Cornerstone Specialty Hospitals Little Rock

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52740 Based on review of policy, patient record review, observations, and staff interviews. It was determined that the facility failed to protect and promote each patient’s rights related to notice of patient rights, prompt resolution of patient grievances, receiving care in a safe setting, and monitoring patient condition during restraint use. 1. Facility was unable to provide evidence that all patients admitted to the facility are given a copy of their patient rights, read a copy of their patient rights, or are able to understand their patient rights. 2. Facility failed to update the patient rights information with the correct name telephone number for their accrediting agency violating the patient’s right to prompt resolution of grievances. 3. Facility failed to provide a safe environment for patients to receive care placing patients at risk for physical or mental harm. 4. Facility failed to follow their policy for monitoring patients who are restrained placing patients at risk for physical or mental harm. The failed practices had the likelihood of affecting the physical and mental health of all patients who are admitted to the facility. See A 0116, A 0120, A 0144, and A 0175”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 52740 Based on policy review, review of patient records, observations, and interviews, it was determined that the facility failed to have a well organized nursing service and that the registered nurses (RN) failed to provide supervision to patient care technicians (PCT) and certified nursing assistants (CNA) in that the facility failed to ensure that patient needs were met by ongoing assessment of patient needs and provide patient care as ordered for 20 of 20 (#1-#20) discharged and currently admitted patients reviewed. This failed practice placed all admitted patients at risk for physical and mental health harm. The findings follow: See A-0392 for details.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 52740 Based on review of policy, clinical record review, and interview, it was determined the facility failed to inform 20 (#1-#20) of 20 patients, whose records were reviewed, of their patient rights. The failed practice did not assure the patient and/or their legal representative were informed upon admission of their patient rights, provided a copy of their rights, or understood their rights. The failed practice had the likelihood of affecting all patients admitted to the facility. Findings follow: A. Review of policy “Patient Assessment, Reassessment and High Risk Screens” dated 05/2022 showed, “The Admissions Coordinator, or designee, will obtain the following information...Advise patient/family of their rights and responsibilities during the admit interview process, by verbal communication and handout.” B. Review of document titled “Patient Rights and Responsibilities” no date, showed “The patient has the right to receive a copy of this document in advance of patient care being furnished or discontinued, whenever possible.” C. A review of 20 (#1-#20) of 20 clinical records reviewed showed no evidence the patient or their legal representative had been informed and/or provided with a copy of their patient rights. Evidence was requested on 07/09/25 at 10:00 AM, which showed each patient and/or their legal representative had their patients rights reviewed with them during the admission process and that they had received a copy. No evidence was provided. D. During an interview on 07/09/25 with the Director of Quality Management and the Chief Clinical Officer the findings in A-C were confirmed.”

“PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 52740 Based on review of policy and procedure, clinical record review, and interview, it was determined the facility failed to provide notification to patients, family members, and visitors regarding how to file timely refferal of a greivance for medicare patients . The failed practice did not allow for medicare patients and/or their legal representative to recieve a timely response or resolution of a greivance. The failed practice had the likelihood of affecting all patients who received care in the facility. Findings follow: A. Review of policy titled “Patient Assessment, Reassessment and High Risk Screens” last reviewed 5/2022 showed, “The Admissions Coordinator, or designee, will...Inform the patient of the complaint process” B. Review of policy titled “Patient Complaints and Grievances” dated 11/2024 showed, “Case management must inform patients of the process to register Complaints and Grievances through the ScionHealth website, and patient Rights and Responsibilities handouts provided during the registration process, and in postings within the facility.” C. During review of 20 (#1-#20) of 20 clincial records, documents in records showed instructions for filing a greivance with the previous Accredting Agency which the hospital no longer used and no instructions were provided for contacting the current Accrediting Agency. Facility was unable to provide evidence of updated forms with correct Accredting Agency information. D. During an interview with the Director of Quality Management and the Cheif Clinical Officer on 07/09/2025 at 12:30 PM, the findings in A-C were confirmed.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 51070 Based on review of policy and procedure, training materials, observation, and interviews, it was determined the facility failed to ensure that patients received safe effective pulmonary care in that inconsistencies were observed during the practice of suctioning ventilated patients, staff did not follow manufacturers guidelines for the closed suction system device or facility procedure, and there was confusion as to which roles could perform closed suctioning on patients on the ventilator or with a tracheostomy collar (T-collar). The failed practice increased the likelihood of harm and/or failure to rescue patients experiencing a respiratory emergency. The failed practice had the likelihood of affecting all patients on a ventilator or a T-collar. Findings follow: A. A policy was requested which identified which roles could perform suction procedures on ventilated patients or those with a T-collar on 07/09/25 at 1:30 PM and again on 07/10/25 at 9:30 AM. None was provided. B. Review of training material titled “Cornerstone Hospital General Hospital Orientation”, no date, showed a picture of a closed suction catheter and stated, “suctioning is a shared task between nurses and respiratory therapy (RT)”. Additionally, a note at the bottom of the training slide showed that staff should seek help from RT if they need additional training or practice with suctioning skills. C. Evidence was requested on 07/09/25 at 1:30 PM and again on 07/10/25 at 9:30 AM which showed that staff members had been trained in respiratory care and suctioning techniques (i.e. open and closed) on ventilated patients or those with a T-collar, None was provided. D. During observations of respiratory procedures on 07/09/25 at 11:00 AM and again on 07/10/25 at 11:00 AM, Surveyor #1 observed different procedures for closed suctioning using the same closed suction system. E. During an interview with RT #1 on 07/09/25 at 11:15 AM, he stated “I push the suction catheter down until I hit the carina and pull back a little and start suctioning”. F. During an interview with RT #2 on 07/10/25 at 11:35 AM, he stated he “pushes the suction catheter down until he meets resistance and begins suctioning”. G. During an interview with Registered Nurse (RN) #2 on 07/10/25 at 12:45 PM, she stated that she “advances the closed suction system until she hits something and then pulls back, but I only suction if RT is busy”. H. During an interview with the Respiratory Therapy Manager on 07/09/25 at 10:00 AM, she confirmed the unit is staffed with two RTs each shift and may be busy with daily respiratory treatments or in an emergency leaving nursing staff to attend to the pulmonary needs of patients within their scope of practice. I. During an interview with the Director of Quality and the Chief Clinical Officer (CCO) on 07/10/25 at 1:30 PM, both stated that nursing staff do not perform closed suction on ventilated patients or those with a T-collar. The CCO confirmed the findings in A-I during the interview. 52740 Based on policy, observation, clinical record review, and interview, it was determined the facility failed to provide a safe environment free from defects, chemical contaminants, and infectious organisms. The failed practice did not prevent the spread of infection or ensure patients and staff were safe from harm. The failed practices had the likelihood of affecting all patients receiving care in the facility. A. Review of policy “Patient Safety Plan” (Review Date 05/2022) showed, “The organization wide patient safety program is designed to reduce unexpected occurrences, undesired outcomes, and hazardous conditions by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety. “... All operational areas of the hospital are monitored for patient safety compliance by its staff continuously and are reported to the Environment of Care/ Patient Safety Committee.” B. Protocol “Clorox Total 360 Disinfection Protocol” showed, “Required Personal Protective Equipment (PPE): Eye protection, gloves, gown or long-sleeved covering, surgical mask or N95 respirator. Pre-use Checklist: Remove people, pets, food, and sensitive electronics from the area. Ensure proper ventilation. Post-Use Procedure: Ventilate the area if needed. Do not allow re-entry until surfaces are dry and safe.” Additionally, the Protocol “Clorox Pro Quick Start Guide” showed steps in utilizing the Clorox Total 360 system includes closing the area off to the public and placing a ‘Cleaning in Progress’ sign outside of room. C. During a tour on the facility on 07/09/2025 between 9:00 AM and 10:30 AM the following was observed. 1. A pill crusher located in the east medication room showed multicolored powdery residue. 2. The east nurse’s station had an alcove with a refrigerator marked “for patient use only” and showed melted food products in the freezer and “Lemon Glycerin Swabs” which should be stored at room temperature per manufactures insert. 3. An electrical panel in the east nurses station was unlocked and the door latch was broken. 4. The handrails on both sides the hall near the administration office had large cracks in the plastic leaving sharp loose edges. 5. The medication refrigerator in the west medication room did not have a locking mechanism allowing for unauthorized access to refrigerated medications. 6. A member of housekeeping was observed using the Clorox 360 disinfectant system in a patient room. The housekeeper did not don eyewear, gloves, or gown while spraying the room with aerosolized bleach particles. Additionally the room had not been closed off per manufacturers instruction to prevent chemical contamination to those walking past the room. D. During an interview with the Chief Clinical Officer on 07/09/25 at 12:30 PM, the findings in A-C were confirmed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 52740 Based on document review, clinical record review, and interview it was determined the facility failed to provide ongoing assessment and monitoring for two of two patients (#8 and #12) who were in non-violent wrist restraints. The failed practice placed all patients, who are restrained for non-violent, non-self-destructive behavior, at risk for possible physical injury and failed to ensure that use of restraint is discontinued at the earliest possible time. Findings follow: A. A review of Cornerstone Specialty Hospitals “Restraint Care Plan (Non-Violent Non-Self Destructive Behavior)” interventions showed: 1) Perform daily restraint assessment specific to behaviors, observations, and other related restraint needs to determine if the need for restraint continues to exist. 2) Perform safety checks and ongoing monitoring q (every) 2 hours or more often if condition warrants. 3) Assess potential for restraint removal during each temporary release. B. A review of Cornerstone Specialty Hospitals “Restraint Monitoring (Non-Violent Non-Self Destructive Behavior)” form showed: 1) Safety Checks and Monitoring (at least Q 2 Hours): Initial when intervention performed- contains grid table with safety interventions listed: date, time, and boxes for initials. 2) Section titled: Daily Assessment to Determine Need for Restraint(s) contains: a) list of behaviors with yes/no and comments area b) question: Is the need for restraint resolved? i) No- Review the Care plan: No change or Updates with area for comments ii) Yes- Restraint removed by: (nurse), Time, Date, Care Plan Resolved c) RN signature line with time and date C. A review of “Arkansas State Board of Health Rules for Hospitals and Related Institutions in Arkansas: Section 13 (Restraints) E.” showed: “Documentation in the patient’s record regarding any type of restraint shall include the time the restraint was applied, released and discontinued, as well as evidence of continual assessment, monitoring and re-evaluation of the patient’s condition during the restraint incident.” D. A review of patient #8’s restraint monitoring showed: 1) On 05/28/2025, no evidence was provided by facility of daily restraint assessment completion and safety checks from 7:00 PM to 5:00 AM on 05/29/2025. 2) On 05/29/2025, no evidence was provided by facility of daily restraint assessment completion, signature by a Registered Nurse (RN), and safety checks from 7:00 PM to 5:00 AM on 05/30/2025. 3) On 05/30/2025, documentation by RN #2 at 12:00 PM showed the need for restraint was resolved, and restraints were removed. At 7:00 PM, another staff member began placing check marks in the intervention boxes and continued to check mark them through 5:00 AM. On May 31, 2025. No evidence was provided by facility that showed restraint re-application was necessary. 4) On 05/31/2025, the facility provided no evidence of daily restraint assessment completion, and no evidence was provided by facility of safety checks from 7:00 AM to 5:00 AM on 06/01/2025. 5) On 06/01/2025, the facility provided no evidence of safety checks from 7:00 AM through 6:00 AM on 06/02/2025. 6) On 06/03/2025, the facility provided no evidence of daily restraint assessment completion. 7) On 06/04/2025, no evidence of restraint monitoring was provided by the facility. 8) On 06/05/2025, the facility provided no evidence of safety checks from 7:00 AM through 7:00 AM on 06/06/2025. 9) On 06/06/2025 at 5:00 AM RN #3 charted “No change” in need for restraint. No evidence of restraint monitoring for 06/06/2025 was provided by facility. 10) Facility provided no evidence of restraint monitoring from 7:00 PM on 06/07/2025 to 5:00 AM on 06/08/2025. 11) At 6:54 PM on 06/12/2025, RN #4 charted assessment determining need for restraint. Facility provided no evidence of restraint monitoring from 7:00 PM to 5:00 AM on 06/13/2025. 12) On 06/15/2025, Facility provided no evidence of daily restraint assessment completion or restraint monitoring from 06/14/2025 at 7:00 PM to 5:00 AM on 06/15/2025. 13) Facility provided no evidence of restraint monitoring from 7:00 AM on 06/15/2025 to 5:00AM on 06/16/2025. 14) Facility provided no evidence of restraint monitoring from 7:00 AM on 06/16/2025 to 6:00 PM on 06/18/2025, . 15) On 06/25/2025, No evidence was provided by facility of daily assessment to determine need for restraints completion. 16) On 06/27/2025, facility provided no evidence of daily assessment to determine need for restraints assessment completion or RN signature. E. Review of patient #12’s restraint monitoring showed: 1)On 04/03/2025, Facility provided no evidence of daily assessment to determine need for restraints was completed. 2) On 04/04/2025, Facility provided no evidence of restraint monitoring from 7:00 PM until 5:00 AM on 04/05/2025. There is no evidence of RN signature on daily assessment to determine need for restraint, 3) On 04/05/2025, facility provided no evidence of completion of daily assessment to determine need for restraints. 4) On 04/06/2025, facility provided no evidence of completion of daily assessment to determine need for restraints or RN signature. 5) On 04/08/2025, facility provided no evidence of restraint monitoring from 6:00 AM to 6:00 PM. 6) On 04/09/2025, facility provided no evidence of completion of daily assessment to determine need for restraints or restraint monitoring from 7:00 AM until 5:00 PM. 7) On 04/10/2025, facility provided no evidence of RN signature on daily assessment to determine need for restraint. 8) On 04/11/2025, facility provided no evidence of restraint monitoring from 3:00 PM to 7:00 PM. 9) On 04/12/2025, facility provided no evidence of restraint monitoring from 3:00 AM to7:00 AM and no evidence of completion of daily assessment to determine need for restraints. 10) From 11:00 PM on 04/12/2025 until 5:00 PM on 04/13/2025, facility provided no evidence of restraint monitoring, no evidence of daily assessment to determine need for restraints completion, and no evidence of RN signature on 04/13/2025. 11) On 04/14/2025, facility provided no evidence of restraint monitoring from 7:00 AM until 7:00 PM. 12) From 7:00 PM on 04/17/2025 to 5:00 AM on 04/19/205, facility provided no evidence of restraint monitoring. 13) On 04/19/2025, facility provided no evidence of completion of daily assessment to determine need for restraints or restraint monitoring from 7:00 PM on 04/19/2025 to 5:00 AM on 04/20/2025. 14) On 04/20/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. 15) On 04/21/2025,facility provided no evidence of RN completion of daily assessment to determine need for restraints. 16) On 04/22/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. 17) On 04/25/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. 18) On 4/26/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. facility provided no evidence of restraint monitoring from 7:00 PM on 04/26/2025 to 7:00 AM on 04/27/2025. 19) On 04/27/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. facility provided no evidence of restraint monitoring from 7:00 PM on 04/27/2025 to 7:00 AM on 04/28/2025. 20) On 04/28/2025, facility provided no evidence of RN completion of daily assessment to determine need for restraints. 21) On 04/29/2025, facility provided no evidencre of restraint monitoring from 7:00 AM to 9:00 AM on 05/01/2025. F. Findings confirmed with COO during debriefing interview on 07/10/2025 at 4:05 PM.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 52740 Based on policy review, review of patient records, observations, and interviews, it was determined that the facility failed to have a well organized nursing service and that the registered nurses (RN) failed to provide supervision to patient care technicians (PCT) and certified nursing assistants (CNA) in that the facility failed to ensure that patient needs were met by ongoing assessment of patient needs and provide patient care as ordered for 20 of 20 (#1-#20) discharged and currently admitted patients reviewed. This failed practice placed all admitted patients at risk for physical and mental health harm. The findings follow: A. Review of Cornerstone Specialty Hospitals “Patient Assessment, Reassessment and High Risk Screens” (policy #CL-2.0 review date 05/2022) showed: 1) The assessment process will be a continuous collaborative effort with all of the healthcare members functioning as a team. 2) Reassessment is ongoing and may be triggered by key decision points and at any interval(s) specified by the department’s ancillary disciplines directly involved in providing patient treatment and/or care. 3) Daily assessment data is documented in the medical record. Initial nursing assessment is done at the beginning of each shift unless special circumstances warrant a more rapid assessment. B. Review of ScionHealth Registered Nurse job description (date revised 01/27/2025) showed: 1) Provides planning and delivery of direct and indirect patient care through the nursing process of Assessment, Planning, Intervention, and Evaluation. 2) Directs, supervises, provides and evaluates nursing care provided to patients. 3) Performs assessment on all patients on admission and reassessments as per policy. 4) Performs patient care responsibilities considering needs specific to the standard of care for patient’s age. 5) Receives physician’s orders, ensures transcription is accurate and documents completion. 6) Performs treatments and provides services to level of licensure. C. Review of ScionHealth Certified Nursing Assistant job description (date revised 02/08/2024) showed: 1) Essential functions: takes and records temperature, pulse, respiration, weight, height, blood pressure, and intake and output measurements accurately. Documents in a timely manner. 2) Provides general nursing care such as positioning the patient, lifting, turning, applying/ utilizing special equipment, assisting in the use of bed pan, urinal or commode, ambulating the patient, pre operative and post operative care, and application of binder or anti embolic stockings, bad bath, oral/hair/back care, changing bed linens, cleaning over bed table, and bedside stand, straightening patient room and other genera care necessary during the shift. 3) Essential functions: Serves and removes patient meal tray in timely manner. Assists with feeding and/or preparing items such as opening milk container, cutting food for patient. D. Review of ScionHealth Patient Care Technician job description (date revised 12/26/2024) showed: 1) Essential functions: takes and records temperature, pulse, respiration, weight, height, blood pressure, and intake and output measurements accurately. Documents in a timely manner. 2) Provides general nursing care such as positioning the patient, lifting, turning, applying/ utilizing special equipment, assisting in the use of bed pan, urinal or commode, ambulating the patient, pre operative and post operative care, and application of binder or anti embolic stockings, bad bath, oral/hair/back care, changing bed linens, cleaning over bed table, and bedside stand, straightening patient room and other genera care necessary during the shift. 3) Essential functions: Serves and removes patient meal tray in timely manner. Assists with feeding and/or preparing items such as opening milk container, cutting food for patient. E. During interview with Chief Clinical Officer (CCO) on 07/10/2025 at 1:55 PM, CCO verified that vital signs are to be obtained every four hours. F. Review of 20 patient charts included 10 patients (#1-#9, and #20) receiving care during survey and 10 patients (#10-#19) discharged prior to survey. 1) Patient #1 chart review showed provider order, written at 1:45 PM on 07/07/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, vitals q 4 hours and PRN (as needed). a) No evidence was provided by facility that admission weight was recorded on patient’s vital sign record b) No evidence was provided by facility that output was recorded for 7P-7A (7:00 PM to 7:00 AM) shift on 07/09/2025 c) No evidence was provided by facility that output was recorded for 7P-7A shift on 07/10/2025 2) Patient #2 chart review showed provider order, written at 1:00 AM on 06/18/2025, for weight on admission and weekly, VS (vital signs) q 6 hours and PRN, I&O q shift a) Weight was recorded on 06/19/2025. No evidence was provided by facility that weight was recorded again until 06/28/2025. No evidence was provided by facility that weight was recorded from 06/28/2025 through 07/10/2025 b) No evidence was provided by facility showing that vital signs were recorded between 8:00 AM and 4:00 PM on 06/18/2025 and between 8:00 PM on 06/18/2025 and 4:00 AM on 06/19/2025. c) No evidence was provided by facility that vital signs were recorded between 8:00 PM on 06/19/2025 and 4:00 AM on 06/20/2025 and between 4:00 AM on 06/20/2025 and 12:00 AM on 06/21/2025. d) No evidence was provided by facility that vital signs were recorded between 8:00 AM and 8:00 PM on 06/21/2025 and between 8:00 PM on 06/21/2025 and 4:00 AM on 06/22/2025. e) No evidence was provided by facility that vital signs was recorded between 8:00 PM on 06/22/2025 and 4:00 AM on 06/23/2025 and between 8:00 AM and 4:00 PM on 06/23/2025. f) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/23/2025 and 8:00 AM on 06/24/2025, and between 8:00 AM and 4:00 PM on 06/24/2025, and between 8:00 PM on 06/24/2025 and 4:00 AM on 06/25/2025. g) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/25/2025 and between 8:00 PM and 4:00 AM on 06/26/2025. h) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/26/2025. i) No evidence was provided by facility that showed output was recorded on the 7:00 AM to 7:00 PM shift on 06/20/2025, 06/21/2025, 06/26/2025. j) No evidence was provided by facility that showed output recorded on 7:00 PM to 7:00 AM shift on 06/23/2025, 06/25/2025, 06/27/2025, 07/05/2025. k) No evidence was provided by facility that showed intake was recorded on the 7:00 AM to 7:00 PM shift on 06/20/2025, 06/21/2025, 06/26/2025. l) No evidence was provided by facility that showed intake was recorded on the 7:00 PM to 7:00 AM shift on 06/23/2025, 06/27/2025, 06/29/2025, 07/05/2025, 07/06/2025. m) No evidence was provided by facility that showed the percentage of meal eaten record was found on 07/07/2025 or dinner on 07/09/2025. 3) Patient #3 chart review showed provider order, written at 11:45 AM on 06/20/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Weight was recorded on admission, but facility provided no evidence of weight being recorded again during admission b) No evidence was provided by facility that vital signs were recorded between 4:00 AM and 8:00 PM on 06/22/2025. c) No evidence was provided by facility that vital signs were recorded between 8:00 AM and 4:00 PM on 06/23/2025, and between 8:00 PM on 06/23/2025 and 4:00 AM on 06/24/2025. d) No evidence was provided by facility that showed that vital signs were recorded between 8:00 AM and 4:00 PM on 06/24/2025, and between 8:00 PM on 06/24/2025 and 4:00 AM on 06/25/2025. e) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/25/2025, and between 8:00 PM on 06/25/2025 and 4:00 AM on 06/26/2025. f) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/26/2025, and between 8:00 PM on 06/26/2025 and 4:00 AM on 06/27/2025. g) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/27/2025, and between 8:00 PM on 06/27/2025 and 4:00 AM on 06/28/2025. h) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/28/2025, and between 8:00 PM on 06/28/2025 and 4:00 AM on 06/29/2025. i) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/29/2025, and between 8:00 PM on 06/29/2025 and 4:00 AM on 06/30/2025. j) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 06/30/2025, and between 8:00 PM on 06/30/2025 and 4:00 AM on 07/01/2025. k) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/01/2025, and between 8:00 PM on 07/01/2025 and 4:00 AM on 07/02/2025. l) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 8:00 PM on 07/02/2025, and between 8:00 PM on 07/02/2025 and 4:00 AM on 07/03/2025. m) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/03/2025, and between 8:00 PM on 07/03/2025 and 4:00 AM on 07/04/2025. n) No evidence was provided by facility that showed that vital signs were recorded between 8:00 AM and 4:00 PM on 07/04/2025, and between 8:00 PM on 07/04/2025 and 4:00 AM on 07/05/2025. o) No evidence was provided by facility that showed vital signs were recorded between 8:00 PM on 07/05/2025 and 4:00 AM on 07/06/2025. p) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/06/2025, and between 8:00 PM on 07/06/2025 and 4:00 AM on 07/07/2025. q) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/07/2025, and between 4:00 PM on 07/07/2025 and 8:00 AM on 07/08/2025. r) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/08/2025, and between 8:00 PM on 07/08/2025 and 4:00 AM on 07/09/2025. s) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/09/2025, and between 8:00 PM on 07/09/2025 and 8:00 PM on 07/10/2025. t) No evidence was provided by facility that showed vital signs were recorded between 8:00 PM on 07/10/2025 and 4:00 AM on 07/11/2025. u) No evidence was provided by facility showing that intake was recorded on the 7:00 AM to 7:00 PM shift on 06/22/2025 and 07/10/2025, or the 7:00 PM to 7:00 AM shift on 06/20/2025, 07/07/2025, and 07/10/2025. v) No evidence was provided by facility showing that output was recorded on the 7:00 AM to 7:00 PM shift on 06/22/2025, 06/25/2025, 06/29/2025, 07/06/2025, and 07/10/2025. w) No evidence was provided by the facility showing that output was recorded on the 7:00 PM to 7:00 AM shift on 07/05/2025 and 07/07/2025. x) No evidence was provided by facility that showed meal percentage consumed was recorded for dinner on 06/22/2025, breakfast on 06/23/2025, dinner on 06/24/2025, dinner on 07/03/2025, breakfast, lunch, or dinner on 07/06/2025, and breakfast, lunch or dinner on 07/10/2025. 4) Patient #4 chart review showed provider order, written at 5:40 PM on 06/30/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 8 hours and PRN (as needed). a) Weight was recorded on 06/30/2025. No evidence was provided by the facility showing weekly weight being recorded. b) No evidence was provided by facility that showed vital signs were recorded between 8:00 PM on 07/03/2025 and 8:00 AM on 07/04/2025. c) No evidence was provided by the facility showing that intake was recorded on the 7:00 PM to 7:00 AM shift on 07/03/2025 and 07/07/2025. 5) Patient #5 chart review showed provider order, written at 3:15 PM on 06/20/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 8 hours and PRN (as needed). a) Patient was admitted on 06/20/2025. There is no evidence provided by the facility showing weight being recorded until 06/28/2025. There is no evidence provided by facility showing weight being recorded from 06/28/2025 through 07/10/2025. b) No evidence was provided by facility that showed vital signs were recorded between 8:00 PM on 06/20/2025 and 8:00 AM on 06/21/2025. c) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 8:00 PM on 06/24/2025. d) No evidence was provided by the facility that showed vital signs were recorded between 4:00 PM on 07/09/2025 and 8:00 AM on 07/10/2025. e) No evidence was provided by facility showing intake was recorded on the 7:00 AM to 7:00 PM shift on 06/27/2025 or the 7:00 PM to 7:00 AM shift on 06/20/2025, 06/21/2025, 06/23/2025, 06/26/2025, 06/27/2025, 07/08/2025, and 07/09/2025. f) No evidence was provided by facility showing output was recorded on the 7:00 PM to 7:00 AM shift on 06/21/2025, 06/26/2025, 06/27/2025, 07/08/2025, and 07/09/2025. g) No evidence was provided by facility that showed meal percentage consumed was recorded for breakfast, lunch, or dinner on 06/29/2025, dinner on 07/01/2025, dinner on 07/02/2025, dinner on 07/03/2025, dinner on 07/04/2025, breakfast, lunch, or dinner on 07/05/2025, and breakfast on 07/10/2025. 6) Patient #6 chart review showed provider order, written at 9:30 PM on 07/08/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). No evidence was provided by facility showing admission weight was obtained. 7) Patient #7 chart review shows patient admitted 05/22/2025, admission orders for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) No evidence was provided by facility showing that admission weight was obtained. No evidence was provided by facility showing weight was recorded on graphic sheets. b) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/02/2025 and 12:00 AM on 06/03/2025. c) No evidence was provided by facility that showed vital signs were recorded between 8:00 PM on 06/09/2025 and 8:00 AM on 06/10/2025. d) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/10/2025 and 8:00 AM on 06/11/2025. e) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/13/2025 and 12:00 AM on 06/14/2025. f) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/19/2025 and 8:00 PM on 06/20/2025. g) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/20/2025 and 8:00 AM on 06/21/2025. h) No evidence was provided by facility that showed vital signs were recorded between 12:00 PM and 8:00 PM on 06/21/2025 and 8:00 PM on 06/21/2025 and 4:00 AM on 06/22/2025. i) No evidence was provided by facility showing that intake was recorded on the 7:00 AM to 7:00 PM shift on 05/30/2025, 6/20/2025, or the 7:00 PM to 7:00 AM shift on 05/31/2025, 06/06/2025, 06/09/2025, 06/13/2025, 06/19/2025, 06/20/2025, 06/21/2025, 07/04/2025, 07/05/2025, and 07/06/2025. j) No evidence was provided by facility showing that output was recorded on the 7:00 AM to 7:00 PM shift on 05/30/2025, 06/20/2025, or on the 7:00 PM to 7:00 AM shift on 05/31/2025, 06/04/2025,06/07/2025, 06/09/2025, 06/19/2025, 06/20/2025, 06/21/2025, 07/04/2025, 07/05/2025, and 07/06/2025. 8) Patient #8 chart review showed provider order, written at 4:00 PM on 05/27/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Weight was recorded on 05/27/2025. The facility provided no evidence of weight being obtained again until 06/14/2025. The facility, also, provided no evidence of weight being obtained between 06/14/2025 and 07/05/2025. b) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/03/2025 and 8:00 AM on 06/04/2025. c) No evidence was provided by facility that showed vital signs were recorded between 12:00 PM on 06/06/2025 and 12:00 AM on 06/07/2025. d) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/09/2025 and 8:00 AM on 06/10/2025. e) No evidence was provided by facility that showed vital signs were recorded between 12:00 PM on 06/10/2025 and 8:00 AM on 06/11/2025. f) No evidence was provided by facility that showed vital signs and I&O were recorded between 4:00 AM on 06/18/2025 and 8:00 AM on 06/21/2025. g) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 06/02/2025 and 12:00 AM on 06/03/2025. h) No evidence was provided by facility that showed vital signs were recorded between 12:00 AM on 07/01/2025 and 8:00 AM on 07/02/2025. i) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 07/03/2025 and 8:00 AM on 07/04/2025. j) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 07/04/2025 and 8:00 AM on 07/05/2025. k) No evidence was provided by facility that showed vital signs were recorded between 4:00 PM on 07/08/2025 and 8:00 AM on 07/09/2025. l) No evidence was provided by facility that showed vital signs were recorded between 12:00 AM on 07/09/2025 and 8:00 AM on 07/10/2025. m) No evidence was provided by the facility showing intake was recorded on the 7:00 AM to 7:00 PM shift on 06/09/2025, 06/19/2025, 06/20/2025 or the 7:00 PM to 7:00 AM shift on 06/19/2025, 06/20/2025, 06/27/2025, 06/28/2025, 06/29/2025, 07/03/2025, 07/04/2025, 07/05/2025. n) No evidence was provided by the facility showing that output was recorded on the 7:00 AM to 7:00 PM shift on 06/10/2025, 06/11/2025, 06/19/2025, 06/20/2025, 07/01/2025, or the 7:00 PM to 7:00 AM shift on 06/19/2025, 06/20/2025, 06/28/2025, 07/01/2025, 07/03/2025, 07/04/2025, and 07/05/2025. 9) Patient #9 chart review showed provider order, written at 11:21 PM on 07/07/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) No evidence was provided by facility that showed vital signs were recorded between 12:00 AM on 07/09/2025 and 8:00 AM on 07/10/2025. b) No evidence was provided by facility that showed vital signs were recorded between 8:00 AM and 4:00 PM on 07/10/2025. 10) Patient #10 chart review showed provider order, written at 11:19 PM on 07/07/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) No evidence was provided by facility that intake or output was recorded on the 7:00 PM to 7:00 AM shift on 07/08/2025. b) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 07/08/2025 and 8:00 AM on 07/09/2025. 11) Patient #11 chart review showed provider order, written at 1:53 AM on 03/13/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Facility provided no evidence of weight being recorded on admission. Weight recorded on 04/12/2025. Facility did not provide evidence of weight being recorded again until 04/26/2025. Facility did not provide evidence of weight being recorded from 05/03/2025 to 06/14/2025. Facility did not provide evidence of weight being recorded from 06/14/2025 to 06/26/2025. b) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 03/14/2025 and 8:00 AM on 03/15/2025. c) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 03/17/2025 and 8:00 AM on 03/18/2025. d) No evidence was provided by facility that showed that vital signs were recorded between 12:00 PM and 8:00 PM on 03/24/2025. e) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 03/27/2025 and 12:00 AM on 03/28/2025. f) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 03/28/2025 and 8:00 AM on 03/29/2025. g) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM and 8:00 PM on 04/01/2025. h) No evidence was provided by facility that showed that vital signs were recorded between 8:00 AM and 8:00 PM on 04/02/2025. i) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 04/06/2025 and 8:00 AM on 04/07/2025. j) No evidence was provided by facility that showed that vital signs were recorded between 12:00 AM and 8:00 AM on 04/08/2025. k) No evidence was provided by facility that showed that vital signs were recorded between 8:00 PM on 04/18/2025 and 4:00 AM on 04/19/2025. l) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 04/21/2025 and 8:00 AM on 04/22/2025. m) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM and 8:00 PM on 04/28/2025. n) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 04/30/2025 and 8:00 AM on 05/01/2025. o) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM and 8:00 PM on 05/03/2025. p) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 05/18/2025 and 8:00 AM on 05/19/2025. q) No evidence was provided by facility that showed that vital signs were recorded between 12:00 PM and 8:00 PM on 05/21/2025. r) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM and 8:00 PM on 05/26/2025. s) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM and 8:00 PM on 05/28/2025. t) No evidence was provided by facility that showed that vital signs were recorded between 12:00 AM and 8:00 AM on 06/07/2025. u) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 06/07/2025 and 8:00 AM on 06/08/2025. v) No evidence was provided by facility that showed that vital signs were recorded between 12:00 PM and 8:00 PM on 06/10/2025. w) No evidence was provided by facility that showed that vital signs were recorded between 4:00 PM on 06/15/2025 and 8:00 AM on 06/16/2025. x) No evidence was provided by facility that showed that vital signs were recorded between 4:00 AM on 06/19/2025 and 8:00 AM on 06/21/2025. y) No evidence was provided by facility that showed that vital signs were recorded between 12:00 AM and 8:00 AM on 06/26/2025. z) The facility did not provide evidence showing intake was recorded on the 7:00 AM to 7:00 PM shift on 3/22/2025, 04/01/2025, 04/02/2025, 04/23/02025, 04/28/2025, 05/03/2025, 05/07/2025, 05/21/2025, 05/28/2025, 06/18/2025, or the 7:00 PM to 7:00 AM shift on 03/14/2025, 03/17/2025, 03/28/2025, 04/06/2025, 04/07/2025, 04/10/2025, 04/11/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/18/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/25/2025, 04/26/2025, 05/04/2025, 05/05/2025, 05/10/2025, 05/18/2025, 05/22/2025, 05/23/2025, or 06/07/2025. aa) The facility did not provide evidence showing output was recorded on the 7:00 AM to 7:00 PM shift on 03/29/2025, 04/01/2025, 04/02/2025, 04/23/2025, 04/28/2025, 05/03/2025, 05/07/2025, 05/09/2025, 05/21/2025, 05/28/2025, 06/12/2025, 06/19/2025, 06/20/2025, 06/21/2025, or the 7:00 PM to 7:00 AM shift on 03/14/2025, 03/17/2025, 03/23/2025, 03/25/2025, 03/28/2025, 04/04/2025, 04/06/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/18/2025, 04/20/2025, 04/21/2025, 04/25/2025, 04/28/2025, 04/30/2025, 05/05/2025, 05/10/2025, 05/13/2025, 05/18/2025, 05/22/2025, 05/23/2025, 05/24/2025, 06/07/2025, 06/15/2025, 06/18/2025 through 06/20/2025, and 06/25/2025. 12) Patient #12 chart review showed provider order, written at 8:00 PM on 04/03/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Facility provided no evidence of vital signs, I&O, or weights for 04/03/2025 to 04/05/2025. b) Facility provided no evidence of weights obtained during admission. c) No evidence was provided by facility that showed that vital signs were recorded from 12:00 PM to 8:00 PM on 04/21/2025. d) No evidence was provided by facility that showed that vital signs were recorded from 8:00 PM on 04/24/2025 until 8:00 AM on 04/25/2025. e) No evidence was provided by facility that showed that vital signs were recorded from 12:00 PM on 04/29/2025 until 8:00 AM on 04/30/2025. f) The facility did not provide evidence showing intake was recorded on the 7:00 AM to 7:00 PM shift on 04/13/2025, 04/22/2025, 04/29/2025, and on the 7:00 PM to 7:00 AM shift on 04/06/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, and 04/29/2025. g) The facility did not provide evidence showing output was recorded on the 7:00 AM to 7:00 PM shift on 04/22/2025, 04/29/2025, and on the 7:00 PM to 7:00 PM shift on 04/20/2025 and 04/29/2025. 13) Patient #13 chart review showed provider order, written at 2:42 PM on 04/15/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Admission weight obtained on 04/15/2025. No evidence was provided showing patient weight was obtained again until 04/26/2025. No evidence was provided showing patient weight was obtained between 04/26/2025 and 05/03/2025. No further evidence of weight records was shown before discharge on 05/19/2025. b) Facility provided no evidence vital signs were obtained from 4:00 PM on 04/27/2025 to 8:00 AM on 04/28/2025. c) Facility provided no evidence vital signs were obtained from 12:00 AM to 8:00 AM on 04/30/2025. d) Facility provided no evidence vital signs were obtained from 12:00 AM to 8:00 AM on 05/06/2025. e) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/18/2025 to 8:00 AM on 05/19/2025. f) Facility provided no evidence showing intake was recorded on the 7:00 PM to 7:00 AM shift on 04/23/2025, 04/24/2025, 04/27/2025, 04/30/2025, 05/04/2025, 05/05/2025, 05/09/2025, 05/10/2025, 05/16/2025, 05/17/2025, and 05/18/2025. g) Facility provided no evidence showing output was recorded on the 7:00 PM to 7:00 AM shift on 04/16/2025, 04/25/2025, 04/27/2025, 04/30/2025, 05/05/2025, 05/17/2025, and 05/18/2025. 14) Patient #14 chart review showed provider order, written at 4:00 PM on 04/18/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Admission weight obtained on 04/18/2025. Facility provided no evidence showing weight from 04/18/2025 to 05/10/2025. Facility provided no evidence showing weight was obtained from 05/10/2025 to 05/18/2025. Facility provided no evidence of weight obtained from 05/18/2025 to 06/14/2025. Facility provided no evidence showing weight was obtained from 06/14/2025 until discharge. b) Facility provided no evidence that vital signs were obtained from 4:00 PM on 04/29/2025 to 8:00 AM on 04/30/2025. c) Facility provided no evidence that vital signs were obtained from 4:00 AM to 8:00 PM on 5/03/2025. d) Facility provided no evidence that vital signs were obtained from 8:00 PM on 05/17/2025 to 8:00 AM on 05/18/2025. e) Facility provided no evidence that vital signs were obtained from 4:00 AM on 05/19/2025 to 8:00 AM on 05/21/2025. f) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 05/23/2025. g) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/23/2025 to 8:00 AM on 05/24/2025. h) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 05/25/2025. i) Facility provided no evidence that vital signs were obtained from 4:00 AM to 8:00 PM on 05/26/2025. j) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/31/2025 to 8:00 AM on 06/01/2025. k) Facility provided no evidence that vital signs were obtained from 12:00 AM on 06/05/2025 to 8:00 AM on 06/06/2025. l) Facility provided no evidence that vital signs were obtained from 4:00 PM on 06/06/2025 to 8:00 AM on 06/07/2025. m) Facility provided no evidence that vital signs were obtained from 4:00 PM on 06/11/2025 to 8:00 AM on 06/12/2025. n) Facility provided no evidence that vital signs were obtained from 12:00 AM on 06/05/2025 to 8:00 AM on 06/06/2025. o) Facility provided no evidence that vital signs were obtained from 4:00 PM on 06/15/2025 to 8:00 AM on 06/16/2025. p) Facility provided no evidence that vital signs were obtained from 4:00 PM on 06/25/2025 to 8:00 AM on 06/26/2025 and from 12:00 PM to 8:00 PM on 06/26/2025. q) Facility provided no evidence showing that intake was recorded on the 7:00 AM to 7:00 PM shift on 05/03/2025, 05/13/2025, 05/14/2025, 05/20/2025, or the 7:00 PM to 7:00 AM shift on 04/22/2025-04/25/2025, 04/27/2025, 04/29/2025, 05/12/2025-05/17/2025, 05/20/2025, 05/23/2025, 05/25/2025, 05/29/2025-5/31/2025, 06/06/2025-06/09/2025, 06/11/2025, 06/15/2025, 06/25/2025. r) Facility provided no evidence showing that output was recorded on the 7:00 AM to 7:00 PM shift on 05/03/2025, 05/09/2025, 05/20/2025, 06/26/2025, or the 7:00 PM to 7:00 AM shift on 04/25/2025, 04/25/2025, 04/29/2025, 05/16/2025- 05/18/2025, 05/20/2025, 05/22/2025, 05/23/2025, 05/25/2025, 05/30/2025, 5/31/2025, 06/06/2025, 06/09/2025, 06/11/2025, 06/15/2025, 06/18/2025, 06/25/2025, 06/27/2025. 15) Patient #15 chart review showed provider order, written at 2:00 AM on 02/18/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). Patient was admitted from 02/18/2025 to 03/31/2025. a) Facility provided no evidence of admission weight obtained. Record showed weight obtained on 03/22/2025. Facility provided no evidence of further weights. b) Facility provided no evidence that vital signs were obtained from 12:00 AM on 02/19/2025 to 8:00 AM on 02/20/2025. c) Facility provided no evidence that vital signs were obtained from 4:00 PM on 02/20/2025 to 8:00 AM on 02/21/2025. d) Facility provided no evidence that vital signs were obtained from 4:00 PM on 02/23/2025 to 8:00 AM on 02/24/2025. e) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/01/2025 to 4:00 AM and 8:00 AM to 4:00 PM on 03/02/2025. f) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/02/2025 to 4:00 AM and 8:00 AM to 4:00 PM on 03/03/2025. g) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/03/2025 to 4:00 AM and 8:00 AM to 4:00 PM on 03/04/2025. h) Facility provided no evidence that vital signs were obtained from 4:00 PM on 03/04/2025 to 8:00 AM on 05/05/2025. i) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/05/2025 to 4:00 AM and 8:00 AM to 4:00 PM on 03/06/2025. j) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/06/2025 to 4:00 AM and 8:00 AM to 8:00 PM on 03/07/2025. k) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/07/2025 to 4:00 AM on 03/08/2025. l) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/08/2025 to 4:00 AM and 4:00 AM to 4:00 PM on 03/09/2025. m) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/10/2025 and 8:00 PM on 03/10/2025 to 4:00 AM on 03/11/2025. n) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/11/2025 and 8:00 PM on 03/11/2025 to 4:00 AM on 03/12/2025. o) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/12/2025 and 4:00 PM on 03/12/2025 to 4:00 AM on 03/13/2025. p) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/13/2025 and 8:00 PM on 03/13/2025 to 8:00 AM on 03/14/2025. q) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/14/2025. r) Facility provided no evidence that vital signs, I&O, or meal percentages were obtained from 8:00 PM on 03/14/2025 to 8:00 AM on 03/17/2025. s) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/17/2025 and 8:00 PM on 03/17/2025 to 4:00 AM on 03/18/2025. t) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/19/2025 and 8:00 PM on 03/19/2025 to 4:00 AM on 03/20/2025. u) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/20/2025 and 8:00 PM on 03/20/2025 to 4:00 AM on 03/21/2025. v) Facility provided no evidence that vital signs were obtained from 8:00 AM to 8:00 PM on 03/21/2025 and 8:00 PM on 03/21/2025 to 4:00 AM on 03/22/2025. w) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/22/2025 and 8:00 PM on 03/22/2025 to 4:00 AM on 03/23/2025. x) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 03/23/2025 and 8:00 PM on 03/23/2025 to 4:00 AM on 03/24/2025. y) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/24/2025 to 4:00 AM on 03/25/2025. z) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/25/2025 to 4:00 AM on 03/26/2025. aa) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/26/2025 to 4:00 AM on 03/27/2025 and 8:00 AM to 4:00 PM on 03/27/2025. bb) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/27/2025 to 4:00 AM on 03/28/2025 and 8:00 AM to 4:00 PM on 03/28/2025. cc) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/28/2025 to 4:00 AM on 03/29/2025 and 8:00 AM to 4:00 PM on 03/29/2025. dd) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/29/2025 to 8:00 AM on 03/30/2025 and 8:00 AM to 4:00 PM on 03/30/2025. ee) Facility provided no evidence that vital signs were obtained from 8:00 PM on 03/30/2025 to 4:00 AM on 03/31/2025 and 8:00 AM to 4:00 PM on 03/31/2025. ff) Facility provided no evidence showing that intake was recorded on the 7:00 AM to 7:00 PM shift on 02/21/2025, 03/07/2025, 03/14/2025, 03/18/2025, 03/22/2025, 03/23/2025, 03/29/2025, or the 7:00 PM to 7:00 AM shift on 02/2025- 02/24/2025, 02/27/2025, 03/02/2025, 03/04/2025, 03/08/2025, 03/13/2025, 03/14/2025, 03/18/2025, and 03/23/2025. gg) Facility provided no evidence showing that output was recorded on the 7:00 AM to 7:00 PM shift on 03/06/2025 and 03/07/2025, or the 7:00 PM to 7:00 AM shift on 02/20/2025-02/23/2025, 03/12/2025, 03/14/2025. hh) Facility provided no evidence showing that meal percentages were recorded for 02/21/2025, 02/22/2025, 03/01/2025- 03/03/2025, dinner 03/06/2025, 03/07/2025, breakfast and dinner 03/08/2025, dinner 03/13/2025, dinner 03/17/2025, dinner 03/19/2025, 03/23/2025, dinner 03/27/2025, and dinner 03/28/2025. 16) Patient #16 chart review showed provider order, written at 3:40 PM on 04/23/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 8 hours and PRN (as needed). Patient was admitted from 02/18/2025 to 03/31/2025. a) Weight obtained upon admission. Facility provided no evidence of weekly weights. b) Facility provided no evidence that vital signs were obtained from 4:00 PM on 04/30/2025 to 8:00 AM on 05/01/2025. c) Facility provided no evidence showing that intake was recorded on the 7:00 AM to 7:00 PM shift on 04/25/2025, 05/04/2025, 05/07/2025, or the 7:00 PM to 7:00 AM shift on 04/30/2025, 05/01/2025- 05/04/2025, and 05/07/2025. d) Facility provided no evidence showing that output was recorded on the 7:00 AM to 7:00 PM shift on 04/24/2025, 04/25/2025, 04/30/2025, 05/02/2025-05/04/2025, 05/07/2025, or the 7:00 PM to 7:00 AM shift on 04/30/2025-05/07/2025. e) Facility provided no evidence showing that meal percentages were recorded for 04/25/2025, dinner 04/30/2025, dinner 05/01/2025, dinner 05/03/2025, 05/04/2025, 05/05/2025, or 05/07/2025. 17) Patient #17 chart review showed provider order, written at 1:00 AM on 04/25/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 8 hours and PRN (as needed). Patient was admitted from 02/18/2025 to 03/31/2025. a) No evidence was provided by facility that showed weekly weights were obtained during admission. b) Facility provided no evidence that vital signs were obtained from 12:00 PM to 8:00 PM on 04/27/2025. c) Facility provided no evidence that vital signs were obtained from 12:00 PM to 8:00 PM on 04/29/2025. d) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 05/01/2025. e) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/02/2025 to 8:00 AM on 05/03/2025. f) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/06/2025 to 12:00 AM on 05/07/2025. g) Facility provided no evidence that vital signs were obtained from 8:00 PM on 05/08/2025 to 4:00 AM on 05/09/2025. h) No evidence was provided by facility showing intake was recorded on the 7:00 PM to 7:00 AM shift on 04/30/2025, 05/02/2025, 05/03/2025, and 05/07/2025. i) Facility provided no evidence showing that output was recorded on the 7:00 AM to 7:00 PM shift on 04/27/2025, or the 7:00 PM to 7:00 AM shift on 04/30/2025 and 05/02/2025. j) Facility provided no evidence showing that meal percentages were recorded for dinner 05/02/2025. 18) Patient #18 chart review showed provider order, written at 2:00 PM on 04/30/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Weight obtained upon admission on 04/30/2025. Facility provided no evidence showing weight was obtained again until 05/10/2025. b) Facility provided no evidence that vital signs were obtained from 4:00 AM to 8:00 PM on 05/07/2025. c) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/09/2025 to 12:00 AM on 05/10/2025. d) Facility provided no evidence that vital signs were obtained from 4:00 PM on 05/10/2025 to 8:00 AM on 05/11/2025. e) Facility provided no evidence that intake was recorded on the 7:00 AM to 7:00 PM shift on 05/07/2025, 05/11/2025, or the 7:00 PM to 7:00 AM shift on 05/10/2025, 05/14/2025, and 05/15/2025. f) Facility provided no evidence that output was recorded on the 7:00 PM to 7:00 AM shift on 05/10/2025 and 05/14/2025. g) Facility provided no evidence that meal percentage consumed was recorded for dinner 05/02/2025, breakfast and dinner 05/03/2025, breakfast, lunch, and dinner 05/06/2025, breakfast, lunch, and dinner 05/08/2025, dinner 05/12/2025, breakfast, lunch, and dinner 05/14/2025, and dinner 05/15/2025. 19) Patient #19 chart review showed provider order, written at 10:57 PM on 01/28/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Facility recorded patient’s weight on admission 01/28/2025. Facility provided no evidence that weight was recorded again until 02/22/2025. Facility provided no evidence showing that weight was recorded between 02/22/2025 and 03/22/2025. b) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 01/29/2025. c) Facility provided no evidence that vital signs were obtained from 12:00 PM to 8:00 PM on 02/07/2025. d) Facility provided no evidence that vital signs were obtained from 8:00 AM on 02/11/2025 to 8:00 AM on 02/12/2025. e) Facility provided no evidence that vital signs were obtained from 4:00 PM on 02/13/2025 to 12:00 AM on 02/14/2025. f) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 02/18/2025. g) Facility provided no evidence that vital signs, intake, and output were recorded from 8:00 AM on 02/25/2025 to 8:00 AM on 02/27/2025. h) Facility provided no evidence that vital signs were obtained from 8:00 AM to 4:00 PM on 02/27/2025. i) Facility provided no evidence that vital signs were obtained from 4:00 PM on 03/13/2025 8:00 AM on 03/14/2025. j) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 03/18/2025 and 8:00 AM on 03/18/2025 to 8:00 AM on 03/20/2025. k) Facility provided no evidence that vital signs were obtained from 4:00 AM on 03/25/2025 to 8:00 AM on 03/26/2025. l) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 03/28/2025. m) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 03/21/2025. n) Facility did not provide evidence of recording intake during the 7:00 AM to 7:00 PM shift on 02/11/2025, 02/25/2025, 02/26/2025, 03/18/2025, and 03/25/2025, or the 7:00 PM to 7:00 AM shift on 1/31/2025, 02/01/2025, 02/03/2025, 02/11/2025, 02/21/2025, 02/22/2025, 02/25/2025, 02/28/2025, 03/01/2025, 03/02/2025 -03/04/2025, 03/13/2025, 03/16/2025, 03/18/2025, 03/19/2025, 03/25/2025, 03/27/2025-03/29/2025. o) Facility did not provide evidence of recording output during the 7:00 AM to 7:00 PM shift on 02/01/2025, 02/07/2025, 02/09/2025, 02/11/2025, 03/18/2025, 03/19/2025, 03/25/2025, or the 7:00 PM to 7:00 AM shift on 02/03/2025, 02/11/2025, 02/28/2025, 03/01/2025, 03/13/2025, 03/18/2025, 03/25/2025, 03/27/2025, 03/28/2025, 03/29/2025. 20) Patient #20 chart review showed provider order, written at 2:20 PM on 06/17/2025, for weight on admission and weekly, I & O (intake and output) q (every) shift, VS (vital signs) q 4 hours and PRN (as needed). a) Facility provided no evidence of weight record from 06/26/2025 to 07/12/2025. b) Facility provided no evidence that vital signs were obtained from 12:00 AM to 8:00 AM on 07/02/2025. c) Facility provided no evidence of recording intake on the 7:00 PM to 7:00 AM shift on 07/03/2025 and 07/05/2025. d) Facility provided no evidence of recording output on the 7:00 PM to 7:00 AM shift on 07/01/2025-07/03/2025, and 07/05/2025.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 52740 Based on review of policy, observation, and interview it was determined the facility failed to store medications in a secure manner that prevented unauthorized access. The failed practice did not ensure that medications were free from tampering or diversion. The failed practice had the likelihood of affecting all patients who receive medication within the facility. A. A review of Cornerstone Specialty Hospitals policy “Crash Carts/Defibrillators” (revise date 05/2022) showed: 1. Crash carts must be maintained in highly visible areas due to the nature of medications stored in them. 2. Daily crash cart inspections: each crash cart will be inspected and tested at least daily to ensure the integrity of its contents and validate that the defibrillator is in working order. The crash cart check includes cart lock number. Documentation of lock changes and rationale. B. Review of Cornerstone Specialty Hospitals policy, “Nursing Unit Inspections” (review date 02/2020) showed: 1. Authorized medications will be stored under proper conditions and in a secure manner in patient care areas. The Pharmacy is responsible for inspecting nursing areas each month in addition to any other areas within the hospitals that medications may be stored. 2. Key points of floor inspections: special storage conditions are maintained; crash carts are maintained according to policy. 3. If the same deficiency on a unit is not corrected by the third month, a performance improvement project must be initiated with follow through monitored using continuous quality improvement procedures. C. A review of Cornerstone Specialty Hospitals Little Rock policy “Pharmacy Security” showed, “The Pharmacy and all storage areas under Pharmacy control will have door closed and area locked at all times.” D. A review of Cornerstone Specialty Hospitals Little Rock policy “Medication Storage Requirements” (review date 02/2020) showed: Medications that are not controlled substances are dispersed from the Pharmacy and are stored only in areas with appropriate security to include: Pyxis MedStations, locked medication rooms, locked crash carts. E. A review of Cornerstone Specialty Hospitals Little Rock policy “Crash Carts and Emergency Drug Supply” (review date 02/2020) showed, “An intact lock on an emergency cart shall signify that the contents are present and have been checked.” F. Review of Pharmacy monthly inspection logs for East nursing unit show Medication Room “Is the room locked?” The “no or N/A” column is marked by the pharmacist with “no door” written in the explanation column from June 2024 through June 2025. G. During a tour of the facility on 07/09/2025 between 9:00 AM and 10:30 AM the following was found: 1. The west medication room was open to the nurse’s station allowing for access by unauthorized personnel. The medication refrigerator was found to be unlocked with four doses of Racephinephrine and a multi dose vial of Tubersol. Additionally, a pillowcase and a box of lemon glycerin swabs were stored in the freezer section of the medication refrigerator. 2. A supply room on the west hall had large red bins that contained intravenous (IV) antibiotics, liquid vitamins, and artificial tears labeled for patient use. During the tour the Chief Operations Officer confirmed both licensed and unlicensed personnel had access to the supply room. 3. One of three crash carts observed had a broken plastic lock allowing for unauthorized access to advanced life saving medications. H. During an interview with the Director of Pharmacy on 07/10/25 at 1:30 PM, he confirmed the findings in A-G.”

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 52740 Based on review of policy, observation, and interview, it was determined that the facility failed to ensure that only authorized personnel may have access to locked areas where drugs and biologicals are stored. The failed practice had the likelihood of affecting all patients who receive medication within the facility. A. Review of Cornerstone Specialty Hospitals policy, “Nursing Unit Inspections” (review date 02/2020) showed: 1. Authorized medications will be stored under proper conditions and in a secure manner in patient care areas. The Pharmacy is responsible for inspecting nursing areas each month in addition to any other areas within the hospitals that medications may be stored. 2. Key points of floor inspections: special storage conditions are maintained 3. If the same deficiency on a unit is not corrected by the third month, a performance improvement project must be initiated with follow through monitored using continuous quality improvement procedures. B. A review of Cornerstone Specialty Hospitals Little Rock policy “Pharmacy Security” showed, “The Pharmacy and all storage areas under Pharmcy control will have door closed and area locked at all times.” C. A review of Cornerstone Specialty Hospitals Little Rock policy “Medication Storage Requirements” (review date 02/2020) showed: Medications that are not controlled substances are dispersed from the Pharmacy and are stored only in areas with appropriate security to include: Pyxis MedStations, locked medication rooms, locked crash carts. D. Review of Pharmacy monthly inspection logs for East nursing unit show Medication Room “Is the room locked?” The “no or N/A” column is marked by the pharmacist with “no door” written in the explanation column for months June 2024 through June 2025. E. During a tour of the facility on 07/09/2025 between 9:00 AM and 10:30 AM the following was found: 1. The west medication room was open to the nurse’s station allowing for access by unauthorized personnel. The medication refrigerator was found to be unlocked with four doses of Racephinephrine and a multi dose vial of Tubersol. 2. A supply room on the west hall had large red bins that contained intravenous (IV) antibiotics, liquid vitamins, and artificial tears labeled for patient use. During the tour the Chief Operations Officer confirmed both licensed and unlicensed personnel had access to the supply room. 3. One of three crash carts observed had a broken plastic lock allowing for unauthorized access to advanced life saving medications. F. During an interview with the Director of Pharmacy on 07/10/25 at 1:30 PM, he confirmed the findings in A through E.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 52740 Based on review of standards of practice, facility procedure document, observation and interviews, the facility failed to maintain a clean and sanitary environment that avoids sources and transmission of infection. The failed practice has the potential to expose all admitted patients to risk for healthcare acquired infections. A. Review of current standards of practice for infection control as outlined in “Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)” (Updated July,2019) showed, “Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector.” B. Review of Common Spirit “Discharge Clean Standard Work Activity Sheet” showed: 1.Check patient room to ensure room is ready to be cleaned. Patient has vacated room/ patient belongings removed. Mobile medical equipment removed. 2. High dusting. Dust all items at eye level and above. 3. Clean and disinfect all high touch surfaces following the same path toward the window and carrying through to the side of bed opposite the door. While maneuvering through the room check walls and spot clean as necessary. 4. Follow facility Service Level Agreement for cleaning bedside toilets and other mobile medical equipment. Use 3M 2A Heavy Duty Multi-Surface cleaner to remove any hardened bio-burden or bio-burden that was not removed during the disinfection process. 5. Restroom Cleaning/ Disinfecting: Clean/ disinfect the following: door, door handle, light switch, hand rails, shower and curtain, sink, dispensers, faucet, countertop, and cabinetry. C. During a tour on the facility on 07/09/2025 between 9:00 AM and 10:30 AM the following was observed. 1. A shower room located on the east hallway and shared by multiple patients showed a heavy build-up of black mold-like substance along the grout lines and in the corners. 2. The east nurse’s station had an alcove with an ice/water machine identified for patient use directly above a refrigerator indicated for staff use. Additionally, staff drink cups and open bags of food were observed next to the ice/water machine. A second alcove had a refrigerator marked for patient use only and showed melted food products in the freezer 3. A tour of patient rooms 6087, 6090 and 6018 all sealed with a sticker stating the room was clean and ready for patient use showed the following: a. Dust on vents throughout. b. Small unsealed holes in laminate and drywall. c. Broken and/or peeling laminate around closets and air conditioners. d. Supplies from previous patients. e. Dead pests in two of three rooms. f. Reddish brown drips on wall in one of three rooms toured. 4. A box in a clean equipment room was overflowing with cables that had fallen onto the floor. There were also tube feeding pumps with dried liquid nutrition on them. 5. Clean supplies were stored next to the arterial blood gasses testing machine without any barrier to prevent potential blood contamination of supplies. 6. There were four partially used rolls of medical tape in one of the drawers in the west medication prep room. 7. In the west medication room, the side of the refrigerator near the sink is covered in rust and the metal is pitting. 8. There is raw wood exposed on the side of the counter where counter tops were replaced. 9. In the nutrition room on the west hallway, the lower cabinet door next to the sink had been screwed shut in the past. The cabinet door had been unscrewed exposing the raw wood cabinet base. 10. Staff had stored their personal items in the lower cabinet in the nutrition room. 11. Clean equipment room (former shower room) on the west hall had two dirty feeding pumps on an IV pole. Staff had hung their back packs and purses on the IV pole. Staff had stored their jackets in the supply room. D. Findings were confirmed with CCO during post tour interview on 07/09/2025.”