Refugio County Memorial Hospital

“A life safety code (LSC) survey was conducted on site on 6/3/2026. An entrance conference was held with the CEO, Maintenance Director, EMS Director, Director of Compliance and Risk Assessment and Interim CNO to discuss the purpose of the LSC survey and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 6/3/2026 in the Hospital. In attendance were the Maintenance Director, Maintenance Staff and Director of Nursing. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 40763 K200 MEANS OF EGRESS REQUIREMENTS - OTHER List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 Based on observation, the facility failed to provide record of annual door testing. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there was no record of the doors in the means being tested annually.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 40763 K500 BUILDING SERVICES - OTHER Based on observation, the facility failed to provide adequate Ventilation system. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there were the following issues. They were: 1. One of the final filter frame was missing in HVAC unit serving the New building ER area. 2. The pre-filters were dirty and has not been changed recently. 3. There is no record of scheduled filters change for the old and new building the hospital 4. There is no record of Relative Humidity reading in ER or the Treatment”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 40763 K741 SMOKING REGULATIONS Based on observation the facility failed to provide adequate ashtrays and no designed smoking areas provided. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there are no designated smoking area and no metal containers with self-closing cover devices into which ashtrays can be emptied.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 40763 K907 GAS AND VACUUM PIPED SYSTEMS - MAINTENANCE PROGRAM Based on observation the facility failed to provide a risk assessment for the medical gas system. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that the facility had not done a risk assessment to determine the procedures and schedule for testing the medical gas system.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 40763 K908 GAS AND VACUUM PIPED SYSTEMS - INSPECTION AND TESTING OPERATIONS Based on observation, the facility failed to provide an adequate record of inspections and testing of the Med gas system. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there was no current record of actual inspections and tests of the Med gas system.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 40763 K911 ELECTRICAL SYSTEMS - OTHER Essential Electrical System Segregation (Life Safety): “The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment.” NFPA 99, 2012, 6.4.2.2.1.1. 6.4.2.2.3 Life Safety Branch. 6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety. 6.4.2.2.3.2 “The life safety branch shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with 101, Life Safety Code, (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code, (3) Hospital communications systems, where used for issuing instruction during emergency conditions, (4) Generator set locations as follows: (a) Task illumination, (b) Battery charger for emergency battery-powered lighting unit(s), (c) Select receptacles at the generator set location and essential electrical system transfer switch locations, (5) Elevator cab lighting, control, communications, and signal systems, (6) Electrically powered doors used for building egress, (7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code.” 6.4.2.2.3.3 “Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch.” 6.4.2.2.3.4 “Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices.” 6.4.2.2.3.5 “No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3.” Based on observation, the facility did not provide adequate egress exist path and no critical branch panels in some of the electrical room. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there were: 1. The egress-electrical control doors are powered from the equipment branch. The electrical control doors shall be powered from the life safety branch. 2. That in most of the electrical rooms, the critical panels are present. 3.In the ATS room, the elevator is shown to be powered from the LS & CR Transfer panel. The elevator shall be powered from the Equipment branch. 4.In the boiler room, remove the Medical gas panels from EQB panel-(Equipment branch) to Life Safety panel. 5.In the generator room, remove the light from light from Life safety branch to Critical branch. Life safety lights are not switchable. 6.All the lights in the Patient care rooms are powered from the normal branch. It shall be powered from the critical branch.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 40763 K914 ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING Based on observation the facility failed to provide evidence adequate testing of line Isolation monitors. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there were the following issues. They were: 1. The testing of the patient care area receptacles is not being tested annually. 2. Records of maintenance, modifications and associated repairs are being kept.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 40763 K918 ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING ESSENTIAL ELECTRIC SYSTEM Based on observation the facility failed to provide adequate testing and maintenance of the electrical systems. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that there were the following issues. They were: 1. The monthly tests were not performed regularly according to the code. The recent test report presented shows the transfer time of 13 seconds. The transfer time shall not be more than 10 seconds. 2. The weekly tests were not being performed correctly. The generator weekly inspections record: shall include fuel level, hoses, belts, oil level, cooling water level, radiator clear, battery electrolyte level, housekeeping of enclosure, and general visual inspection for damage. 3. The 36-month load test for 4 continuous hours was not being performed. No record of performance provided. 4. The main and feeder circuit breakers annual inspection records were not provided at time of inspection. 5. There were inadequate and incomplete records of maintenance and testing provided at the time of inspection. 6. All the EES electrical panels and circuits are not marked correctly and readily identiable.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 40763 K919 ELECTRICAL EQUIPMENT - OTHER Generator Remote Manual Stop: “All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building” - NFPA 110, 2010, 5.6.5.6* Note: “For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.” A.5.6.5.6. Based on observation, the facility failed to provide a remote emergency generator shut down switch at the correct location. The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that the remote shutdown switch for the generator was located inside the generator room. The kill switch shall be installed outside the generator enclosure.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 40763 K921 Electrical Equipment - Testing and Maintenance Requirements Based on observation the facility failed to provide adequate qualification verification of the Portable Patient Care Related Electrical Equipment (PCREE) System testing technicians The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/3/2026, that the qualification of contractors performing the PCREE testing are not being verified.”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure the development and implementation of a comprehensive, data-driven QAPI program that provides effective oversight and sustained performance improvement across all departments. The facility failed to ensure: 1.) A structured, governing QAPI program, 2.) Data-driven performance improvement, 3.) Effective Governing Body oversight, and 3.) Effective infection prevention/ control and safe medication practices. These deficient practices have the potential to affect all patients receiving care at the facility. The cumulative effect of these systemic failures resulted in The facility’s inability to meet the conditions of participation for QAPI. See Tags: C-1306, C-1311, C-1313 and C-1325,”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 21935 Based on a facility tour and interview with accompanying staff there were areas in the facility that were unclean and needed better sanitary practices. The facility failed to maintain a clean and sanitary environment, as shown by dust on ventilation vents, unclean and disorganized storage drawers in the dietary department, inadequate environmental cleaning practices throughout the facility, poor maintenance of the exterior waste disposal area, and a lack of protection for clean equipment from environmental contamination. These issues could lead to greater risks of environmental contamination, pest activity, and infection transmission. Findings: 1. Observation during the environmental tour revealed multiple areas requiring improved cleaning and sanitation practices. In the dietary department, all ceiling ventilation vents contained visible dust accumulation. Kitchen drawers used to store utensils and miscellaneous items were observed to be cluttered and soiled. Additional areas throughout the facility demonstrated a need for enhanced high-dusting to maintain a clean and sanitary environment. 2. Observation of the hospital’s exterior waste disposal area revealed the trash compactor and an adjacent cardboard waste container. The cardboard container was observed open, creating the potential for rodent access and the removal or dispersal of waste materials. Miscellaneous debris and trash were also observed on the ground within the waste disposal area, which was expected to be maintained in a clean condition. 3. Observation of the clean equipment storage room on the second floor revealed patient care equipment stored uncovered. The equipment was not protected from environmental contamination, and its clean status could not be readily identified. 4. During an interview conducted on May 13, 2026, at approximately 9:30 a.m., Staff #4 accompanied the surveyor during the kitchen tour and acknowledged the dust accumulation on the ceiling vents and the unclean condition of the kitchen floors. 5. During an interview conducted on May 13, 2026, at approximately 2:30 p.m., Staff #11 accompanied the surveyor during the facility tour and acknowledged multiple areas where additional high-dusting was needed. 6. During an interview conducted on May 12, 2026, at approximately 2:45 p.m., Staff #23 who worked in the nursing area was asked about the uncovered equipment stored in the second-floor clean equipment room. Staff #23 stated they did not know whether the equipment was clean or why it had been left uncovered and unprotected from environmental contaminants.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure the development and implementation of a comprehensive, data-driven QAPI program that provides effective oversight and sustained performance improvement across all departments. The facility failed to ensure: 1.) Data-driven performance improvement, 2.) Effective infection prevention and control, and 3.) Safe medication practices These deficient practices have the potential to affect all patients receiving care at the facility. Findings included: Record review of the Quality Improvement meeting minutes, dated for the time period of January 2026 through April 2026 revealed the following information: 02/24/26- Chart Audits: Acute Care- 72%; Valuables/belongings, call light demonstration, shift change report not being documented in EMR. -Braden Scale - 82%; Not completing upon discharge -Discharging - 90%; admitting physician, doesn’t have a place for discharge upon admission in the EMR. Emergency Department: -Chest Pain - 76%; Need complete set of vital signs within 15min of discharge, Initial pain scale not documented in EMR. -Transfers - 87%; Need complete set of vital signs within 15min of transfer, physicians not inputting transfer orders into the EMR (simply stating discharge orders), -Documentation of patient home medication in EMR needs to be done. This is a reportable requirement to the State. -Trauma - 75%; Initial plain scale on flowsheets needs to be documented. -Physicians need to order ETOH/UDS lab orders per trauma activation protocols. Further review of the 02/24/26 QAPI minutes revealed in the section entitled Outcome: “No action required,” with no evidence of implementation of corrective actions or performance improvement processes. 03/31/25- Chart Audits: -Acute Care - 74%; Valuables/belongings, call light demonstration, shift change report not being documented in EMR. -Braden Scale - 85%; Not completing upon discharge -TREATMENT ROOM - 84%; Repeat vital signs after 1 hour od stay and within 15min of discharge needs to be completed. Emergency Department: -Chest Pain - 61%; Need complete set of vital signs hourly and within 15min of discharge; -Initial pain scale not documented in EMR. -Transfers - 81%; Need complete set of vital signs within 15min of transfer, physicians not inputting transfer orders into the EMR (simply stating discharge orders), -Documentation of patient home medication in EMR needs to be done. This is a reportable requirement to the State. -Critical Patient - 89%; Need complete set of vital signs -Trauma - 91%; Need to complete trauma flow sheet, and EMS summary report missing from a few charts. Further review of the 03/31/26 QAPI minutes revealed in the section entitled Outcome: “See above deficient areas and remedies” with no evidence of implementation of corrective actions or performance improvement processes. 04/28/26- Quality Reporting by Department: Nursing: -Need to improve nurse charting metrics across the board. Further review of the 04/28/26 QAPI minutes revealed no evidence of implementation of corrective actions or performance improvement processes. In an interview conducted on 05/12/26 at 1:10 pm, the facility RN Infection Preventionist, who also functions as the Quality Director, confirmed that the facility did not have a formal Quality Committee, and performance issues were addressed informally rather than through a structured governing QAPI body. He further stated that the preveious QAPI Director retired in December 2025, so he recieved no training in QAPI. He revealed that he was unaware of what subjects/ areas need to be incorporated in the QAPI program, so he was just “deconstructing” the previous years QAPI information. In addition, the facility administrative leadership was asked by the survey team for the facility’s infection control, QAPI and medication management policies. As of survey exit on 05/13/26, no information was provided.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (5) Address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure the development and implementation of a comprehensive, data-driven QAPI program that addressed outcome indicators related to infection control outcomes and the prevention and reduction of medication varriances/errors. the facility failed to ensure: 1.) An effective, facility-wide infection prevention and control program with active oversight, monitoring, and sustained improvement. and 2.) Safe medication practices, including monitoring, reconciliation, and resolution of medication variances and controlled substance accountability. These deficient practices have the potential to affect all patients receiving care at the facility. Findings included: Record review of the Quality Improvement meeting minutes, dated for the time period of January 2026 through April 2026 revealed the following information: 1.) Infection prevention and control: - 02/24/26- No mention of Infection control or prevention activities in QAPI minutes. - 03/31/36- No mention of Infection control or prevention activities in QAPI minutes. - 04/28/26- Topic of Discussion: Hand washing Audit. - “Administrative staff have observed for the past 4 weeks, that across the board we are at 15% hand hygiene compliance. We need to do better as department directors and managers to ensure our staff is foaming in and foaming out appropriately.” Further review of the 04/28/26 QAPI minutes revealed no evidence of implementation of corrective actions or performance improvement processes. In an interview conducted on 05/12/26 at 1:10 pm, the facility RN Infection Preventionist, who also functions as the Quality Director, confirmed that the facility did not have a formal Quality Committee, and performance issues were addressed informally rather than through a structured governing QAPI body. He further stated that the preveious QAPI Director retired in December 2025, so he recieved no training in QAPI. He revealed that he was unaware of what subjects/ areas need to be incorporated in the QAPI program, so he was just “deconstructing” the previous years QAPI information. 2.) Medication practices: 2/24/26- Topic Discussion: Emergency Department Transfer Communication. - 33% for January due to patient home medications not being reconciled in the EMR. Reportable requirement to State. Outcome: Nurses agreed to start reconciling patient home meds in the ER. Further review of the 02/24/26 QAPI minutes revealed no evidence of implementation of corrective actions or performance improvement processes. 03/31/26- Topic Discussion: Emergency Department Transfer Communication. -47% for February due to patient home medications not being reconciled in the EMR. Reportable requirement to State. Outcome: Nurses agreed to start reconciling patient home meds in the ER. Further review of the 03/31/26 QAPI minutes revealed no evidence of implementation of corrective actions or performance improvement processes. 04/28/26- Topic Discussion: Pharmacy Med Variance Reports: - January 2026 = 7 - February 2026 = 13 - March 2026 = 4 -Will continue to monitor end of shift counts, temperature logs, unit inspections. -Created planning worksheet for identifying expired medications. Further review of the 04/28/26 QAPI minutes revealed no evidence of implementation of corrective actions or performance improvement processes. In an interview conducted on 05/12/26 at 2:30 pm, the facility Pharmacy Director identified ongoing issues with medication variances and controlled substance discrepancies, including inconsistent nursing practices such as failure to perform end-of-shift counts and failiure adequately preform medication reconcilliations. In addition, the facility administrative leadership was asked by the survey team for the facility’s infection control, QAPI and medication management policies. As of survey exit on 05/13/26, no information was provided.”

“QAPI CFR(s): (c) Standard: Governance and leadership. The CAH’s governing body or responsible individual is ultimately responsible for the CAH’s QAPI program and is responsible and accountable for ensuring that the QAPI program meets the requirements of paragraph (b) of this section. This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility’s Governing Body failed to provide effective oversight and sustained performance improvement across all departments. The governing body failed to ensure that the QAPI program was comprehensive, data-driven and that quality indicators were analyzed and utilized to implement and sustain performance improvement and sustain corrective actions in response to identified performance deficiencies. These deficient practices have the potential to affect all patients receiving care at the facility. Findings included: Record review of the Quality performance data for the time period of January 2026- April 2026 demonstrated ongoing quality preformance issues, including persistent medication errors reaching patients across multiple months, unresolved medication variances, repeated documentation ommissions, and lack of effective, facility-wide infection prevention and control program with active oversight, monitoring, and sustained improvement. Further review of the Quality Performace data for January 2026- April 2026 revealed that despite data reflecting suboptimal performance, there was no evidence of sustained corrective action, trending analysis, or monitoring to resolution as required by the QAPI plan. In an interview conducted on 05/12/26 at 1:10 pm, The facility RN Infection Preventionist, who also functions as the facility Quality Director, confirmed the facility did not have a formal Quality Committee, and that performance issues were addressed informally rather than through a structured governing QAPI body. In addition, the facility administrative leadership was asked by the survey team for the facility’s infection control, QAPI and medication management policies. As of survey exit on 05/13/26, no information was provided.”

“QAPI CFR(s): (e) Standard: Program data collection and analysis. The program must incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program incorporated quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. The facility failed to: -Incorporate data relating to hospital infection surveillance and -Incorporate identified medication safety risks. These deficient practices have the potential to affect all patients receiving care at the facility. Findings included: Record review of the Quality Improvement Performance indicator data, dated for the time period of January 2026 through April 2026 reflected approximately 15% hand hygiene compliance across departments, indicating significantly low adherence without documented evidence of effective corrective action or sustained improvement. Further review revealed continued medication errors reaching patients, ongoing unresolved medication variances, and variation in controlled substance count compliance across units, including decreased compliance on the 3rd floor. There was no evidence that infection control surveillance data and/or identifed medication safety risks were consistently included within the QAPI processes. In an interview conducted on 05/12/26 at 1:10 pm, the facility RN Infection Preventionist, who also functions as the Quality Director, stated infection prevention activities were limited to periodic monitoring (e.g., chart reviews, handwashing audits) without evidence of a structured infection control committee or formal governance structure. In an interview conducted on 05/12/26 at 2:30 pm, the facility Pharmacy Director identified ongoing issues with medication variances and controlled substance discrepancies, including inconsistent nursing practices such as failure to perform end-of-shift counts and failiure adequately preform medication reconcilliations. In addition, the facility administrative leadership was asked by the survey team for the facility’s infection control, QAPI and medication management policies. As of survey exit on 05/13/26, no information was provided.”