N in patient 1’s room revealed: *The white board stated the patient was to be up with one assist for activity. *The patient’s activity status was to be shared at shift change. *The whiteboards in the patients’ rooms helped remind the staff of patient activity assistance needs for transfers and ambulation status. 11. Interview on 1/15/26 at 1:50 p.m. with RN G and RN H regarding shift change report revealed: *The shift change report was held every day at 7:00 a.m. and 7:00 p.m. face-to-face. *Items covered in the shift report would include the patient’s: -Vital signs. -Mental status. -Lab values. -Diet. -Code status. -Activity, such as weight bearing, walking, or bedrest. -Medication changes. -Goals. 12. Review of the provider’s revised 5/21/25 RN III job description revealed: *”Essential Job Functions.” -“Provides patient care by reviewing physician prescriptions; communicating the nursing care plan and all pertinent information to other members of the health care team; coordinating with other healthcare providers; providing physical, emotional, psychological, and spiritual support to patients, families, and friends; conferring with physicians.” -“Evaluates patient care by adhering to therapeutic standards; measuring health outcomes against patient care standards; reviewing patient records; noting changing conditions and needs; re-evaluating care objectives; modifying nursing care plan. -“Maintains safe, secure, and healthy patient care environment by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations; adhering to organization standards and policies, and to legal regulations; alerting others regarding potential concerns.” 13. Review of the provider’s undated RN Orientation Core Curriculum revealed: *”Hand-Off a. I have been provided instruction on providing report. b. Orientee delivers shift report, includes PCT/NA (patient care tech/nursing assistant) in shift report and/or shares information with PCT/NA.””

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 27198 Based on observation, testing, and interview, the provider failed to maintain a corridor separation from areas not protected by an approved electrically supervised automatic smoke detection system (fire alarm) in one randomly observed area (recovery room). Findings include: 1. Observation, testing, and interview on 1/14/26 at 2:47 p.m. revealed the recovery room had a sliding door to help facilitate entry to the room with a patient bed. Testing of that door at that same time revealed it did not have any means to provide positive latching and therefore left that area open to the corridor. Further observation at that same time revealed the recovery room was not furnished with a smoke detector connected to the building’s fire alarm system. Interview with the director of plant operations at that same time confirmed those findings. The deficiency could affect 100% of the smoke compartment occupants. Ref: LSC 19.3.6.1(1)(c), NFPA 72 chapter 17.”