Frio Regional Hospital

“K000 CURRENT ASC (USE THIS ONE) A life safety code (LSC) survey was conducted on site on 6/04/2026. An entrance conference was held with the Chief Executive Officer (CEO) and the Facility Director to discuss the purpose of the LSC survey and to explain survey process. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussions. 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 6/04/2026 in the Hospital. In attendance were the Chief Executive Officer (CEO) and the Facility Director. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussions. 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 Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/4/2026, that there was no record of the doors in the means egress having been 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 Emergency Shutoff: “Each air distribution system shall be provided with at least one manually operable means for stopping the operation of the supply, return, and exhaust fan(s) in an emergency. The means of manual operation shall be located at an approved location.” NFPA 90A, 2012, 6.2.1 & 6.2.2. The emergency stop or kill switch is typically a red “mushroom” button at a nurse station. There may be one switch for each air handler or one switch that shuts down multiple air handlers. Based on observation, the facility failed to provide adequate emergency system. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026 that there are six Roof Top Units (RTUs) serving the facility and there are no Kill Switches at the Nurses’ stations for patient care areas not served by the PTAC units-Med Surg area. Ensure that each kill switch is labelled to match the unit or units it controls and ensure that the kill switches are located around the nurse stations. Final filters and Frames: Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler. Based on observation, the facility failed to provide adequate monthly pressure drop records or scheduled filter change records. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that there was no record of the monthly pressure drops across the filters in the air handling units and there is no record of schedule for the filter change with the type of filters changed. RTU #4-Serving the Emergency Department does not have Fresh air intake source. Hospital HVAC Fresh Air Intakes are critical infrastructure designed to dilute airborne pathogens and manage indoor pollutants. To ensure patient safety, systems must adhere to strict engineering regulations like ASHRAE 170, which dictates mandatory minimum distances from contamination sources and set specific air change rate for different areas in the hospital. HLR, 2010: Figure: 25 TAC §133.169(c) Table 3. Based on observation, the facility failed to provide adequate Ventilation system. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that: 1. RTU #4 serving the Emergency Department did not have Fresh Air intake source. 2. The pre-Filters had not been changed and were very dirty. 3. The asepsis control quality of the Emergency Department is severely impaired.”

“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 Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that there are no designated smoking area and no metal containers with self-closing cover devices into which ashtrays can be emptied.”

“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 failed to provide adequate essential electrical system. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am am to 5:00 pm on 6/04/2026 that there were: 1. FACP is not powered by the Life Safety branch. It shall be powered by the Life safety branch. 2. The generator location receptacle is not powered from Life safety branch. It shall be powered by the Life safety branch. 3. The ATS location receptacle is not powered from the Life Safety Branch. It shall be powered by the Life safety branch.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 40763 K913 ELECTRICAL SYSTEMS - WET PROCEDURE LOCATIONS Based on observation the facility failed to provide adequate risk assessment for all the operating rooms. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026 that risk assessment was not performed by the governing body to determine if the Operating rooms were wet or dry locations. If determined to be wet, they shall be protected by line isolation monitors or GFCIs.”

“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 adequate inspection of the electrical system. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that there were the following issues: 1. There were no records of testing data and test interval of the patient care area receptacles as defined by Documented Performance Data. 2. The Line Isolation Monitor was not tested monthly or annually per the code. 3. There were no records of where, type of repair performed and date of electrical maintenance and required tests performed in all the patient care areas.”

“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 Essential Electric System Maintenance and Testing. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, 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 2 seconds. That shows the transfer time not properly being performed. 2. The weekly tests were not 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 identifiable.”

“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 biomedical electrical maintenance and inspection reports. The inspector observed, while accompanied by the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that the facility was not keeping records of personnel training or continuing education on the personnel responsible for equipment test and maintenance in the facility.”

“Gas Equipment - Testing and Maintenance Requi CFR(s): NFPA 101 Gas Equipment - Testing and Maintenance Requirements Anesthesia apparatus are tested at the final path to patient after any adjustment, modification or repair. Before the apparatus is returned to service, each connection is checked to verify proper gas and an oxygen analyzer is used to verify oxygen concentration. Defective equipment is immediately removed from service. Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables. Manufacturer service manuals are used to maintain equipment and a scheduled maintenance program is followed. 11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99) This Standard is not met as evidenced by: 40763 K924 GAS EQUIPMENT - TESTING AND MAINTENANCE REQUIREMENTS Based on observation, the facility failed to provide adequate medical gas equipment testing. The inspector observed, while accompanied by the Chief Executive Officer (CEO) and the Facility Director during the hours of the inspection from 10:00 am to 5:00 pm on 6/04/2026, that the facility had no scheduled maintenance program for medical gas equipment.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 26870 Based on record review and interview, the facility failed to ensure that that 5 (Patient #1, #3, #4, #8,and #9) out of 20 charts reviewed for informed consent contained the required delivery of information necessary for informed consent and/or properly executed informed consent forms. These forms included the required consent to treat upon admission, delivery of patient rights (necessary for patients to make informed decisions about how they wish to proceed with treatment). Findings included: Records review of patient medical records on 5/6/2026 for required documentation of patient consent to treat upon admission, delivery of patient rights, revealed the following: Patient #1 Review of Patient #1’s chart revealed that he was admitted to the facility on 11/30/2025. Forms titled Conditions of Admission and Consent was missing 4 out of 8 pages. There was no documentation of delivery of patient rights. No record was found of the consent to treat or record of delivery of patient rights upon admission. Patient #3 Review of Patient #3’s chart revealed that she was admitted to the facility on 3/5/2026. There was documentation of Patient #3 signed her Patient Rights; however, there was no date nor time documented. Patient #4 Review of Patient #4’s chart revealed that he was admitted to the facility on 2/4/2026. Forms titled Conditions of Admission and Consent was missing 5 out of 8 pages. There was no documentation of delivery of patient rights or Advanced Directives. No record was found of the consent to treat or record of delivery of patient rights upon admission. Patient #8 Review of Patient #8’s chart revealed that she was admitted to the facility on 4/3/2026. Review of the Medical Care and Surgical Consent revealed the Physician signed the form; however, there was no time nor date documented. Patient #9 Review of Patient #9’s chart revealed that she was admitted to the facility on 4/3/2026. Review of the Medical Care and Surgical Consent revealed the Physician signed the form; however, there was no time nor date documented. Interview on 5/7/26 at 10:30AM with Staff #13 revealed there was a problem with scanning in medical forms and there are some patient records where not all forms were uploaded. Further interview revealed surgeon’s had created a new form for surgical consents and had forgotten to add a line for including the date and time of when the surgeon signed the surgical consent.”

“RECORDS SYSTEM CFR(s): Dated signatures of the doctor of medicine or osteopathy or other health care professional. This Standard is not met as evidenced by: 26870 Based on record review and interviews, the facility failed to ensure entried in the medical record were times, dated and authenticated. Specifically, 2 (#8 and #9) out of 20 patient records reviewed did not have surgical consents dated and timed at the time the surgeon signed his name. These forms included the required consent to treat upon admission, delivery of patient rights (necessary for patients to make informed decisions about how they wish to proceed with treatment. Findings included: Records review of patient medical records on 5/6/2026 for required documentation of patient consent to treat upon admission, delivery of patient rights, revealed the following: Patient #8 Review of Patient #8’s chart revealed that she was admitted to the facility on 4/3/2026. Review of the Medical Care and Surgical Consent revealed the Physician signed the form; however, there was no time nor date documented. Patient #9 Review of Patient #9’s chart revealed that she was admitted to the facility on 4/3/2026. Review of the Medical Care and Surgical Consent revealed the Physician signed the form; however, there was no time nor date documented. Interview with Staff #13 at the time of the patient record review revealed surgeon’s had created a new form for surgical consents and had forgotten to add a line for including the date and time of when the surgeon signed the surgical consent.”

“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: 26870 41048 Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following: 1.) The Medical Surgical area 2.) The Newborn Nursery 3.) The Labor and Delivery area 4.) The Rehabilitation Center at facility B 5.) The surgical services area 6.) The Dietary/Kitchen area and 7.) Linen/Laundry area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. These deficient practices placed the patients’ health and safety at risk for the transmission of infections and/or communicable diseases. Findings included: Observations on 5/5/2026 at 10:45 AM of the facility with the Infection Control Nurse present revealed the following: 1.) Newborn Nursery a) there was a vital sign machine that had a dusty base. 2.) Labor and Delivery Room 2 a) in labor and delivery room 2, the bedframe was dusty. b) a step stool that was identified as being clean, was dusty on the feet. c) a recliner in the clean patient room, when opened, revealed a dusty metal frame. 3.) Hallway in Medical Surgical Department a) Several vital sign machines had a dusty base. Several Computer on Wheels also had a dusty base. b) There were twowheel chairs in the hallway, the foot pedals that were folded up, revealed a thick layer of dust. 4.) Room 102 a) picture frames hanging in the clean patient room was dusty on top. b) Bed frame revealed dust under the mattress. 5.) Clean Supply Room a) The plastic bins contained light dust in each bin. 6.) Medication Room a) Pill crushers contained pill residue and were dirty on the outside. 7.) Nourishment Room a) Plastic bins contained dust. b) Patient refrigerator had patient food, containing fish, with no date nor time, Another bag containing patient food had a date of 4/22/26. That patient meal was in the fridge for 13 days. Confirmed by the CNO who was touring with the surveyors. c) Inside the microwave oven, the ceiling had food/drink splatters. 8.) Surgical Services a) A wheelchair was stored in OR hallway, staff surveyors were touring with could not tell surveyors if the wheel chair was clean or dirty. b) Two beds in the Pre-Op had tears, exposing the weaved lined from the torn vinyl cover. c) Another bed had a sticky residue from when Velcro was removed. Sticky residue could not be wiped off. d) 3 intravenous (IV) pumps on the counter that were not wrapped. Staff touring with the surveyors could not identify the IV pumps as clean or dirty. 9.) In Patient Rehab Services a) Plastic bins containing rehab equipment contained dust inside bins. b) Wood clothespins in use were stored in plastic bins, wood clothes pins are porous and can not be wiped and sanitized between patients, Observations on 5/6/2026 at 8:30 AM at Facility B, of the facility’s Rehabilitation Center with the Infection Control Nurse present revealed the following: 10.) Rehabilitation Center a) A mat in the pediatric room had a tear along the seam, exposing linen weave. b) A bean bad chair in the pediatric room, had a tear in the seam, exposing linen weave. c) Exam bed in the examination room, had a dusty metal frame, d) Patient freezer had a build up of ice. 11.) Facility Kitchen/Dietary Observations conducted on 05/26/2026 from 10:00 AM to 11:00 AM of the facility’s Kitchen area with the Director of Dietary present revealed the following observations: -The three compartment dishwashing sink area had white substance in the sanitizer compartment. -There was a rack of cookie sheets, the bottom cookie sheet had food particles. -Wire shelves, had a spill on the floor under the shelves. 12) Laundry/Linen a) main linen sorting and linen supply area revealed two washers which have settings numbered from 1-6. These numbers are settings for different types of wash programs. A matrix explaining the settings water temperatures and chemical mixture was not readily available by the washer. Interview on March 05, 2026 at 10:01am with facility staff #11 revealed she was not sure if a matrix or explanation was available to evaluate the different settings of the washers. Staff #11 further stated they didn’t know the washing water temperature for any of the machine-washing settings. Staff #11 confirmed they did not sanitize the machine after each washing cycle, including mops and housekeeping towels. Interview on 05/6/28at 13:30 AM with the Director of Dietary in the kitchen area of the facility confirmed the findings in the kitchen and stated he would get right on it and get it taken care of. During an interview on 05/6/23 at 3:50 PM with the Infection Disease Nurse during observations during the hospital tour revealed that when it comes to the nursing equipment, it is the nurses responsibility to clean the vital machines and computer on wheels during the nurses shift. It is Environmental Services (EVS) responsibility to clean the facility and patient rooms. The following facility records and policies were reviewed: Record review of the facility’s policy titled, “Laundering Linen and Towels” Policy EVS054, effective 3/27/2025 and approved by Governing Board states, in part: Suggested formulas and types of loads for which they are designed - appear on the wall charts furnished with your chemicals. Make the necessary temperature settings. The terminal temperature of the cooldown cycle is not more than 15 degrees above the incoming cold-water temperature. Review of the policy titled, Dietary Services dated 01/2023 revealed the following, in part: 2. Dietary Service manager: -To develop and maintain clean, sanitary work areas, storage areas and equipment for handling of supplies in accordance with state and local health department standards. 3. Infection control Practices - All floors in the Dietary Services food preparation area will be cleaned daily with approved disinfectant. -Separate areas shall be specified for food preparation and for cleanup. Record review of the facility policy, titled Infection Control, last revised 05/2020, states in part... “All healthcare providers, in partnership with the medical staff, are responsible for the safety, health and well-being of all patients, physicians, visitors and healthcare workers (HCW). This responsibility maybe met by working together continuously to promote safe infection control practices, observing all rules, regulations, procedural guidelines and continually assessing the program to identify risks involved with the facility’s demography of patients, in an effort to improve the quality of patient care.” Record review of the facility policy, titled General Hospital Wide Infection Control, last revised 11/2001, states in part... “Equipment and Cleaning of: Machines: Damp wipe with approved disinfectant daily and PRN by Imaging/Radiology Department personnel. Exam tables: Wipe with disinfectant between patients by Imaging/Radiology Department personnel. Furniture, floor, walls, counters, sinks, ceiling tracks, gurneys and wheelchairs: Environmental Services personnel clean floors daily, spot wash or thoroughly clean walls as needed, clean sinks daily, ceiling tracks as necessary, gurneys and wheelchairs when visibly soiled. Minor spills of blood, body fluid, and/or other potentially infectious material: Imaging/Radiology departmental personnel are to clean minor spills immediately utilizing approved disinfectant and wearing appropriate personal protective equipment. Major spills of blood, body fluid, and/or other potentially infectious material: Contact Environmental Services personnel to manage major spills.””

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 26870 Based on record review and interview, the facility failed to inform 3 (Patient #1, #3, and #4) out of 20 charts reviewed of their patient rights, in advance of furnishing or discontinuing care whenever possible. Findings included: Records review of patient medical records on 5/6/2026 for required documentation of patient consent to treat upon admission, delivery of patient rights, revealed the following: Patient #1 Review of Patient #1’s chart revealed that he was admitted to the facility on 11/30/2025. Forms called Conditions of Admission and Consent was missing 4 out of 8 pages. There was no documentation of delivery of patient rights. No record was found of the consent to treat or record of delivery of patient rights upon admission. Patient #3 Review of Patient #3’s chart revealed that she was admitted to the facility on 3/5/2026. There was documentation of Patient #3 signed her Patient Rights; however, there was no date nor time documented. Patient #4 Review of Patient #4’s chart revealed that he was admitted to the facility on 2/4/2026. Forms called Conditions of Admission and Consent was missing 5 out of 8 pages. There was no documentation of delivery of patient rights or Advanced Directives. No record was found of the consent to treat or record of delivery of patient rights upon admission. Interview on 5/7/26 at 10:30AM with Staff #13 at the time of the patient record review revealed there was a problem with scanning in medical forms and there are some patient records where not all forms were uploaded.”