Phoenix Specialty Hospital

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 43788 Based on a review of theArizona Administrative Code (A.A.C.). facility’s state licensing file, observations, and a staff interview, it was determined that the Administrator failed to notify the Department and obtain approval for a substantial modification to the second-floor patient care areas. This deficient practice poses a risk to patients’ health and safety if renovations are not approved, potentially creating an unsafe environment. Findings include: Review of the Arizona Administrative Code (A.A.C.) Chapter 9, Title 10, Article 1 General revealed: “...(4. A change in the physical plant, including facilities or equipment, that costs more than $300,000; or 5. A change in the building where a health care institution is located that affects compliance with: a. Applicable physical plant codes and standards incorporated by reference in A.A.C. R9-1-412, or b. Physical plant requirements in the specific Article in this Chapter applicable to the health care institution)... R9-10-104. Architectural Plans and Specifications A. For the construction or modification of a health care institution that is required by this Chapter to comply with any of the physical plant codes and standards incorporated by reference in R9-10-104.01, an applicant shall submit as part of the health care institution license application to the Department an application packet including:... 2. A statement signed by the governing authority or the licensee that the architectural plans and specifications comply with applicable licensing requirements in A.R.S. Title 36, Chapter 4 and this Chapter; If the health care institution is located on land under the jurisdiction of a local governmental agency, one of the following: a. b. 3. A building permit for the construction or modification issued by the local governmental agency; or If a building permit issued by the local governmental agency is not required, zoning clearance issued by the local governmental agency that includes: i. The health care institution ’ s name, street address, city, state, zip code, and county; ii. iii. The health care institution ’ s class or subclass and each type of medical services, nursing services, or health-related services to be provided; and A statement signed by a representative of the local governmental agency stating that the address listed is zoned for the health care institution ’ s class or subclass; Review of the Arizona Department of Health Services Bureau of Medical Facilities Licensing file for the facility on March 3, 2026 revealed no modification applications, no approval from the department, no documentation that the facility had notified the Department of any structural changes to the building including placing bars on the windows of the 2nd floor. Observation on tour, March 3, 2026, revealed areas of the hospital that had been modified by adding bars to the outside windows and other minor modifications. Documents provided by the facility showed no approval by the fire department and no approvals by the Building department; the facility could not show a completed building permit or provide a Modification application or architectural Attestations as required by statute. Employee #9 confirmed during the tour and during document review that the listed modifications were not made with approval from the city building and fire departments, and a building permit was never obtained. As well, the department was never notified of the modification.”

“MEDICAL STAFF - BYLAWS CFR(s): 482.12(a)(3) [The governing body must] assure that the medical staff has bylaws. This Standard is not met as evidenced by: 46598 Based on facility documents and interview the Department determined the administrator failed to ensure the Governing Body meeting minutes revealed a discussion was held regarding taking on the care and rehabilitation of ICE detainees. This deficient practice poses a health and safety of patients if the hospital is unable to provide proper care and resources to keep patients safe and meet patient needs. Hospital document titled “Phoenix Specialty Hospital Governing Body Bylaws.” Revealed: “ ...Article 11 Quality of Professional Services 1. Governing Body Responsibility ...The Governing Body shall conduct a review and evaluation of activities on a continuing basis to assess, preserve, and improve the overall quality and efficiency of patient care in the Hospital. The Governing Body shall, within the reasonable capabilities of the Hospital, provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and the ongoing operation of these review and evaluation activities, including utilization review and review of the quality of patient care ....” A request and review of the Governing Body Meeting minutes dated 03/2025, through 03/2026, did not reveal any discussion or approval by the Governing Body to provide medical care and/or rehabilitation of ICE detainee patients. Employee # 4 confirmed in an interview dated 03/04/2026, when asked if the governing body approved the collaboration with ICE, as we did not see any mention of the Governing Body meeting minutes, he stated that he is on the board and he is sure it was discussed.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46598 Based on facility documents, Observation and interview, the department determined the facility failed to treat patients with dignity and respect as evidenced by: 1. Not allowing incarcerated patients the use of a bathroom for toileting purposes; 2. Not allowing patients to use the shower; This practice constitutes a breach of the standard of care, which may cause emotional harm, fear, and reduced trust. Findings Include: Policy titled “Patient Rights and Responsibilities” revealed: “ ... POLICY: All disciplines within Phoenix Specialty Hospital are expected to demonstrate respect for the human rights and individual dignity of each patient in the delivery of all aspects of health care and services ....” Policy titled “Activities of Daily Living (ADLs)” revealed: “ ...PURPOSE This policy will outline the procedures for assessing and assisting patients with basic self-care tasks. Their goal is to maintain the patient’s independence, dignity, and safety, while ensuring their needs are met during their stay upon discharge ...Toileting: Offer toileting assistance on a routine schedule, every 2 hours, and as needed ...Bathing. Offer daily hygiene opportunities (full bath, shower, or partial wash per patient preference and tolerance) ...Patient Rights: respect patient preferences, cultural considerations, and privacy at all times ... Hospital Document titled “Patient Rights” revealed: “ ...1. A patient is treated with dignity respect, and consideration. Review of medical records for 7 out of 7 patients (Patients #7, #8, #9 , #10, #11, #12, #13 revealed no documentation of ambulation to bathroom or shower. Upon tour of the second-floor unit on 03/03/2026, it was observed that all ICE detainee patients are shackled to the bed at the ankle. All patients admitted from Core Civic are handcuffed or shackled to the bed. Per the Core Civic guards, their patients are not allowed to get out of bed to use the bathroom or get washed. Employee #3 and Employee #5 confirmed on 03/03/2026 that the patients that are in law enforcement custody receive patient care in the presence of the corrections officers. Employee #3 and Employee #5 confirmed that the incarcerated patients are not allowed to use the bathroom for toileting, that the patients are required to use bedpans or urinals for toileting. Employee #3 confirmed that the incarcerated patients are not allowed to shower.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, medical records, observations, and staff interviews, it was determined that the Governing Authority failed to ensure that the hospital was provided with adequate personnel and resources to provide a safe environment to provide patient care. This deficient practice poses a risk to the health and safety of patients if the hospital is unable to provide the proper care and resources to keep patients safe and meet patient needs. Findings include: Review of hospital document titled, “Phoenix Specialty Hospital Organizational Plan for Providing Patient Care, 2026”, revealed: “...The scope of services includes but is not limited to pulmonary medicine, infectious disease, psychiatry and wound care management, medically complex care, and medical rehabilitation....” Review of Physical Therapy and Rehabilitation staffing revealed the following: *Speech Therapist (ST): One (1) ST scheduled every Monday from 9:00AM to 3:00PM, no scheduled Saturdays or Sundays; *Physical Therapist (PT): One (1) PT scheduled every Monday,Tuesday, Thursday and Friday from 9:00 AM to 3:00 PM, Off every Wednesday, not scheduled Saturdays or Sundays; * Physical Therapy Assistant (PTA): One (1) PTA scheduled every Monday to Friday from 7:30 Am to 3:30 PM, not scheduled on Saturdays or Sundays; *Occupational Therapist (OT): One (1) scheduled every Monday to Friday from 7:00 AM to 3:00 PM, not scheduled on Saturdays or Sundays; *Certified Occupational Therapy Assistant (COTA): One (1) scheduled every Monday to Friday from 7:30 AM to 3:30 PM, not scheduled on Saturdays or Sundays. Review of Patient #7 medical record revealed a Speech Therapy Consult for evaluation and treatment dated 02/09/2026 recommending speech therapy two times a week for 6 weeks. Review of Patient #7 speech therapy notes revealed Patient #7 received speech therapy from 02/09/2026 to 03/03/2026 once a week. Review of the Rehab staff schedule revealed there was only one (1) speech therapist scheduled once a week during that time frame. Review of Patient #12 medical record revealed an Occupational Therapy Consult for evaluation and treatment dated 02/02/2026 recommending OT 3 to 5 times a week for 6 weeks. Review of the OT notes revealed Patient #12 had not received any OT during the timeframe of 02/02/2026 to 03/03/2026. Employee #2 confirmed on 03/03/2026 that there are not enough rehab staff and patients do not get the recommended PT/OT/ or ST recommended each week. Employee #5 confirmed there is only speech therapy available one day a week. Review of Center for Disease Control (CDC) Infection Control: Recommendations for Disinfection and Sterilization in Healthcare Facilities Guidelines (12/7/2023), revealed: “...2. Cleaning of Patient-Care Devices...Clean medical devices as soon as practical after use...Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned, and disinfected or sterilized....” Observation on tour 03/03/2026 and 03/04/2026 revealed multiple patient care devices in disrepair, broken, with mismatched parts or taped repairs. The following items were found in need of repair or disposal from patient use: -Parallel Gait Bars found to be unadjustable to different patient body types, base was unsteady and wobbly when in use; - 3 pairs of crutches with mismatched arm and hand pads, pads were torn and ripped; - 1 caddy transfer chair with hand written sign on seat “Broken, do not use”; - 10 walkers with adhesive tape around the hand grips and legs, many were rusty and were difficult to fold or unfold; -15 wheelchairs with missing foot rests, brakes were loose or did not engage; adhesive tape was found on many of the wheelchair seats, some seats had tears, hand grips were loose or worn and torn; -6 hoyer lifts with non working batteries; - stationary bike non-functioning Further observation on tour revealed the following equipment was not present: -slings for the hoyer lifts -battery replacements for hoyer lifts or functioning hoyer lifts -new crutches or matching crutches with intact hand grips and arm pads - a functioning caddy transfer chair for each floor - a functioning stationary bike -an OT kitchen to prepare patients for home -a sit to stand device for each floor - bedside commodes -shower chair for each floor - a swallow evaluator known as FEES for speech therapy -walkers that did not have tape repairs or rust present -wheelchairs with foot rests and operational brakes -parallel bars that were adjustable to patient body type and stable when in use Employee #5 confirmed on 03/03/2026 that the facility had multiple patient care equipment that were broken or in disrepair. Employee #5 confirmed torn or ripped equipment or equipment with tape repairs could be properly cleaned or disinfected. Employee #4 confirmed on 03/04/2026 that the above listed equipment needed to be removed from use and replaced.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 46598 Based on facility documents and interviews, the department determined that the administrator failed to ensure that completed history and physicals were documented in the patient’s medical record. This deficient practice poses the possibility of a missed diagnosis and or an incorrect treatment plan. Hospital document titled “Phoenix Specialty Hospital Medical Staff Rules and Regulations” revealed: “ ...Medical Records 1. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current for each patient. The record shall include identification data, medical history, physical examination ...3. The History and Physical shall include the following:a. presenting symptoms or complaints. b. relevant past medical and social history, including family history if appropriate. c. Review of systems, including mental status examination where appropriate. d. allergies and medication. e. vital signs and with (if appropriate to the presenting condition) f. Examination of the body area relevant to the presenting complaint. g. Relevant laboratory data. h. admitting diagnosis. i. plan of care ....” A review of 14 medical records revealed13 patients had incomplete documentation on the patient’s History and Physical.(Patients #1-#13). Employee # 1, Employee # 2, and Employee # 8 all confirm that the13 medical records that were reviewed on 03/03/2026 and 03/04/2026 were missing documentation in the patient ’ s history and physical.”

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 46598 Based on Review of Arizona Department of Health facility licensing file, document review, observation, and interview, it was determined that the administrator failed to ensure the facility did not admit med/surg patients to licensed rehab beds, which poses a potential risk of impacting the quality of patient care provided. Repeat deficiency, rule previously cited, Survey Event # ES5W11 dated 09/17/2025 Findings include: Review of hospital license dated 2/18/2026 revealed total licensed beds: 48. Further review of the facility license revealed 38 Med-surg beds, 6 ICU beds, 4 Rehab beds. Review of Arizona Department of Health facility licensing file revealed Rooms 201-204 designated as single occupancy Rehabilitation beds. Observation on 03/03/2026 revealed all 4 rehab rooms were occupied by patients not admitted for rehab services. Employee # 4 confirmed in an interview dated 03/03/2026, that there were no rehab patients in the state-licensed rehab beds, as Medicare denied the application.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 43788 Based on review of Center for Disease Control (CDC) Infection Control: Recommendations for Disinfection and Sterilization in Healthcare Facilities Guidelines (12/7/2023), observation and staff interviews, it was determined the administrator failed to ensure the removal of broken, unusable medical equipment was removed from patient use. This deficient practice poses a risk to the health and safety of patients if patient care is provided using medical equipment that is broken, damaged or its integrity is in disrepair leading to potential infections, injury or harm to the patient or staff. Findings include: Request was made for facility policy on cleaning and maintenance of patient care items/patient medical equipment. None was provided. Employee #4 provided CDC Infection Control Guide stating the facility utilized the CDC guidelines. Review of Center for Disease Control (CDC) Infection Control: Recommendations for Disinfection and Sterilization in Healthcare Facilities Guidelines (12/7/2023), revealed: “...2. Cleaning of Patient-Care Devices...Clean medical devices as soon as practical after use...Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned, and disinfected or sterilized....” Observation on tour 03/03/2026 and 03/04/2026 revealed multiple patient care devices in disrepair, broken, with mismatched parts or taped repairs. The following items were found in need of repair or disposal from patient use: -Parallel Gait Bars found to be unadjustable to different patient body types, base was unsteady and wobbly when in use; - 3 pairs of crutches with mismatched arm and hand pads, pads were torn and ripped; - 1 caddy transfer chair with hand written sign on seat “Broken, do not use”; - 10 walkers with adhesive tape around the hand grips and legs, many were rusty and were difficult to fold or unfold; -15 wheelchairs with missing foot rests, brakes were loose or did not engage; adhesive tape was found on many of the wheelchair seats, some seats had tears, hand grips were loose or worn and torn; -6 hoyer lifts with non working batteries; - stationary bike non-functioning Employee #5 confirmed on 03/03/2026 that the facility had multiple patient care equipment that were broken or in disrepair. Employee #4 confirmed on 03/04/2026 that the above listed equipment needed to be removed from use and replaced.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 43788 Based on a review of hospital records and an interview, it was determined that the provider failed to have an Infection Preventionist trained in infection control practices and procedures. This deficient practice poses the risk of infectious organisms not being identified, contagions spreading throughout staff and patient populations, the inability to track trends throughout the hospital, and no monitoring of infection control mitigation. Findings Include: Hospital document titled “Phoenix Specialty Hospital Infection Prevention Plan 2026”, revealed: “ ...RESPONSIBILITIES AND AUTHORITY ...Governing Board. The Governing Board of Phoenix Specialty Hospital has the final authority and responsibility for the Infection Prevention Program and the delivery of optimal quality and safe patient care. The Governing Board has delegated oversight for the development and implementation of the organization-wide Infection Prevention Program to the Director of Quality and Risk, Infection Control Coordinator, and to the Infection Prevention Committee...Infection Control Coordinator: The Infection Control Coordinator has the authority to develop and implement a system for surveillance and prevention of infections, identifying, reporting, and analyzing clusters of infections, outbreaks, sentinel events, emerging pathogens and special studies or reports. Reports data to the Director of Quality Improvement/Risk Management and maintains a close working relationship with the Chief Clinical Officer and Infectious Disease Physician....” Hospital document titled “Phoenix Specialty Hospital Job Description Evaluation Infection Control Coordinator/ Employee Health Nurse” revealed “ ... Qualifications 3. Continued Education in the area of Infection Control/Epidemiology preferred ....” Observation while on tour on 03/03/2026 revealed multiple patient rooms with isolation precautions signs posted and PPE (personal protective equipment) carts outside of these patient rooms. Staff members and visitors were observed entering the isolated patient rooms without proper PPE. Observation on 03/03/2026 outside room 207 revealed 2 visitors in room, a staff RN came to doorway and informed one of the visitors that the patient was in isolation and the visitor needed to don PPE. The other visitor was not informed to don PPE. An interview was conducted on 03/03/2026 with a visitor upon leaving Patient #11 room. Patient #11 was in contact isolation. Visitor confirmed that they were unaware that the patient was in contact isolation or that PPE was required before entering the room. Employee #4 confirmed during an interview on 03/03/2026 that the hospital did not have an Infection Control Coordinator but was actively recruiting for one.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 46598 Based on facility documents, staff interviews, and observation, the Department determined the administrator failed to ensure that contact precautions were implemented when providing care to a patient. This deficient practice increases the risk of healthcare-associated infections and cross-transmission via contaminated surfaces. The policy titled “Isolation” revealed: “ ...PURPOSE: To minimize the exposure of patients, visitors, and caregivers to microorganisms and communicable diseases ...POLICY: 1. General Guidelines ...3. Precautions need to be implemented when infection is suspected or confirmed ...Transmission-Based Precautions ...3. Types of transmission-based precautions include: a. Contact Precautions: example Candida Auris, RE, CRE ...MDROs ...4. Personal Protective Equipment (PPE) must be worn in accordance with transmission-based precaution requirements. The specialized clothing or equipment must be worn for protection against blood, body fluids, secretions, and excretions, non-intact skin, and mucous membranes ...9. Inpatient Settings: Education related to the type of precautions and the procedures to be adhered to, the importance of Hand Hygiene, and their responsibility in reducing the transmission of pathogens must be provided to patients/ families/visitors ...Contact Precautions: PPE required for entry into patient room: ’ fluid resistant; gown and gloves ....” Patient # 11 ’ s medical record revealed that the patient was admitted on 02/11/2026 with a diagnosis of right lower extremity cellulitis/abscess, surgical I&D with drain, sepsis, requiring long-term antibiotics for Methicillin Resistant Staph Aureus (MRSA) infection. Tour of the facility, second floor, dated 03/03/2026, revealed patient #11 was on contact precautions. Gowns, gloves, and masks were located outside the patient’s room. A contact precautions sign was posted outside the patient’s room . It was observed that when the ICE agent entered the patient’s room, {he} was not wearing the required PPE. When questioned, {he} stated that {he} was unaware of the precautions. Employee #3 confirmed on 03/03/2026 that there was not an Infection Control Coordinator for the facility. Employee #3 could not confirm that visitors or law enforcement agents are made aware of isolation precautions by staff members when necessary.”

“ORGANIZATION OF REHABILITATION SERVICES CFR(s): 482.56(a) The organization of the service must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, staffing schedules, medical records, observation, and staff interviews, it was determined the administrator failed to ensure there was sufficient rehabilitation staff to provide rehabilitation services as ordered to patients. This deficient practice poses a risk to the health and safety of patients if patients do not get the required rehab services due to a lack of sufficient, qualified staff. Findings include: Review of hospital document titled, “Phoenix Specialty Hospital Organizational Plan for Providing Patient Care, 2026”, revealed: “...The scope of services includes but is not limited to pulmonary medicine, infectious disease, psychiatry and wound care management, medically complex care, and medical rehabilitation...Rehabilitation Services (Rehab): Rehabilitation Services provides therapeutic intervention and training to meet the rehab needs of patients at Phoenix Specialty Hospital...Skilled rehabilitation services include Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) as well as the utilization of non-skilled functional maintenance programs (FMP). Each patient is evaluated by each discipline per physician’s order. Treatment plans are then established which may include but are not limited to: therapeutic exercise, therapeutic activity, Activities of Daily Living (ADL) training, fait training, balance training, activity tolerance training, range of motion, thermal modalities, electrical modalities, training in assistive devices, splinting, positioning, strengthening, dysphagia/swallowing, speech/language training, perceptual-cognitive training, wheelchair management, manual therapy, neuromuscular re-education, patient/family education...Hours of Operation: Monday -Friday 08:00-17:00 (PT,OT,ST), Saturday and Sunday as available...Staffing plan: Rehab services are provided by licensed PT (physical therapist), PTA (physical therapy assistant), OT (occupational therapist), COTA (certified occupational therapy assistant, and ST (speech therapist) professionals within their scope of practice. Rehab aides are utilized as well to facilitate non-skilled aspects of the department and to assist licensed staff as needed. The normal length of shift is 8 hours....” Review of Physical Therapy and Rehabilitation Schedule dated January 2026 revealed the following staff were scheduled: *Speech Therapist (ST): One (1) ST scheduled every Monday from 9:00AM to 3:00PM, no scheduled Saturdays or Sundays; *Physical Therapist (PT): One (1) PT scheduled every Monday,Tuesday, Thursday and Friday from 9:00 AM to 3:00 PM, Off every Wednesday, not scheduled Saturdays or Sundays; * Physical Therapy Assistant (PTA): One (1) PTA scheduled every Monday to Friday from 7:30 Am to 3:30 PM, not scheduled on Saturdays or Sundays; *Occupational Therapist (OT): One (1) scheduled every Monday to Friday from 7:00 AM to 3:00 PM, not scheduled on Saturdays or Sundays; *Certified Occupational Therapy Assistant (COTA): One (1) scheduled every Monday to Friday from 7:30 AM to 3:30 PM, not scheduled on Saturdays or Sundays. Review of Physical Therapy and Rehabilitation Schedule dated February 2026 revealed the following staff were scheduled: *Speech Therapist (ST): One (1) ST scheduled every Monday from 9:00AM to 3:00PM, no scheduled Saturdays or Sundays; *Physical Therapist (PT): One (1) PT scheduled every Monday,Tuesday, Thursday and Friday from 9:00 AM to 3:00 PM, Off every Wednesday, not scheduled Saturdays or Sundays; * Physical Therapy Assistant (PTA): One (1) PTA scheduled every Monday to Friday from 7:30 Am to 3:30 PM, not scheduled on Saturdays or Sundays; *Occupational Therapist (OT): One (1) scheduled every Monday to Friday from 7:00 AM to 3:00 PM, not scheduled on Saturdays or Sundays; *Certified Occupational Therapy Assistant (COTA): One (1) scheduled every Monday to Friday from 7:30 AM to 3:30 PM, not scheduled on Saturdays or Sundays. Review of hospital daily patient census for January 2026 revealed: 01/01/2026 - 18 patients 01/02/2026 - 18 patients 01/03/2026 - 18 patients 01/04/2026 - 19 patients 01/05/2026 - 19 patients 01/06/2026 - 20 patients 01/07/2026 - 20 patients 01/08/2026 - 22 patients 01/09/2026 - 23 patients 01/10/2026 - 23 patients 01/11/2026 - 22 patients 01/12/2026 - 22 patients 01/13/2026 - 23 patients 01/14/2026 - 22 patients 01/15/2026 - 22 patients 01/16/2026 - 21 patients 01/17/2026 - 21 patients 01/18/2026 - 21 patients 01/19/2026 - 24 patients 01/20/2026 - 24 patients 01/21/2026 - 24 patients 01/22/2026 - 24 patients 01/23/2026 - 24 patients 01/24/2026 - 25 patients 01/25/2026 - 25 patients 01/26/2026 - 25 patients 01/27/2026 - 23 patients 01/28/2026 - 23 patients 01/29/2026 - 25 patients 01/30/2026 - 28 patients 01/31/2026 - 28 patients Review of hospital daily patient census for February 2026 revealed: 02/01/2026 - 27 patients 02/02/2026 - 26 patients 02/03/2026 - 25 patients 02/04/2026 - 23 patients 02/05/2026 - 25 patients 02/06/2026 - 24 patients 02/07/2026 - 26 patients 02/08/2026 - 24 patients 02/09/2026 - 25 patients 02/10/2026 - 25 patients 02/11/2026 - 27 patients 02/12/2026 - 25 patients 02/13/2026 - 26 patients 02/14/2026 - 26 patients 02/15/2026 - 25 patients 02/16/2026 - 23 patients 02/17/2026 - 24 patients 02/18/2026 - 24 patients 02/19/2026 - 23 patients 02/20/2026 - 27 patients 02/21/2026 - 29 patients 02/22/2026 - 29 patients 02/23/2026 - 30 patients 02/24/2026 - 31 patients 02/25/2026 - 31 patients 02/26/2026 - 30 patients 02/27/2026 - 31 patients 02/28/2026 - 34 patients Review of hospital daily patient census for 03/03/2026 revealed 37 patients. Review of Patient #7 medical record revealed a Speech Therapy Consult for evaluation and treatment dated 02/09/2026 recommending speech therapy two times a week for 6 weeks. Review of Patient #7 speech therapy notes revealed Patient #7 received speech therapy from 02/09/2026 to 03/03/2026 once a week. Review of the Rehab staff schedule revealed there was only one (1) speech therapist scheduled once a week during that time frame. Review of Patient #12 medical record revealed an Occupational Therapy Consult for evaluation and treatment dated 02/02/2026 recommending OT 3 to 5 times a week for 6 weeks. Review of the OT notes revealed Patient #12 had not received any OT during the timeframe of 02/02/2026 to 03/03/2026. Employee #2 confirmed on 03/03/2026 that there are not enough rehab staff and patients do not get the recommended PT/OT/ or ST recommended each week. Employee #5 confirmed on 03/03/2026 that a rehab therapy session could be 30 minutes to 60 minutes for each patient depending on patient tolerance. Employee #5 confirmed an average of 8-12 patients are seen each day by a rehab therapist. Employee #5 confirmed that patients only receive speech therapy once a week and that the average number of patients seen by the speech therapist is 8 in a day. Employee #5 confirmed if a patient needs speech therapy more than once a week they will not receive it. Employee #5 confirmed that as the patient census has increased the rehab staffing has not and patients are not getting the hours of therapy needed each week. Employee #5 confirmed that ideally each patient should receive 30-60 minutes of therapy 5 days a week. Employee #6 confirmed on 03/03/2026 that the Physical Therapist does the patient consults and determines treatment and frequency. Employee #6 confirmed the Occupational Therapist does the patient consults and determines treatment and frequency. Employee #6 confirmed the COTA and PTA conduct the majority of the therapy sessions with the patients. Employee #6 confirmed that the average number of patients seen by the COTA and PTA daily is between 8-12 patients each. Employee #6 confirmed that there is not enough rehab staff to get the recommended hours of therapy recommended each week. Employee #7 confirmed on 03/04/2026 that there is not enough rehab staff, and patients do not get rehab services as recommended. Employee #7 confirmed that if a patient is recommended to have 3 to 5 times a week, it will be 3 times a week but usually no more than that and for only 30 minutes a session.”

“ORDERS FOR REHABILITATION SERVICES CFR(s): 482.56(b) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, patient medical records, observation, and staff interviews, it was determined the administrator failed to ensure: 1. one patient (Patient #7) receiving Rehabilitation Services had a current provider order in place; 2. Rehabilitation Services were provided to two (2) patients (Patient #7 and Patient #12) as ordered . This deficient practice poses a risk to the health and safety of patients if Rehabilitation Services are provided unnecessarily or not provided as needed leading to potential or further injury, contractures and lack of mobility. Findings include: Review of hospital document titled, “Phoenix Specialty Hospital Organizational Plan for Providing Patient Care, 2026”, revealed: “...The scope of services includes but is not limited to pulmonary medicine, infectious disease, psychiatry and wound care management, medically complex care, and medical rehabilitation...Rehabilitation Services (Rehab): Rehabilitation Services provides therapeutic intervention and training to meet the rehab needs of patients at Phoenix Specialty Hospital...Skilled rehabilitation services include Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) as well as the utilization of non-skilled functional maintenance programs (FMP). Each patient is evaluated by each discipline per physician’s order. Treatment plans are then established which may include but are not limited to: therapeutic exercise, therapeutic activity, Activities of Daily Living (ADL) training, fait training, balance training, activity tolerance training, range of motion, thermal modalities, electrical modalities, training in assistive devices, splinting, positioning, strengthening, dysphagia/swallowing, speech/language training, perceptual-cognitive training, wheelchair management, manual therapy, neuromuscular re-education, patient/family education...Hours of Operation: Monday -Friday 08:00-17:00 (PT,OT,ST), Saturday and Sunday as available...Staffing plan: Rehab services are provided by licensed PT (physical therapist), PTA (physical therapy assistant), OT (occupational therapist), COTA (certified occupational therapy assistant, and ST (speech therapist) professionals within their scope of practice. Rehab aides are utilized as well to facilitate non-skilled aspects of the department and to assist licensed staff as needed. The normal length of shift is 8 hours....” Hospital policy titled, “Rehabilitation Therapy Services”, revealed: “...Phoenix Specialty Hospital physical, occupational, and speech therapy services will: b. be provided based on Phoenix Specialty Hospital physician’s orders for evaluation and treatment...g. document care provided to a patient in the medical record according to Phoenix Specialty Hospital policy....” 1. Review of 14 patient medical records revealed one (1) patient (Patient #7) was receiving rehabilitation services without an active rehabilitation order in place. Review of Patient #7 medical record revealed a provider order for PT consult for evaluation and treatment dated 02/08/2026. Review of Patient #7 medical record revealed a PT consult for evaluation and treatment dated 02/09/2026. Further review of the PT evaluation revealed no PT was recommended. Review of Patient #7 medical record revealed physical therapy treatment notes were recorded on the following dates: 02/10/2026, 02/11/2026, 02/12/2026, 02/13/2026, 02/16/2026, 02/17/2026, 02/18/2026, 02/19/2026, 02/20/2026, 02/23/2026, 02/24/2026, 02/26/2026, 02/27/2026, and 03/02/2026. Employee #2 confirmed during medical record review that the PT evaluation dated 02/09/2026 recommended no PT needed. Employee #2 confirmed that Patient #7 was receiving PT services without a current order in place. 2. Review of 14 patient medical records revealed two patients (Patient #7 and Patient #12) were not receiving rehabilitation services as ordered. Review of Patient #7 Speech Therapy consult for evaluation and treatment dated 02/09/2026 recommended speech therapy 2 times a week for 6 weeks. Review of the speech therapy notes revealed Patient #7 received speech therapy once a week from 02/09/2026 through 03/03/2026. Review of Patient #12 Occupational Therapy consult for evaluation and therapy dated 02/02/2026 revealed OT services ordered for 3 to 5 times a week for 6 weeks. Review of Patient #12 OT rehab notes revealed no documentation of OT services being provided from 02/02/2026 through 03/03/2026. Employee #2 confirmed on 03/03/2026 that Patient #7 did not receive Speech Therapy twice a week from 02/09/2026 through 03/03/2026. Employee #2 confirmed that Patient #12 did not receive any OT services from 02/02/2026 through 03/03/2026.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(1) All rehabilitation services orders must be documented in the patient’s medical record in accordance with the requirements at §482.24. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, medical records, and staff interviews, it was determined the administrator failed to ensure Rehabilitiation Services documentation was completed as required for 14 patients (Patients # 1-14). This deficient practice poses a risk to the health and safety of patients if documentation is not thorough and complete leading other care givers to not receive proper information regarding a patient’s progress or decline in health and conditions. Findings include: Hospital document titled, “Phoenix Specialty Hospital Organizational Plan for Providing Patient Care, 2026”, revealed: “...The scope of services includes but is not limited to pulmonary medicine, infectious disease, psychiatry and wound care management, medically complex care, and medical rehabilitation...Rehabilitation Services (Rehab): Rehabilitation Services provides therapeutic intervention and training to meet the rehab needs of patients at Phoenix Specialty Hospital...Skilled rehabilitation services include Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) as well as the utilization of non-skilled functional maintenance programs (FMP). Each patient is evaluated by each discipline per physician’s order. Treatment plans are then established which may include but are not limited to: therapeutic exercise, therapeutic activity, Activities of Daily Living (ADL) training, fait training, balance training, activity tolerance training, range of motion, thermal modalities, electrical modalities, training in assistive devices, splinting, positioning, strengthening, dysphagia/swallowing, speech/language training, perceptual-cognitive training, wheelchair management, manual therapy, neuromuscular re-education, patient/family education....” Hospital policy titled, “Rehabilitation Therapy Services”, revealed: “...Phoenix Specialty Hospital physical, occupational, and speech therapy services will: b. be provided based on Phoenix Specialty Hospital physician’s orders for evaluation and treatment...g. document care provided to a patient in the medical record according to Phoenix Specialty Hospital policy....” Review of 14 patient medical records revealed 14 patients with missing information from all Rehabilitation Services documentation. “Missing information” was noted as being marked in the electronic medical record next to each individual rehabilitation service note. Review of each patient’s rehabilitation services notes revealed missing documentation in areas indicating type of treatment received for that session, patient tolerance of treatment, signature of the therapist and date and time completed. Employee #2, #4, #5, and #6 confirmed on 03/03/2026 that the 14 patients’ rehabilitation services progress notes were incomplete and missing required documentation.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 43814 Based on record review and staff interview, it was determined that the facility failed to ensure that its Emergency Preparedness plan incorporated updated documentation of the needs of the patient population it serves as part of the continuity of operations. Failure to update the continuity plan for the patient population may disrupt services to patients/clients during an emergency, leading to harm. Findings include: Observation during review on March 3, 2026, revealed that the facility was unable to locate updates to the documentation addressing the needs of the patient population within the current written plan. The facility recently changed its patient population by accepting handcuffed patients and possibly adding up to 28 law enforcement officers to guard them. Employee #9 confirmed during the document review that the facility was unable to locate any updated documentation addressing the needs of the patient population. .”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 43814 Based on a review of the facility’s emergency plan and a staff interview, it was determined that the facility failed to ensure that new staff reviewed the emergency preparedness plan. Failure to have staff review the emergency preparedness plan in accordance with their expected roles may cause harm to residents and/or staff during an emergency. Findings include: Observations, interviews, and record review conducted on March 3, 2026, revealed that the facility failed to provide documentation that new full-time law enforcement personnel had received any emergency preparedness training. In addition, the law enforcement staff was questioned, but no one could locate the required emergency preparedness policies or phone numbers. The law enforcement staff was not familiar with the emergency Preparedness program and didn’t recall receiving any training. Management was unable to locate any training for these new people regarding the EP. Employee #9 confirmed during the tour that the facility failed to provide documentation that new law enforcement personnel had reviewed the emergency preparedness policies and procedures.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 43814 Based on observations and a document review, the facility made modifications to the building without obtaining a building permit or updating the Certificate of Occupancy to reflect the intended occupancy. Failure to obtain a change of classification and a building permit could result in patients being trapped and the fire department being unaware of their existence. 2012 KNFPA Life Safety Code Chapter 4 4.6.11 Change of Use or Occupancy Classification. In any building or structure, whether or not a physical alteration is needed, a change from one use or occupancy classification to another shall comply with 4.6.7. 4.6.7 Building Rehabilitation. 4.6.7.1 Rehabilitation work on existing buildings shall be classified as one of the following work categories in accordance with 43.2.2.1: (1)Repair, (2)Renovation (3)Modification (4)Reconstruction (5)Change of use or occupancy classification (6)Addition43.2.2.1.3 Modification. The reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment. International Building Code Under the International Building Code (IBC), a hospital is classified as an Institutional Group I-2 occupancy. In the International Building Code (IBC), a correctional facility is classified as Institutional Group I-3 Condition 5 fully restricted patients Group 1-3 Inhabited by more than five persons who are under restraint or security. An I-3 facility is occupied by persons who are generally incapable of self-preservation due to security measures not under the occupants ’ control. This group shall include, but not be limited to, the following: Prisons Jails Reformatories Detention centers Correctional centers Prerelease centers Findings include: Observations during a tour on March 3, 2026, revealed that the facility had installed bars on the windows of rooms on the second floor to restrict the movement of detainees and prisoners. The facility did not obtain or notify the city or the fire department of these changes. The city requires a change of classification when individuals are under restraint for security reasons. The facility was housing (10 ) ten patients who were handcuffed to the bed, and detention officers were being kept in the hallways to maintain custody. No permit or change of classification was requested from the city of Meas. Employee #9 confirmed during the tour that the bars were placed in the windows and the patients were being housed in chains starting in December 2025, and the city was not notified”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 43814 Based on observations and interviews with staff, it was determined that the facility failed to provide an updated written plan to protect all patients in the event of a fire or emergency. Failure to provide policies, procedures, and training for staff may cause harm to patients and staff during an emergency. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 Fire Safety Plan. “A written health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire Findings include: During a review of the facility’s documentation on March 3, 2026, it was found that the facility had not modified or updated its written emergency policy manual. The facility installed bars in the windows in the second story of the hospital housing 14 patients, and began housing patients who were chained to the beds and described as under custody. In addition, the facility had detention officers in the hallways who had not received any training on the hospital’s fire or emergency plan. Employee #9 confirmed during the tour and document review that the hospital’s fire plan was not updated when the change of status occurred in December 2025, and that the detention officers did not receive any fire or life safety training”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 43814 Based on Observation, it was determined that the facility failed to maintain the alarm annunciator for the diesel generator, which is a storage battery-powered and is provided to operate outside the generating room in a location readily observed by operating personnel. Failure to have an alarm annunciator or supplemental devices to monitor the generator during a power outage could harm staff in an emergency. NFPA 101 2012 Life Safety Code NFPA 99 Chapter 6 Section 6.4.1.1.17, 6.4.1.1.17.5 Electrical Systems - Essential Electric System Alarm Annunciator. A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. Findings include: Observations during a tour on March 3, 2026, revealed that the facility failed to maintain the diesel generator’s remote alarm annunciator in an operable condition. The remote panel at the second-story nurses’ station shows a red alarm indicator lamp illuminated, alarm disabled. Staff informs me they were told the panel was disabled for testing earlier in the day. Employee #9 confirmed during the tour that the remote alarm panel for the diesel generator had been disabled during the generator’s testing that morning and was not restored to normal operation after the run.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 43814 Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement certain CMS required emergency preparedness policies and procedures based on the Emergency Plan. Failure to develop policies and procedures related to processes for handling an emergency situation could cause potential harm to staff and patients if they are not aware of what they are expected to do. Findings include: Observation during the emergency plan review September 18, 2025, revealed the plan did not include emergency preparedness policies and procedures for Emerging Infectious Diseases, these are listed as CMS April 16th, 2021 revision required in the Emergency Plan. Employees #1 and #2 conformed during the exit conference that the Emergency Plan did not include emergency preparedness policies and procedures for Emerging Infectious Diseases.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 43814 Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available. Finding include During observations while on tour September 18, 2025, it was revealed that the facilities did not have the needed amounts of water needed to sustain the staff patients and visitor the four days as described in their plan. The needed amount suggested by FEMA 1 gallon per person perday was not meet the facility listed 45 patients and 25 staff but only had 90 gallons on hand. Employees # 1, and #2 confirmed during the exit interview conducted on September 18, 2025, that the sustenance on hand was not nearly enough.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 43814 Based on a review of the facility’s Emergency Plan, record review, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for the use of volunteers in an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency and lead to potential harm. Findings include: During the document review on September 19, 2025, it was revealed the facility’s Emergency Plan (EP) did not include policies and procedures to address the use of volunteers in an emergency. Employees #1 and #2 confirmed during an interview that the facility EP did not include policies and procedures to address the use of volunteers in an emergency.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 43814 Based on review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency. Findings include: During document review on September 19, 2025, it was revealed the facility’s Emergency Plan related to the section which addresses policies and procedures describing the facility’s role in providing care and treatment at alternate care sites under an 1135 waiver did not include policies and procedures describing the facility’s role in providing care and treatment at alternate care sites under an 1135 waiver. Employees #1, and #2 confirmed during document review that the facility EP plan did not include policies and procedures describing the facility’s role in providing care and treatment at alternate care sites under an 1135 waiver.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 43814 Based on review of the facility’s emergency plan and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency. Findings include: Observations, interview and record review made on September 19, 2025, revealed the facility failed to provide documentation that the students from Pima Collage and ASU reviewed the emergency preparedness policies and procedures. In addition, the students were questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. Employee #1 and #2 confirmed during the exit interview the facility failed to provide documentation that students currentlt training at the facility had reviewed the emergency preparedness policies and procedures.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 43814 Based on review of the facility’s Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency. Findings include: During document review on September 19, 2025, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or based exercise or table top drills for the last two cycles.The facility has participated in drills in the past years and some this year but did not write an after action report wich discribed the incident or actions to be taken to improve the emergency plan. In addition the facility had a cyber related emergency emergency during the survey with the internet downs for daysbut not documentation was found discribing establishment of the command stuructire or action to be taken to midigate the effects on the staff and patient population. The facility had a plan for information management infrastructor incudents a copy of the plan was requested but not provided and it was listed in their Hazard Vulnability Assessment (HVA) as requiring a policy. Employee #1, and #2 confirmed during the exit interview that the facility was not able to locate proof of proper documentation of a full-scale exercise that was community-based or a facility based exercise in the last four years.”

“Based on Observation the facility failed to properly store full oxygen (O2) cylinders. This could result in the combustible items becoming oxygen-saturated and easily ignitable which could cause a fire to start prematurely. Failing to properly store oxygen could result in personnel entering the area unaware of the hazards inside NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart.” Hospital 42 CFR Part 482 -- Conditions of Participation The facility must meet the applicable provisions of the 2012 Edition of the National Fire Protection Association’s Life Safety Code. This is a Recertification survey for Medicare under LSC 2012, Chapter 19, Existing. The entire facility was surveyed on September 19, 2025. The facility meets the standards based on acceptance of a plan of correction.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 43814 Based on Observation it was determined the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 “Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 “ Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.” Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress there from, or visibility thereof. Observations on tour September 18-19,2025, revealed the hospital failed to maintain a clear path to the exit in the following areas. 1. the east halway in the patient care area 2nd foor had a linen cart and other items that were no inuse at the time parked in the hallway 2. the main corridor 1st floor floor had equipment in all exit corridor that were not in current use. such as blood pressure minitors plugged but not moved for over two hours Employees # 1 and #2 confirmed during the tour that the above listed exit pathways were restricted.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 43814 Based on Observation, it was determined that the facility allowed the use of power strips but did not use the wall outlet receptacles for appliances. Failure to properly use power strips and outlets could lead to electrical overload or fire, which could harm the patients and staff. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 “Mandatory References” NFPA 99 “Standard for Health Care Facilities, “ 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , “All Patient Care Areas,” Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)” Minimum Number of Receptacles.” “The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity: o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 o Power strips cannot be used for non-medical equipment If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity: o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363 If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity: o UL power strips could be used with precautions Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions. 10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart-mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2)* The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4)* The electrical and mechanical integrity of the assembly is regularly verified and documented. 10.5.2.3 Adapters and Extension Cords. Any use of adapters and/or extension cords within health care facilities, while permitted subject to the conditions listed in 10.2.4.1 through 10.2.4.2.3, should be used with caution. The nature of this caution includes attention to the introduction of trip hazards for patients, staff, or visitors; increased possibility of damage to cords that are lying on the floor; ease with which grounding resistances or power cord ampacity can be exceeded; and possibility of incorrect polarization. Conducting periodic performance verification of adapters and extension cords as part of the equipment control program is effective only if all adapters and extension cords are properly identified and labeled. Findings include: Observations made during the tour from September 18-19, 2025, revealed that the following locations had power strips plugged into equipment with heavy load-drawing appliances (refrigerators, microwaves, and large printers). 1. A Microwave plugged into a power strip in the break room 2. A Refrigerator and microwave plugged into a power strip in the wound care office . A policy was requested but not provided for the personal use of non-facility-owned electrical equipment. During the exit conference conducted on September 19, 2025, Employees # 1 and #2 confirmed the improper use of power strips.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 43814 Based on Observation, the facility failed to store full oxygen (O2) cylinders properly. This could result in the combustible items becoming oxygen-saturated and easily ignitable, which could cause a fire to start prematurely. Failing to store oxygen properly could result in personnel entering the area unaware of the hazards inside NFPA 101 Chapter 5 section 5.1.3.3.1.7 Cylinders in use and in storage shall be prevented from reaching temperatures in excess of 54°C (130°F). NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1 ‘A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING” NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3 “Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft)(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour Findings include: Observation while on a tour conducted on September 19, 2025, revealed the following locations with Oxygen (O2) being stored without signage on the door and within 5 ft of combustible materials: 1. The oxygen storage room on the first floor. 2. The oxygen storage room on the second floor 3. In addition, there were 12 E-size cylinders in the outdoor O2 storage area, not secured. These tanks were shown as empty on the sign posted. Employees #1 and #2 confirmed throughout the tour that oxygen is improperly stored throughout the facility.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 52757 Based on the review of clinical records, policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations and hospital functions provide a safe environment for the patient population. This Condition Level deficiency is the result of the Condition Level and Standard deficiencies found under the Conditions of Patient Rights, Medical Records, Utilization Review, and Physical Environment as evidenced by: Cross reference: A-0022: The Governing Body: 1. failed to ensure the facility did not admit med/surg patients to licensed rehab beds; 2. failed to ensure the scope of services was accurate with current services provided; 3.failed to notify the state licensing agency within 30 days, in writing, a change in the hospital administrator. 4. Failed to provide complete acquiescence to requested files and documents including electronic medical records and committee meeting minutes. Cross reference: A-0049 The Governing Body failed to ensure to ensure a provider (Provider #2) had current credentials for Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS). Cross reference: A-0057: The governing Body failed to notify the State Licensing agency in writing within 30 days of a change in the facility ’ s administrator and document the new CEO appointment in meeting minutes. Cross reference: A-0084: The hospital failed to have a plan in place to evaluate effectiveness and quality of contracted services Cross reference: A-0085: The governing body failed to ensure that the facility maintained a list of contracted services. Cross reference: A-0115 Patient Rights (Condition) Cross reference: A-0116: The Administrator failed to ensure four (4) out of 20 (twenty) patient consent to treatment admission form were completed entirely. Cross reference: A-0117: The facility failed to ensure language translation and interpretation services were provided to Patient #20 during admission to the facility. Cross reference: A-0122: The facility failed to ensure the grievance process for Patient #20’s family member was followed. Cross reference: A-0131: The hospital failed to ensure patients were notified at the time of admission that a physician is not available onsite at the hospital 24 hours a day, seven days a week. Cross reference: A-0144: The Administrator failed to ensure: Equipment and medications were maintained free from a condition or situation that may cause a patient or others harm: a.Bladder scanners were cracked and/or broken. b.Oxygen tanks storage area without appropriate signage on room c.Lab specimen work area has no sink d.Medication rooms left unsecured e.Ten pound weight in Physical Therapy (PT) room torn material f.Pillow with torn material in PT room One (1) patient/staff patio area on the second-floor was free pigeon feces. orientation for staff members occurred within the first 30 days Cross reference: A-0173: The facility failed to ensure four patients (Patients #15, 16, 17, and 18), restraints were used without documented renewal of restraint orders within the required 24-hour timeframe to justify continued use. Cross reference: A-0174: The facility failed to ensure that hospital personnel and medical staff followed the approved policies and procedures for restraints by failing to document restraint release trials in four (4) patient restraint episodes. Cross reference: A-0392: The facility failed to ensure (2) patients, Patient #20 and #21, were provided assistance with appropriate hygiene care during admission to the facility. Cross reference: A-0407: The hospital or provider failed to ensure verbal orders for 14 (fourteen) of 20 (twenty) patients were electronically signed in the appropriate timeframe as required by the Verbal and Telephone Medication Orders policy and Medical Staff Bylaws Rules and Regulations Cross reference: A-0431 Medical Records (Condition) Cross reference: A-0438: The administrator failed to ensure Patient medical records were available for access 24/7 via the electronic medical record system. Cross reference: A-0441: The administrator failed to ensure hard copies of patient medical records were secured from unauthorized access. Cross reference: A-0620: The administrator failed to ensure: 1. open, bulk dry goods were protected from contamination; 2. packages of frozen food that were not in their original packages were properly sealed, and date marked with an expiration/discard date; and 3. individual food packets not stored in original containers were date marked with an expiration/discard date; and 4. discarding expired food and food items; and 5. storing patient nutrition supplements properly and safely. Cross reference: A-0631: The hospital failed to ensure the current diet manual available to personnel members and medical staff was approved by a registered dietitian. Cross reference: A-0652 Utilization Review (Condition) Cross reference: A-0653: The governing body failed to ensure that the facility ’ s Utilization review plan was implemented Cross reference: A-0654: The governing body failed to ensure Medical Staff Bylaws were followed when appointing members to the Utilization Committee. Cross reference: A-0655: The governing body failed to ensure that quarterly Utilization review meetings were held. Cross reference: A-0657: The governing body failed to ensure that an effective Utilization review plan was in place to monitor a patient’s extended stay. Cross reference: A-0658: The governing body failed to ensure that an effective Utilization review plan was in place to review services provided by the facility. Cross-reference: A-0700: Physical Plant (Condition) Cross-reference: A-0722: The governing body failed to initiate the facility ’ s emergency plan for a cyber-related emergency when the facility’s internet was down for over five (5) days. Cross reference: A-0724: The Administrator failed to ensure: 1.Sterile medical supplies that were expired were removed from use and discarded 2.Laboratory specimen tubes expired were removed from use and discarded 3.Multi use ultrasound gel was marked with an open date and discard date Linen was not touching the floor while stored on linen cart Shower room floor tiles were secure and grout was free from stains and mold-like substances Patient supplies were not stored next to a handwashing sink Cross reference: A-0748: The governing body failed to have an Infection Preventionist trained in infection control practices and procedures. Cross reference: A-0774: The governing body failed to ensure the Infection Preventionist was responsible for the communication and collaboration with Quality Assurance. Cross reference: A-0777: the governing body failed to ensure that the infection preventionist was in communication and collaboration with Antibiotic Stewardship. Cross reference: A-0826: The administrator failed to ensure medical records accompany two (2) patients (Patient #7 and Patient #9) during transfer. The cumulative effect of these systemic deficient practices resulted in the facility ’ s failure to meet the requirement for the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52757 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: A-0116: The governing body failed to ensure four (4) out of 20 (twenty) patient consent to treatment admission form were completed entirely. A-0117: The governing body failed to ensure language translation and interpretation services were provided to Patient #20 during admission to the facility. A-0122: The governing body failed to ensure the grievance process for Patient #20’s family member was followed. A-0131: The governing body failed to ensure patients were notified at the time of admission that a physician is not available onsite at the hospital 24 hours a day, seven days a week. A-0144: The governing body failed to ensure: Equipment and medication was maintained free from a condition or situation that may cause a patient or other individual to suffer physical harm. A .Bladder scanners were cracked/broken. B. Oxygen tanks were in a room with the appropriate signage. C. A handwashing sink was in the lab work area. D. The medication room on the first floor was locked. E. Ten-pound weight in Physical Therapy room with torn leather F. Pillow with tear in material in Physical Therapy room One (1) patient/staff patio on the second floor had pigeon feces Orientation for staff members occurred within the first 30 days. A-0173: The governing body failed to ensure four patients (Patients #15, 16, 17, and 18), restraints were used without documented renewal of restraint orders within the required 24-hour timeframe to justify continued use. A-0174: The governing body failed to ensure that hospital personnel and medical staff followed the approved policies and procedures for restraints by failing to document restraint release trials in four (4) patient restraint episodes. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 52757 Based on review of policies and procedures, hospital documents, medical records and interviews, it was determined the hospital failed to ensure the each individual patient’s medical record was maintained and complete as demonstrated by the following Standard level citations: A-0022: The Governing Body failed to provide complete acquiescence to requested files and documents including electronic medical records A-0173: The facility failed to ensure four patients (Patients #15, 16, 17, and 18), restraints were used without documented renewal of restraint orders within the required 24-hour timeframe to justify continued use. A-0174: The facility failed to ensure that hospital personnel and medical staff followed the approved policies and procedures for restraints by failing to document restraint release trials in four (4) patient restraint episodes. A-0407: The hospital or provider failed to ensure verbal orders for 14 (fourteen) of 20 (twenty) patients were electronically signed in the appropriate timeframe as required by the Verbal and Telephone Medication Orders policy and Medical Staff Bylaws Rules and Regulations A-0438: The administrator failed to ensure Patient medical records were available for access 24/7 via the electronic medical record system. A-0441: The administrator failed to ensure hard copies of patient medical records were secured from unauthorized access. A-0722: The governing body failed to initiate the facility ’ s emergency plan for a cyber-related emergency when the facility’s internet was down for over five (5) days. A-0826: The administrator failed to ensure medical records accompany two (2) patients (Patient #7 and Patient #9) during transfer. The cumulative effect of these systemic problems resulted in the hospital not ensuring medical records were maintained and complete, leading to a failure to meet the requirements of the Condition of Participation for Medical Records.”

“UTILIZATION REVIEW CFR(s): 482.30 The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This Condition is not met as evidenced by: 43788 Based on a review of staff interview and facility records, it was determined that the provider failed to ensure that there was an effective utilization review plan that provides for review of services furnished by the institution and by members of the medical staff as evidenced by: Cross reference: A-6053: The governing body failed to ensure that the facilities Utilization review plan was implemented Cross reference: A-0654: The governing body failed to ensure Medical Staff Bylaws were followed when appointing members to the Utilization Committee. Cross reference: A-0655: The governing body failed to ensure that quarterly Utilization review meetings were held. Cross reference: A-0657: The governing body failed to ensure that an effective Utilization review plan was in place to monitor a patient’s extended stay. Cross referency: A-0658: The governing body failed to ensure that an effective Utilization review plan was in place to review services provided by the facility. The cumulative effect of these systemic deficiant practices resulted in the facilitys failure to meet the requirent for the Ondition of Partivipation for Utilization Review”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 52757 Physical Environment Condition Based on review of documents, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Physical Environment as evidenced by the following references to standard level deficiencies: A-0722: The governing body failed to initiate the facility ’ s emergency plan for a cyber-related emergency when the facility’s internet was down for over five (5) days. A-0724: The Administrator failed to ensure: 1.Sterile medical supplies that were expired were removed from use and discarded 2.Laboratory specimen tubes expired were removed from use and discarded 3.Multi use ultrasound gel was marked with an open date and discard date 4. Linen was not touching the floor while stored on linen cart 5. Shower room floor tiles were secure and grout was free from stains and mold-like substances 6. Patient supplies were not stored next to a handwashing sink The cumulative effects of these systemic practices resulted in the failure of the hospital to deliver statutorily mandated compliance with Federal regulations for Physical Environment.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 43788 Based on Review of Arizona Department of Health facility licensing file, document review, observation, and interview, it was determined that the facility: 1. failed to ensure the facility did not admit med/surg patients to licensed rehab beds; 2. failed to ensure the scope of services was accurate with current services provided; 3.failed to notify the state licensing agency within 30 days, in writing, a change in the hospital administrator; 4. failed to provide complete acquienscence to requested files and documents including electronic medical records and committee meeting minutes The cumulative systemic effect of these defcient practices poses a risk to the health and safety of patients if the state licensing agency does not have proprer information regarding the oversight and day to day operation of the licensed hospital. Cross reference: A-0043, A-0057, A-0700, A-0722 Findings include: 1. Review of hospital license dated 7/12/2025 revealed total licensed beds: 48. Further review of the facility license revealed 23 Med-surg beds, 6 ICU beds, 19 Rehab beds. Review of Arizona Department of Health facility licensing file revealed Rooms 201-213 designated as Rehab beds with break down as Rooms 201, 202, 203, 204, 211, 212, 213 designated as single occupancy patient room and Rooms 205, 206, 207, 208, 209, and 210 designated as double occupancy patient rooms. Review of hospital admissions from 05/22/2025 to 09/15/2025 revealed med/surg patients admitted and receiving care in beds designated as rehab beds. Observation on 09/15/2025 revealed nine (9) rehab beds occupied by patients. Review of the patient census for 09/15/2025 revealed the nine (9) patients were admitted as med/surg patients and placed in Rehab designated licensed beds.. Employee #3 confirmed during an interview on 09/15/2025 that the current hospital census was 21. Employee #3 confirmed the second floor unit of the hospital was licensed as Rehab beds. Employee #3 confirmed that there were no rehab patients in the rehab beds and that the rehab beds were occupied by med/surg patients. Employee #3 confirmed that there had not been any rehab patients admitted to the hospital since the hospital had changed the licensed bed count in May, 2025 to include the 19 rehab beds. 2. Review of hospital document titled, “Organizational Plan for Providing Patient Care 2025”, revealed: “...Transfusion Services: Vitalant: Description: Blood transfusion services are provided as a contracted service with Blood Systems Laboratory for transfusion of blood and blood products...Scope of Service: Transfusion services are provided for patients who require blood and blood products as ordered by a physician....” Review of hospital contracted vendors revealed no current contract in place for blood services with Vitalant. Employee #1 confirmed on 09/16/2025 that the blood services contract with Vitalant had expired and the hospital was currently in contract negotiations with Vitalant. Employee #1 confirmed there was not a current blood services vendor and patients were currently being sent out to other facilities if blood services were needed. 3. Upon arrival to facility on 09/15/2025 for compliance survey, Compliance Officers were informed Employee #3 was the Chief Executive Officer/Administrator. Review of the Arizona Department of Health facility licensing file revealed the Chief Executive Officer/Administrator as Employee #18. Review of Governing Board Meeting Minutes for 2025 revealed no documentation of appointment approval for the current Chief Executive Officer/Administrator. Request was made on 09/15/2025 during the survey by the Compliance Officer for documentation of the Governing Board approval and appointment of the current Chief Executive Officer. None was provided. Employee #3 confirmed during an interview on 09/15/2025 that they were the Chief Executive Officer/Administrator and had been the Chief Executive Officer/Administrator since the end of April 2025. 4. During entrance conference with hospital staff on 09/15/2025, Compliance Officers informed hospital staff that patient medical record chart review would be conducted during the survey process. Staff informed the Compliance Officers that the hospital utilized the electronic medical record (EMR) system “Wellsky”. On 09/15/2025 Compliance Officers requested access to the EMR Wellsky for patient medical record chart review. Employee #1 informed Compliance Officers that the internet service was not working and there was no access to patient medical records. Employee #1 informed Compliance Officers that there was a limited number of mobile hotspots available to staff to use to access the EMR system. Employee #1 provided two (2) staff members with computers and mobile hotspots to access the patient medical records for the Compliance Officers on 09/16/2025. At the end of the survey on 09/17/2025, the hospital ’ s internet service was still non-operational. Employee #3 confirmed on 09/15/2025 that the internet service was not operational, as the hospital ’ s internet bill had not been paid and service was discontinued by the service provider. Employee #3 stated the internet had not been operational since the previous Friday, 09/12/2025. Employee #3 confirmed that the internet service bill had been paid on 09/15/2025 but it could be up to 72 hours before the internet service was operational. Request was made on 09/15/2025 for the following documents: Governing Body Board Meeting Minutes for the past 12 months; Quality Assessment and Performance Improvement Committee Meeting Minutes for the past 12 months; Infection Control Committee Meeting Minutes for the past 12 months; Utilization Review Committee Meeting Minutes for the past 12 months; Pharmacy and Therapeutics Committee Meeting Minutes for the past 12 months; Governing Body Board Meeting Minutes for August 11,2025, August 28, 2025 and September 2, 2025 were provided. Quality Assessment and Performance Improvement Committee Meeting Minutes were provided for July 29, 2025 was provided. Infection Control Committee Meeting Minutes were provided for July 29, 2025. No Utilization Review Committee Meeting Minutes were provided for the past 12 months. Pharmacy and Therapeutics Committee Meeting Minutes were provided for July 29, 2025. Employee #1 and #3 confirmed there were no other Governing Body Board Meeting Minutes available for review besdies the August and September 2025 meetings. Employee #1 and #3 confirmed there were no Quality Assessment and Performance Improvement Meeting Minutes available for review prior to July, 2025. Employee #1 and #3 confirmed there were no Infection Control Committee Meeting Minutes available for review prior to July, 2025. Employee #1 and #3 confirmed there were no Medical Executive Committee Meeting Minutes available for review prior to April 2025. Employee #1 confirmed there were no Utilization Review Committee Meeting Minutes available for the past 12 months. Employee #1 confirmed there were no Pharmacy and Therapeutic Committee Meeting Minutes available for review other than the July 29, 2025 minutes.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 52995 Based on review of policies, medical staff credential files, The American Board of Internal Medicine (ABIM) and staff interviews, it was determined that the administrator failed to ensure a provider (Provider #2) had current credentials for Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS). This lack of professional compliance poses a risk to the health and safety of patients during medical emergencies. Cross Reference A0043, A0144 Findings include: Policy titled, “Medical Staff Rules and Regulations (09/2024)” revealed “...Continuing Medical Education 1. All practitioners shall meet the continuing education requirements established by the State Licensing Boards and accrediting bodies. 2. All practitioners are encouraged to participate in pertinent self-assessment programs and in basic cardiopulmonary resuscitation training....” Review of ABIM standards (2025) for Internal Medicine Providers revealed “...2002-2006: 1. Interpreting electrocardiograms 2. Performing the following procedures; understanding their indications, contraindications, and complications; interpreting their results: · Advanced cardiac life support (American Heart Association documentation of successful training within the teaching institution is accepted)...”. “...2006-Current Time: ABIM does not specify a minimum number of procedures to demonstrate competency; however, to assure adequate knowledge and understanding of the common procedures in internal medicine, each resident should be an active participant for each procedure five or more times. Know, Understand, Explain Safely Perform... ACLS....” During an interview with employee #10 it was revealed that “Medical Providers who are functioning as Internal Medicine providers are required to maintain current BLS and ACLS, providers functioning as specialist such as Infectious Disease or Nephrology, are not required to maintain current BLS or ACLS”. Employee #3 and employee #10 confirmed that Provider #2 did not have current BLS and ACLS in the credential file.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 43788 Based on review of the Arizona Department of Health facility licensing file, document review, observation, and interview, it was determined the facility failed to notify the state licensing agency in writing within 30 days of a change in the facility’s administrator and document the appointment of the new CEO in the meeting minutes. This deficient practice poses a risk to the health and safety of patients if the Department is not aware of who is responsible and accountable for the hospital ’ s oversight. Cross reference: A-0022, A-0043 Findings include: Upon arrival to facility on 09/15/2025 for compliance survey, Compliance Officers were informed Employee #3 was the Chief Executive Officer/Administrator. Review of the Arizona Department of Health facility licensing file revealed the Chief Executive Officer/Administrator as Employee #18. Review of Governing Board Meeting Minutes for 2025 revealed no documentation of appointment approval for the current Chief Executive Officer/Administrator. Request was made on 09/15/2025 during the survey by the Compliance Officer for documentation of the Governing Board approval and appointment of the current Chief Executive Officer. None was provided. Employee #3 confirmed during an interview on 09/15/2025 that they were the Chief Executive Officer/Administrator and had been the Chief Executive Officer/Administrator since the end of April 2025.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility records, it was determined that the provider failed to ensure that the facility evaluated its contracted services. This deficient practice may pose a health and safety risk when unapproved contractors are used to provide facility services. Cross reference: A-0043, A-0085 Findings include: Policy on Contracted Services requested, none provided Document request for evaluations of contracted services provided to the facility requested. None provided. Employee # 1 confirmed in an interview dated 09/17/2025 that the facility does not have a policy on contracted services. Employee # 1 confirmed in an interview dated 09/17/2025, that the facility does not have an evaluation of each service provided.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(2) The hospital must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility records, it was determined that the provider failed to ensure that the facility maintained a list of contracted services. This deficient practice may pose a health and safety risk when unapproved contractors are used to provide facility services. Cross reference: A-0043, A-0084 Findings include: A list of the facilities contracted services requested. An incomplete list was provided. Employee # 1 confirmed in an interview dated 09/17/2025 that the facility could not provide a complete list of contracted services.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 52757 Based on staff interview and facility records, it was determined the Administrator failed to ensure four (4) out of 20 (twenty) patient consent to treatment admission form were completed entirely. This deficient practice poses a risk to patient health and safety because critical and time sensitive procedures can be delayed if a patient ’ s signed consent form is incomplete. Cross reference: A-0043, A-0115 FINDINGS INCLUDE: Policy titled “Advance Directives, Interdisciplinary” revealed: “ ... PURPOSE:... To provide in the medical record, a consolidated confirmation of the patient ’ s decision(s) regarding medical treatment provisions for terminal illness or end-of-life care ... To provide in the medical record, patient/legal representative consultation, provider documentation and direction for terminal illness or end-of-life care management ... POLICY: All patients will be offered the opportunity to complete an Advance Directive at the time of admission, and at any time during their hospitalization. Patients may modify their Advance Directive at any time during their hospitalization. Additionally, patients shall be offered the opportunity to modify their Advance Directives when warranted by an evident change in condition ... PROCEDURE:... 2. Upon admission to the hospital, an Admissions Team member or Nursing staff member will provide the patient with educational material, via the Patient Handbook, on their right to make, withhold, or refuse medical treatment and on Advance Directives. ...” Hospital document titled “PATIENT CONSENT TO TREATMENT ADMISSION FORM” revealed: “”... 13. ACKNOWLEDGEMENT STATEMENT (Check either Yes, No, or Not applicable (N/A) for each statement) 1. I have been advised of the law and Hospital policy regarding Advance Directives and have been given information regarding this subject. 2. I have executed an Advance Directive. a. I understand that my Advance Directive will not be honored until I have given the appropriate documents to my physician and/or the hospital. b. I have given my physician and/or Hospital a copy of my Advance Directive. 3. I want to execute an Advance Directive and would like the Hospital ’ s assistance. 4. I have executed a Durable Healthcare Power of Attorney (“POA”). a. I understand that my POA will not be honored until I have given the appropriate documents to my physician and/or the Hospital. b. I have given my physician and/or Hospital a copy of my POA. 5. I have received a copy of the Patient Handbook which includes information regarding Patient Rights and Notice of Privacy Practices. 6. I consent to allow disclosure of Protected Health Information in accordance with the Notice of Privacy Practices (If “No,” complete section below.)....” Further review of Patient #1, #3, #13, and #22 ’ s medical record failed to reveal documentation of the acknowledgement statements of the consent to treat. Employee #12 confirmed during an interview conducted on 09/17/2025 that Patient #1 and Patient #3 consent to treatment admission form was not complete. Employee #1 confirmed during an interview conducted on 09/17/2025 that Patient #13 and Patient #22 consent to treatment admission form was not complete.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) 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: 45706 Based on policy and procedures, facility documents, and staff interview, it was determined the facility failed to ensure language translation and interpretation services were provided to Patient #20 during admission to the facility. This deficient practice poses a risk to patient health and safety including misdiagnosis, medical errors, adverse drug reactions, and delays in treatment if patients are unable to communicate their healthcare information. Cross reference: A-0043, A-0115 Findings include: Policy titled, “Patient Rights and Responsibilities” revealed: “...Federal law requires that your healthcare provider or healthcare facility recognize your rights while you are receiving medical care and that you respect the healthcare provider’s or healthcare facility’s right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your healthcare provider or healthcare facility...A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English, or visual, hearing, or expressive impairments prevent effective communication...” Incident report dated 07/10/2025 revealed the following documentation from a staff member involved in Patient #20’s care: “...I went in to check on (Patient #20) throughout the day and gave (Patient #20) ice chips. Had housekeeper translate for me. (Patient #20) was looking for (Patient #20) phone....” Employees #11 and 14 confirmed on 09/16/2025 the facility did not have language and interpretation services available to patients. Further interview with both employees revealed hospital staff members ask ICE (Immigration and Customs Enforcement) Agents and Core Civic Correctional Officers to interpret to non-English speaking patients within their custody. Employee #1 confirmed on 09/16/2025 the facility utilizes Language Line services for interpretation. Further interview revealed most staff members are unaware of how to use this service.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 45706 Based on policy and procedure, facility documents, and staff interview, it was determined the facility failed to ensure the grievance process for Patient #20’s family member was followed. This deficient practice poses a risk to patient health and safety if hospitals do not completely investigate patient care concerns, thereby comprising quality of care. Cross reference: A-0043, A-0115 Findings include: Policy titled, “Complaint and Grievance Process” revealed: “...Any difference of opinion, concern, complaint or grievance between a patient or his/her representative and Phoenix Specialty Hospital will be investigated and resolved in a timely manner. The governing body is responsible for the effective operation of the grievance process. The governing body delegates review and resolution of grievances to a grievance committee composed of the Chief Executive Officer (CEO) or designee, Chief Clinical Officer (CCO) or designee, Director of Quality and Risk Management (DQRM) and others as required...Patient complaints that are considered grievances also include situations where a patient or a patient’s representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance...A response is provided to the patient or patient’s representative within seven days of the report...If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the facility is to inform the patient or the patient’s representative via letter, that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within a specific stated number of days....” A request for complaint and grievance logs covering the past 12 months was made on 09/15/2025; however, only the log for July 2025 was provided. Employee #1 confirmed on 09/17/2025 s/he was unable to locate complaint and grievance logs prior to June 27, 2025. A review of the grievance dated July 2025 revealed that Patient #20 ’ s family member submitted a formal grievance letter to the hospital. The investigation review showed that the Director of Quality did not send a response letter to the family member upon conclusion of the investigation. Employee #1 confirmed on 09/17/2025 that a final letter at the conclusion of the grievance investigation was not sent to Patient #20’s family member.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 43788 Based upon a review of documents, observation, and interview, it was determined that the hospital failed to ensure patients were notified at the time of admission that a physician is not available onsite at the hospital 24 hours a day, seven days a week. This deficient practice poses the risk of patients being unaware that a physician is not onsite 24/7 and readily available, and is a violation of a patient’s right to be informed of healthcare practices at the facility. Cross reference: A-0043, A-0115 Findings include: Review of hospital policy titled, “A Guide to Patient Services”, revealed no documentation informing the patient that there was not a physician available onsite 24 hours a day, seven days a week. Review of hospital document titled, “Patient Consent to Treatment Admission Form”, revealed no documentation informing the patient that there was not a physician onsite 24 hours/7 days a week. Request was made for any document informing how patients are notified that there was not a physician onsite 24 hours a day/7 days a week. None was provided. Observation on tour revealed no posted sign in the main lobby informing patients that there was not a physician onsite 24 hours/7 days a week. Employee #2 confirmed on 09/15/2025 that there were no signs posted informing patients that there was not a physician onsite 24 hours a day/ 7 days a week.”

“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: 52995 Citation #1 Based on policy review, observation, and staff interview, is was determined the Administrator failed to ensure equipment and medication was maintained free from a condition or situation that may cause a patient or other individual to suffer physical harm. These deficient practices pose a risk to the health and safety of patients and other individuals. 1.Equipment that is broken and cracked cannot be cleaned and disinfected properly could lead to physical injury, including skin lacerations and infection. 2.Oxygen tanks in use poses an increased environmental threat of fire and physical injury. 3. Not having hand washing available in laboratory work area can lead to exposure of bodily fluids/bloodborne pathogens. 4.Unsecured medications can lead to misappropriation of medications, medical supplies and tampering of medications. 5. Equipment that has torn material cannot be cleaned and disenfected properly which can lead to transmission of pathogens and infectious diseases. 6 Equipment that has torn material cannot be cleaned and disenfected properly which can lead to transmission of pathogens and infectious diseases. Cross Reference A0043, A0144, A0724 Findings: 1. Bladder scanners Policy Titled “Cleaning of Patient Care Equipment” revealed: “...Purpose 1. To minimize the risk of nosocomial infection that may occur if shared patient equipment is inadvertently used before being cleaned by establishing guidelines for the cleaning and disinfection of that equipment....”. Observation on 09/15/2025 revealed a bladder scanner on the first floor Intensive Care Unit (ICU) had small “fissure-like” cracks in the plastic ultrasound probe of the bladder scanner. Observation on 09/24/2025 revealed a bladder scanner on the second-floor nurses station medical supply room plastic ultrasound probe device was cracked and had missing pieces of plastic with sharp edges present. Employee #20 confirmed the broken bladder scanner. Employees #1 and #2 confirmed the bladder scanners were in disrepair and needed to be removed from service until they were replaced or repaired. 2. Oxygen tank room Review of Occupational Safety Health Administration OSHA standards for compressed gas revealed “...Compressed gases can be toxic, flammable, oxidizing, corrosive, or inert. Leakage of any of these gases can be hazardous. Leaking inert gases (e.g., nitrogen) can quickly displace air in a large area creating an oxygen-deficient atmosphere; toxic gases (e.g., can create poison atmospheres; and flammable (oxygen) or reactive gases can result in fire and exploding cylinders. In addition, there are hazards from the pressure of the gas and the physical weight of the cylinder. A gas cylinder falling over can break containers and crush feet. The gas cylinder can itself become a missile if the cylinder valve is broken off....” Observation on 09/15/2025 revealed oxygen tanks (4 items) in a storage room. The storage room did not have signage identifying the room as an “oxygen” storage area. 3. Lack of Hand washing sink in lab work area Policy “Exposure Control Plan”(2024) revealed: “...Hand hygiene is the single most important strategy for preventing hospital acquired infections...” “...After touching inanimate objects that are likely to be contaminated with pathogenic microorganisms, such as urine-measuring devices and secretion collection apparatuses (must use soap and water)....” Review of Occupational Safety Health Administration OSHA standards (2025): “...Each laboratory contains a facility for hand washing and an eyewash facility which is readily available within the work area, 29 CFR 1910.1030(e)(3)(i);....” Observation on 09/15/2025 revealed no sink in area in which laboratory samples are processed and secured for transport. Employee #2 confirmed there was no sink in the lab area. 4. Medication room not locked Observation on 09/15/2025 revealed that the medication room on first floor nurses station was not locked. Further observation revealed that second floor medical supply room was unsecured and not locked. Employee #2 confirmed the medication rooms were not locked and secured. 5. Ten-pound weight in Physical Therapy room Policy Titled “Cleaning of Patient Care Equipment” revealed: “...Purpose, 1. To minimize the risk of nosocomial infection that may occur if shared patient equipment is inadvertently used before being cleaned by establishing guidelines for the cleaning and disinfection of that equipment....”. Observation on 09/15/2025 revealed second floor physical therapy room 10 pound weight used for therapy was torn with the leather covering missing and the cloth liner exposed. 6. Pillow covering torn Policy Titled “Cleaning of Patient Care Equipment” revealed: “...Purpose 1. To minimize the risk of nosocomial infection that may occur if shared patient equipment is inadvertently used before being cleaned by establishing guidelines for the cleaning and disinfection of that equipment....”. Observation on 09/15/2025 revealed a multi-use pillow covering torn, with the ability to clean properly hindered. Employees #1 and #2 confirmed that equipment in disrepair needs to be removed from use and replaced. Citation #2 Based on policy and procedure, Centers for Disease Control, observation, and staff interview, it was determined the Administrator failed to ensure (1) patient/staff patio area on the second-floor was free pigeon feces. This deficient practice poses a risk to patient, staff, and visitor health and safety by spreading airborne fungal and bacterial diseases when fecal accumulation is not properly removed and disinfected. Cross reference : A-0043, A-0115 Findings include: Policy titled, “Infection Prevention Plan” revealed: “...The Infection Prevention and Control Program is designed to improve the quality of care for patients while reducing the risk of acquired Healthcare Associated Infections (HAIs) for patients, staff and visitors. The Infection Prevention Program coordinates prevention, surveillance, investigation and control of infectious agents and reports information to external agencies as required...Surveillance: Regularly conducting inspections of the facility to ensure that risks for the transmission of infections or occupation hazards are minimized....” Policy titled, “Exposure Control Plan” revealed: “ ...This exposure plan covers all individuals who have potential exposure to blood and other potential infectious materials while at Phoenix Specialty Hospital. This includes all hospital personnel, contracted employees, physicians and practitioners, visitors, volunteers, and all individuals in training (students) for healthcare professions. It is the responsibility of all hospital department managers to assure that each person in his or her department understands and complies with the procedures contained herein ... Phoenix Specialty Hospital provides appropriate personal protective equipment (PPE) at no cost to employees and it is readily available. PPE includes, but is not limited to gloves, gowns, surgical masks, face shields, eye protectors, resuscitation bags, mouthpieces or other resuscitation devices. Normal work clothes or uniforms not intended to function as protection against a hazard are not considered PPE ... N95 Respirator: a respiratory protective mask with a filter efficiency of at least 95%... Personal Protective Equipment (PPE): includes gloves, gowns, masks, and eye protection or face shields ....” Centers for Disease Control and Prevention revealed: “ ...Histoplasmosis is a lung infection caused by breathing in spores from the fungus, Histoplasma ... People can get histoplasmosis by breathing in spores from the fungus, Histoplasma. The fungus is typically found in soil and bird or bat droppings in certain areas of the United States and the world ... Cryptococcosis is a fungal disease caused by breathing in spores from Cryptococcus, a fungus found in the environment. The infection can affect the different parts of the body but usually causes lung or brain infections (cryptococcal meningitis) ... Avoiding C. neoformans is generally difficult because it is common in the environment. Outdoor occupations, like landscaping and outdoor construction, have been associated with increased risk of cryptococcosis.3 Little is known about the specific activities that may increase risk of C. neoformans infection. However, working near bird droppings may increase exposure ...Psittacosis is a disease caused by bacteria that often infect birds. People who have contact with pet birds and live poultry are at increased risk. Psittacosis is usually a mild illness, though it can cause pneumonia....” Observation of staff/visitor patio located on the second floor revealed a balcony with (2) concrete tables and (8) bench style chairs. Additionally, the balcony contained an approximate 4-foot wall with metal railing attached to the top. Within the balcony area were piles of pigeon feces accumulated on the top of wall, corners of walls where the floor adjoins, floor, and table/bench area. Observation of the exterior windows on the second floor and ledges on the building revealed either netting or pigeon spikes attached to prevent the birds from landing on the building. Employee #14 confirmed on 09/16/2025 that proper PPE is not readily available to employees responsible for cleaning and disinfecting pigeon feces. Additionally, facilities staff will ask nursing if N95 masks are available for use. Employee #20 confirmed on 09/15/2025 the pigeon feces is an ongoing problem. Further interview revealed facilities management utilizes a pressure washer to remove the feces with the last clean-up occurring less than a month ago. Citation #3 Based on policy review, employee personnel files, and staff interviews, it was determined that the administrator failed to ensure that orientation for staff members occurred within the first 30 days. This deficient practice poses a risk to the health and safety of patients and employees, if employees are not familiar with policies and procedures such as infection control, blood-borne pathogens, personal and patient safety and security, emergency plans and protocols, patient rights and responsibilities. Cross reference: A-0043, A-0115 Findings include: Policy titled, “New Employee Orientation”, revealed: “...New employee orientation is the joint responsibility of the Human Resources Department and appropriate departmental supervision. Proper orientation can pay lasting dividends in terms of higher morale, greater loyalty and job satisfaction, and better performance. An employee’s department manager or supervisor will introduce new employees to their jobs and Phoenix Specialty Hospital during the first several weeks of employment. Subsequently, new employees will be required to attend the next-scheduled new employee orientation program conducted by the Human Resources Department....” Further review of policy revealed “...NEW EMPLOYEE INDUCTION CHECKLIST 1. Received Phoenix Specialty Hospital Employee Handbook 2.) Universal Precautions and Procedures Outlined Discussion of the following: 3.) Phoenix Specialty ’ s History & Future 4.) Schedule Employee for General Orientation Session 5.) Human Resources Department Services and Functions 6.) Infection Control 7.) Scheduled Time for Employee to Complete Physical and Lab Work 8.) Benefit Enrollments 9.) Identification Badge 10.) I-9 Immigration form 11.) W-4 forms (State and Federal) 12.) Nursing Service Orientation Schedule (Nursing Only) 13.) Security and Parking 14.) Fire, Safety, and Disaster Plan 15.) Patient Rights/Confidentiality of Information 16.) Emergency Codes 17.) Body Mechanics 18.) Other: ________________________________ ________________________________ I have received my copy of the Phoenix Specialty Hospital Employee Handbook. I will read these policies and procedures and become thoroughly familiar with them. I fully understand my privileges and obligations as an employee of this Company. I also understand that I can get clarification of any item that I do not understand by discussing such items with my supervisor or by contacting a representative of the Human Resources Department....” Review of 10 employee personnel files revealed: 2 files did not have documentation of employee orientation within the first 30 days of employment. Review of employee #7 personnel file revealed no documented evidence of employee orientation within the first 30 days of employment. Review of employee #17 personnel file revealed no documented evidence of employee orientation within the first 30 days of employment. On 09/16/2025 during interviews Employee #3 and Employee #9 confirmed that Employee #7 and Employee #17 had no documentation of employee orientation within the first thirty (30) days of employment.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 45706 Based on a review of policies and procedures, medical records and interview, it was determined the facility failed to ensure four patients (Patients #15, 16, 17, and 18), restraints were used without documented renewal of restraint orders within the required 24-hour timeframe to justify continued use. This deficient practice poses a risk to the patient of injury, deteriorating skin conditions, harm to patients for being restrained for extended amounts of time without release or attempts at release and/or loss of autonomy. Cross reference: A-0043, A-0115, A-0174 Finding include: Policy titled, “Patient Rights and Responsibilities” revealed: “ ...A patient has the right to be called by his/her proper name, treated with courtesy and respect, with appreciation of his/her individual dignity and with protection of his or her need for privacy ....” Policy titled, “Restraints”, revealed: “ ...A. Patients have the right to be free from restraints. B. Restraints are only used in Phoenix Specialty Hospital when they are therapeutically necessary and ordered by the physician for the safety of patients and others. C. The use of restraints will be monitored for appropriateness and patient safety outcomes ... B. Therapeutic Use of Restraints. There are two therapeutically justified situations for using restrains in the acute medical-surgical area: Medical Safety Need/Non-Violent. Those situations requiring the limitation of mobility to protect the integrity of essential treatment conditions. For example, to immobilize an extremity to prevent a patient from pulling out IV lines or pulling at ventilator tubing ... The procedures for placing patients in restraints for either medical safety or aggressive behavior need are outlined in Appendix A ... APPENDIX A PROCEDURES FOR PLACING PATIENTS IN RESTRAINTS ...Emergent need - apply least restrictive possible - Obtain MD order immediately after application. Non-emergent Need - Obtain MD order prior to placing patient in restraints ... Discontinue restraints as soon as possible, based on clinical findings. If RN determines the patients can be released from restraints, then the restraints are removed. A new order must be obtained to reapply the restraints even if reapplied within the time frame of the initial order. This can be a verbal order ... Must in-person evaluate patient on next calendar day. If the need for restraint continues, a new order is entered. Each order is for one calendar day .... MD’s initial order is valid until next calendar day ....” Policy titled, “Verbal and Telephone Orders” revealed: “ ...Orders that are not written by a prescriber (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt ....” Patient #15 was admitted to the facility on 11/01/2024 and discharged on 01/08/2025. Patient’s electronic medical record was incomplete with no documentation of restraint orders. Employee #12 confirmed the partial medical records would be found in paper charting for the time frame of admission. Surveyor requested the paper medical record on 09/16/2025. No medical record was provided by the time of exit. Patient #16 was admitted to the facility on 01/03/2025 and discharged on 02/27/2025. Patient was placed in restraints on 01/07/2025 through 01/27/2025. Of 19 verbal restraint orders, 9 were not renewed by the provider in the required 24-hour time frame. Patient #17 was admitted to the facility on 05/01/2025. Patient was placed in restraints on 05/01/2025 through 05/06/2025. Of 5 verbal restraint orders, 2 were not renewed by the provider in the required 24-hour time frame. Patient #18 was admitted to the facility on 02/15/2025. Patient was placed in restraints on 02/15/2025 through 02/19/2025. Of the 5 verbal restraint orders, 3 were not renewed by the provider in the required 24-hour time frame. Employee #12 confirmed on 09/17/2025 that the required restraint documentation was not present for Patient’s #15, 16, 17, and 18.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 45706 Based on a review of policies and procedures, medical records and interview, it was determined the facility failed to ensure that hospital personnel and medical staff followed the approved policies and procedures for restraints by failing to document restraint release trials in four (4) patient restraint episodes. Cross reference: A-A-0043,A-0115, A-0173, A-0407 Findings include: Policy titled, “Patient Rights and Responsibilities” revealed: “ ...A patient has the right to be called by his/her proper name, treated with courtesy and respect, with appreciation of his/her individual dignity and with protection of his or her need for privacy ....” Policy titled, “Restraints”, revealed: “ ...A. Patients have the right to be free from restraints. B. Restraints are only used in Phoenix Specialty Hospital when they are therapeutically necessary and ordered by the physician for the safety of patients and others. C. The use of restraints will be monitored for appropriateness and patient safety outcomes ... B. Therapeutic Use of Restraints. There are two therapeutically justified situations for using restrains in the acute medical-surgical area: Medical Safety Need/Non-Violent. Those situations requiring the limitation of mobility to protect the integrity of essential treatment conditions. For example, to immobilize an extremity to prevent a patient from pulling out IV lines or pulling at ventilator tubing ... The procedures for placing patients in restraints for either medical safety or aggressive behavior need are outlined in Appendix A ... APPENDIX A PROCEDURES FOR PLACING PATIENTS IN RESTRAINTS ...Emergent need - apply least restrictive possible - Obtain MD order immediately after application. Non-emergent Need - Obtain MD order prior to placing patient in restraints ... Discontinue restraints as soon as possible, based on clinical findings. If RN determines the patients can be released frame of the initial order. This can be a verbal order ... Must in-person evaluate patient on next calendar day. If the need for restraint continues, a new order is entered. Each order is for one calendar day .... MD’s initial order is valid until next calendar day ....” Patient #15 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record. Patient #16 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record. Patient #17 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record. Patient #18 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record. Employee #12 confirmed on 09/17/2025 that Patient’s #15, 16, 17, and 18’s medical record did not contain evidence a restraint release trial was documented.”

“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: 45706 Based on policy and procedure, medical record review and staff interview, it was determined the facility failed to ensure (2) patients, Patient #20 and #21, were provided assistance with appropriate hygiene care during admission to the facility. This deficient practice poses risk to patient health and safety putting a patient at risk for healthcare associated infections and skin breakdown. Additionally, malnutrition causes weakened immunity and slower recovery. Cross reference: A-0043 Findings include: Policy titled, “Nutrition Services” revealed: “...KPC/Promise Hospital Clinical Services Departments shall collaborate with Nutrition Services to maintain and/or improve the nutrition of the patients admitted to the facility and shall support the standards set forth by the Nutrition Services Department. 3. Clinical Services staff shall be responsible for: d. Assisting patients who are unable to feed themselves and setting-up trays for those patients who require aid ....” Policy titled, “Patient Rights and Responsibilities “ revealed: “...A patient has the right to be called by his/her proper name, treated with courtesy and respect, with appreciation of his/her individual dignity and with protection of his or her need for privacy ....” Policy titled, “Basic Activities of Daily Living Training” was requested however did not contain any policy or procedure outlining patient care services such as linen and gown changes, peri care/incontinence care, oral care, and bathing requirement or frequency. Policy titled, “Clinical Documentation” revealed: “...Staff members of the clinical team will document on the designated interdisciplinary care team forms, as appropriate, in addition to routine documentation on the discipline-specific flow sheets.c. A nutritional and functioning screen will be completed within 24 hours of admission ....” Policy titled, “24 Hour Patient Care Record” revealed: “ ...To provide written evidence of daily patient care management by nursing. To promote the planning and continuity of care through utilization of a documentation process that promotes review, study, and evaluation of the patient’s planned care. To provide a legal record that can be used to protect the patient, the hospital, or the healthcare team of professionals who provide patient care. To serve as a means of communication regarding significant information about the patient ...Utilization of the 1. The I/O, Vital Signs, and nurse rounding contains flow sheet and narrative components ...intake and output ... Nutrition related to dietary intake identifying the method of intake, % of meal/ snack intake, feeding assist level, and elimination patterns will be documented upon occurrence. Documented in the I/O flowsheet ...” Patient #20’s medical record dated 07/03/2025 through 07/21/2025 identified no detailed documentation of gown changes, linen changes, bathing, or incontinence care. The following “total hands on assist” was entered into the medical record with no detailed notes outlining any type of activities of daily living (ADL) for the patient. Further review of the medical record flow sheets revealed a notes section attached to drop down menu labeled, “total hands on assist”. However, no notes were entered in that section. Employee #12 confirmed on 09/16/2025 that Patient #20’s medical record did not contain detailed documentation that the patient received ADL care during admission to the facility. Patient #21’s medical record dated 06/07/2025 through 06/12/2025 identified the following for intake on intake/output summary: 06/07/2025 day-25%, night 30% 06/08/2025 day 38%, night-no documentation 06/09/2025 day 8%, night 0% 06/10/2025 day 13%, night-no documentation 06/11/2025 day 25%, night-no documentation 06/12/2025 day 0% Review of Patient #21’s medical record dated 06/06/2025 through 06/12/2025 revealed no physician order for 1:1 personal to assist patient with oral intake. Further review of medical record I/O flowsheets revealed the following documentation on input/output, “Total hands on” was the only recorded entry. Surveyor unable to determine if Patient #21 received assistance with oral intake as no documentation was available in the medical record. Additionally, Clinical staff did not document how Patient #21 would be assisted with intake as outlined in the Nutrition Services policy and procedure. Employee #12 confirmed on 09/16/2025 that Patient #21’s medical record did not contain evidence that the patient received assistance with oral intake during admission to the facility. Patient #21’s medical record dated 06/07/2025 through 06/12/2025 identified not detailed documentation of gown changes, linen changes, bathing, or incontinence care. The following “total hands on assist” was entered into the medical record with no detailed notes outlining activities of daily living (ADL) for the patient. Employee #12 confirmed on 09/16/2025 that Patient #21’s medical record did not contain detailed documentation that the patient received ADL care during admission to the facility.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 52757 Based on staff interview and facility records, it was determined the hospital or provider failed to ensure verbal orders for 14 (fourteen) of 20 (twenty) patients were electronically signed in the appropriate timeframe as required by the Verbal and Telephone Medication Orders policy and Medical Staff Bylaws Rules and Regulations. This deficient practice poses a potential risk to the health and safety of patients when physician orders are not authenticated within 24 hours as stipulated in the Medical Bylaws and Medical Rules and Regulations of the facility as this can lead to miscommunication and potential errors. Cross reference: A-0043, A-0174 FINDINGS INCLUDE: Policy titled “Verbal and Telephone Medication Orders” revealed: “ ... POLICY ... The use of verbal orders (including telephone or other oral orders) shall be minimized. Verbal orders shall be processed in accordance with medical staff rules and regulations as described in this policy ... AUTHENTICATION (VERIFICATION) OF VERBAL ORDERS ... Orders that are not written by a prescriber (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt ....” Policy titled “Medical Staff Rules and Regulations” revealed: “... This document sets for the Rules and Regulations of the Medical Staff and is subject to the provisions of the Medical Staff Bylaws. The terms defined in the Medical Staff Bylaws shall have the same meanings herein ... General Conduct of Care ... 1. All orders for treatment shall be in writing. A telephone order shall be considered to be in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their scope of practice and signed by the responsible practitioner. All telephone orders shall be “read back” to the physician to assure correctness ... All orders dictated over the telephone shall be dictated by the practitioner and shall be signed by the appropriately authorized persons who dictated with the name of the practitioner. The responsible practitioner shall authenticate such order within 24 hours ....” Patient #1 ’ s medical record dated 08/08/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient one time only, Request Type: Now, Room Class: Telemetry ... Order Date: 08/08/2025 07:30 ... Electronically Signed On: 08/12/2025 10:30 ....” Patient #2 ’ s medical record dated 09/14/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Metoclopramide HCL INJECTABLE (Reglan INJ) 10MG/2ML, Inject 10 mg (2 mL) IV push every 6 hours ... Order Date: 09/14/2025 19:12 ...” Patient #2 ’ s medical record dated 09/12/2025, revealed an order titled “Consult Orders” revealed: “...Description: Admit to Dr. one time only, Request Type: Now ... Order Date: 09/11/2025 14:49 ....” Patient #3 ’ s medical record dated 08/26/2025, revealed an order titled “Laboratory Orders” revealed: “...Description: “Culture, Urine one time only ... Order Date: 08/26/2025 10:15 ... Electronically Signed On: 09/02/2025 09:57 ....” Patient #4 ’ s medical record dated 01/14/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: oxyCODONE HCL IR ... Order Date: 01/14/2025 21:11 ... Electronically Signed On: 01/22/2025 07:18 ....” Patient #4 ’ s medical record dated 01/15/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Acute Transfer one time only ... Order Date: 01/15/2025 06:56 ... Electronically Signed On: 01/22/2025 07:18 ....” Patient #5 ’ s medical record dated 01/24/2025, revealed an order titled “Laboratory Orders” revealed: “... Description: Serum Potassium Level one time only ... Order Date:: 01/23/2025 17:28 ... Electronically Signed On: 03/0/3/2025 19:14 ....” Patient #6 ’ s medical record dated 07/08/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Budesonide...Order Date: 07/08/2025 15:40 ...Start Date: 07/08/2025 19:01 ... Electronically Signed On: 07/21/2025 18:45 ....” Patient #7 ’ s medical record dated 05/26/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Zolpidem TARTRATE...Order Date: 05/26/2025 08:22 ...Start Date: 05/26/2025 11:54 ... Electronically Signed On: 05/28/2025 13:14 ....” Patient #7 ’ s medical record dated 05/26/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit ...Order Date: 05/26/2025 ... Electronically Signed On: 08/02/2025 ....” Patient #8 ’ s medical record dated 07/26/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Enoxaparin Sodium...Order Date: 07/26/2025 20:57 ...Start Date: 07/26/2025 21:00 ... Electronically Signed On: 07/29/2025 11:58 ....” Patient #8 ’ s medical record dated 07/26/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient ...Order Date: 07/26/2025...Start Date: 07/26/2025 20:27 ... Electronically Signed On: 08/12/2025 10:30 ....” Patient #9 ’ s medical record dated 08/01/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Methylprednisolone...Order Date: 08/01/2025 16:10 ...Start Date: 08/02/2025 09:00 ... Electronically Signed On: 08/05/2025 09:08 ....” Patient #9 ’ s medical record dated 08/01/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit ...Order Date: 08/01/2025 16:56...Start Date: 08/02/2025 02:05 ... Electronically Signed On: 08/12/2025 10:30 ....” Patient #10 ’ s medical record dated 03/17/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Cefepime...Order Date: 03/17/2025 16:00 ...Start Date: 03/17/2025 21:00 ... Electronically Signed On: 03/20/2025 14:03 ....” Patient #10 ’ s medical record dated 02/27/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit ...Order Date: 02/27/2025...Start Date: 02/27/2025 16:29 ... Electronically Signed On: 03/20/2025 14:03 ....” Patient #11 ’ s medical record dated 04/23/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient ...Order Date: 04/23/2025 13:10...Start Date: 04/23/2025 14:55 ... Electronically Signed On: 06/10/2025 05:38 ....” Patient #12 ’ s medical record dated 01/21/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit ...Order Date: 01/21/2025 13:59...Start Date: 01/21/2025 16:00 ... Electronically Signed On: 02/26/2025 06:15 ....” Patient #13 ’ s medical record dated 12/18/2024, revealed an order titled “Pharmacy Orders” revealed: “...Description: Fluconazole...Order Date: 12/18/2054 09:32 ...Start Date: 12/19/2024 09:00 ... Electronically Signed On: 02/04/2025 21:17 ....” Patient #13 ’ s medical record dated 12/07/2024, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient ...Order Date: 12/07/2024 17:02...Start Date: 12/07/2024 17:02 ... Electronically Signed On: 12/31/2024 16:07 ....” Patient #14 ’ s medical record dated 03/02/2025, revealed an order titled “Pharmacy Orders” revealed: “...Description: Cefepime ...Order Date: 03/02/2025 08:44 ...Start Date: 03/02/2025 13:00 ... Electronically Signed On: 07/21/2025 18:45 ....” Patient #14 ’ s medical record dated 02/10/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient ...Order Date: 02/10/2025 21:00 ...Start Date: 02/10/2025 21:00 ... Electronically Signed On: 02/17/2025 12:37 ....” Patient #16 ’ s medical record dated 01/07/2025 through 01/27/2025, revealed the following days the provider failed to sign a verbal order for restraints: “... 01/07/2025 verbal order placed at 0519, No Provider signature on order ... 01/07/2025 verbal order placed at 2342, Provider signed the order 01/19/2025 0918 ... 01/10/2025 verbal order placed at 0040, Provider signed the order 01/14/2025 1551 ... 01/11/2025 verbal order placed at 0638, Provider signed the order 01/14/2025 1551 ... 01/12/2025 verbal order placed at 0616, Provider signed the order 01/14/2025 1511 ... 01/13/2025 verbal order placed at 0149, Provider signed the order 01/14/2025 1551 ... 01/15/2025 verbal order placed at 0050, Provider signed the order 01/22/2025 0718 ... 01/16/2025 verbal order placed at 0041, Provider signed the order 01/22/2025 0718 ... 01/17/2025 verbal order placed at 0550, Provider signed the order 02/26/2025 0615 ... 01/18/2025 verbal order placed at 0029, Provider signed the order 02/26/2025 0615 ... 01/19/2025 verbal order placed at 0046, Provider signed the order 02/26/2025 0615 ... 01/20/2025 verbal order placed at 0217, Provider signed the order 02/26/2025 0615 ... 01/21/2025 verbal order placed at 0306, Provider signed the order 02/26/2025 0615 ... 01/22/2025 verbal order placed at 0042, Provider signed the order 02/26/2025 0615 ... 01/24/2025 verbal order placed at 0032, Provider signed the order 03/03/2025 1914 ....” Patient #17 ’ s medical record dated 05/01/2025 through 05/062025, revealed the following days the provider failed to sign a verbal order for restraints: “... 05/03/2025 verbal order placed at 0540, Provider signed the order 05/05/2025 1045 ... 05/04/2025 verbal order placed at 0210, Provider signed the order 06/10/2025 0558 ...05/05/2025 verbal order placed at 0035, Provider signed the order 06/10/2025 0538 ... 05/06/2025 verbal order placed at 0114, Provider signed the order 06/10/2025 0538 ....” Patient #22 ’ s medical record dated 08/30/2025, revealed an order titled “Nursing Orders Orders” revealed: “...Description: Admit to Inpatient ...Order Date: 02/10/2025 21:00 ...Start Date: 08/30/2025 15:34 ... Electronically Signed On: ....” Employee #12 confirmed during an interview conducted on 09/17/2025 that Patient #1, #2, #3, #4, #5, #16, and #17 verbal orders were not signed by a physician according to policy. Employee #1 confirmed during an interview conducted on 09/17/2025 that Patient #6, #7, #8, #9, #10, #11, #12 #13 and #14, and #22’s verbal orders were not signed by a physician according to policy. Employee #12 confirmed during an interview conducted on 09/17/2025 that Patient #2 Metoclopramide and admit order had not yet been signed.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 43788 Based on review of documents, observation, and staff interviews, it was determined the hospital failed to ensure Patient medical records were available for access 24/7 via the electronic medical record system. This deficient practice poses a risk to the health and safety of patients if medical records are not accessible when needed for review and consultation. Cross reference: A-0022, A-0043, A-0431, A-0700, A-0722 Findings include: Review of the hospital policy titled, “Medical Record Emergency Disaster Plan-EHR Downtime”, revealed: “...Purpose: In the event of unplanned, unscheduled downtime, staff will need to be prepared to handle working without computerized technology and be able to transition to a paper process until the EHR functionality resumes ....” Further review of the Medical Record Emergency Disaster Plan-EHR Downtime policy revealed the policy did not address how to access a patient’s electronic medical record if the internet was non-functional. During entrance conference with hospital staff on 09/15/2025, Compliance Officers informed hospital staff that patient medical record chart review would be conducted during the survey process. Staff informed the Compliance Officers that the hospital utilized the electronic medical record (EMR) system “Wellsky”. On 09/15/2025 Compliance Officers requested access to the EMR Wellsky for patient medical record chart review. Employee #1 informed Compliance Officers that the internet service was not working and there was no access to patient medical records. Employee #1 informed Compliance Officers that there was a limited number of mobile hotspots available to staff to use to access the EMR system. Employee #1 provided two (2) staff members with computers and mobile hotspots to access the patient medical records for the Compliance Officers on 09/16/2025. At the end of the survey on 09/17/2025, the hospital ’ s internet service was still non-operational. Employee #3 confirmed on 09/15/2025 that the internet service was not operational, as the hospital ’ s internet bill had not been paid and service was discontinued by the service provider. Employee #3 stated the internet had not been operational since the previous Friday, 09/12/2025. Employee #3 confirmed that the internet service bill had been paid on 09/15/2025 but it could be up to 72 hours before the internet service was operational.”

“PROTECTING PATIENT RECORDS CFR(s): 482.24(b)(3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This Standard is not met as evidenced by: 43788 Based on review of documents, observation, and staff interviews, it was determined that the hospital failed to ensure hard copies of patient medical records were secured from unauthorized access. This deficient practice poses a risk to the health and safety of patients if medical records are not kept secure from access by unauthorized individuals leading to potential loss of protected, private health information. Cross reference: A-0044, A-0431 Findings include: Hospital policy titled, “Medical Record Content and Ownership”, revealed: “...Purpose: To establish guidelines for the contents and maintenance of patient Medical Records that met the requirements in Federal and State laws and regulations whether in paper or electronic format that comprises the medical record ...The Health Information Management Director is responsible for establishing appropriate safeguards and security measures for the medical record ...Currently, the Medical Record is considered a hybrid record, consisting of both electronic and paper documentation ....” Further review of the policy revealed the policy did not address secure storage of the paper medical record from unauthorized access. Observation on tour on 09/15/2025 revealed unsecured patient paper medical records: ICU 6 patient paper medical records at nurse ’ s station desk visible to individuals in the ICU; Second floor nurse ’ s station had 9 patient paper charts visible to individuals on the second floor. At the time of this observation, no staff were present in the nurse ’ s station. Employee # 11 confirmed the patient paper charts were not stored in a secure location and were easily accessible by unauthorized individuals.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 43788 Based on policy and procedure, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, observation, and interview, the Department determined that the administrator failed to ensure: 1. open, bulk dry goods were protected from contamination; 2. packages of frozen food that were not in their original packages were properly sealed, and date marked with an expiration/discard date; and 3. individual food packets not stored in original containers were date marked with an expiration/discard date; and 4. discarding expired food and food items; and 5. storing patient nutrition supplements properly and safely. The effect of these deficient practices poses a potential risk of harm to patients and other individuals who may consume food improperly stored and outdated if the facility does not follow the required dietary guidelines. Cross reference: A-0043 Findings include: Arizona Administrative Code (A.A.C.) requires: “...ARTICLE 1. FOOD ESTABLISHMENTS...R9-8-101. Purpose and Definitions...A. The Department incorporates by reference the United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration and shall comply with the 2017 Food Code (FC) as specified in this Article. This incorporation by reference contains no future editions or amendments. The incorporated material is on file with the Department and is available for order at: https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm239035.htm, refer to publication number IFS17...R9-8-103. Food A. The Department incorporates FC Chapter 3 in whole, unless otherwise specified....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...3-2 SOURCES, SPECIFICATIONS, AND ORIGINAL CONTAINERS AND RECORDS...3-202.15 Package Integrity...FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants....3-3 PROTECTION FROM CONTAMINATION AFTER RECEIVING...Preventing Contamination from the Premises...3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination....” 1. Hospital policy titled, “Nutrition Services”, did not address the storage of dry goods. Observation on 09/15/2025 in the kitchen revealed the following open, bulk foods: an open, plastic storage bin labeled “Salt”. The container had a lift up lid that was not in place and the storage bin contents were exposed to the environment. The shelf the storage bin was located was adjacent to a handwashing sink. Employees #2 and #7 confirmed on 09/15/2025 that the above listed item was not stored in a manner that prevented contamination from the environment. 2, 3, and 4: Hospital policy titled, “Nutrition Services”, revealed: “ ...Clinical Services is responsible for: b. Dating nutritional items when they are opened ...c. Disposing of singular food items within 24 hours and multiple serve refrigerated containers within 3 days ....” Observation on 09/15/2025 revealed the following undated foods in the kitchen freezers: · Two (2) packages of beef patties in sealed plastic bags with no date mark labeled with a discard/expiration date · One (1) Extra large Ziplock style plastic storage bag, unsealed and open to the air, with no date mark labeled with a discard/expiration date · One (1) large, blue plastic bag containing what was identified by staff as frozen egg bites, unsealed and open to the air, with no label identifying the food item and no date mark labeled with a discard/expiration date · Two (2) large, clear plastic bags containing what staff identified as frozen omelettes, unsealed and open to the air, with no label identifying the food item, and no date mark labeled with a discard/expiration date · Two (2) packages of frozen waffles with no label identifying the food item and no date mark labeled with a discard/expiration date · Two packages of frozen cookies with no label identifying the food item and no date mark labeled with a discard/expiration date · Observation in the kitchen on 09/15/2025 revealed a large black tray type container with multiple sections containing the following individual size food packets: · Individual mayonnaise packets · Individual jellies packets · Individual Italian Salad Dressing packets · Individual Maple Syrup packets · Individual Low Cal Maple Syrup packets · Individual yellow mustard packets Further observation revealed no date mark labeled with a discard/expiration date for each type of food packet. Observation on 09/15/2025 in the kitchen refrigerator revealed a plastic container labeled crushed garlic with label stating “ opened 09/08/2025 discard 09/14/2025 Employee #2 and #7 confirmed on 09/15/2025 that the frozen foods were not stored properly and did not have a documented expiration/discard date. Employee #7 confirmed on 09/15/2025 that the individual serving packets should have a label with a discard/expiration date and they were missing from the dispensing trays. Employee #7 confirmed on 09/15/2025 that the crushed garlic should have been discarded the day before on 09/14/2025. Observation of the second-floor nutrition room revealed 2 bottles of Prostat with no date mark label with open date and discard date. Review of the Prostat manufacturer label revealed discard the contents 3 months after opening. Employee #1 confirmed on 09/16/2025 that the Prostat did not have an open or discard date label. 5. Hospital policy titled, “Nutrition Services”, did not address proper storage of patient nutrition items. Hospital policy titled, “Hazardous Materials and Waste Management Plan 2024”, revealed: “...Phoenix Specialty Hospital maintains appropriate handling and storage areas for hazardous wastes to minimize the possibility of contamination of food, clean and sterile goods, or contact with staff, visitors or patients ....” Observation on tour on 09/15/2025 revealed in the ICU on the counter of the hand washing sink outside Room 3 there were 4 Ensure supplement drink bottles and 5 individual juice containers next to 2 containers of Microkill Sani Wipes. Observation on 09/15/2025 revealed in the kitchen a broom and dust pan, mop heads and cleaning liquids placed in the storage area where dry goods and canned goods were being stored. Employee #2 confirmed on 09/15/2025 that the Ensure and juice should not have been stored near the Microkill sani wipes. Employee #7 confirmed on 09/15/2025 that the cleaning supplies should not be stored in the dry goods/canned goods storage area.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 43788 Based on record review and staff interview, it was determined the hospital failed to ensure the current diet manual available to personnel members and medical staff was approved by a registered dietitian. This deficient practice poses a risk to the health and safety of patients if the unapproved diet manual utilized by hospital staff does not meet the nutrition needs of the patients. Cross reference: A-0043 Findings include: Request was made on 09/15/2025 for the hospital Dietary Manual. Review of the Dietary Manual provided revealed on the last page of the manual a designated area for approval with an area for a signature and date, which were blank. Review revealed no documentation that the Dietary Manual was approved by the Registered Dietician or the Governing Board. Employee #13 confirmed on 09/16/2025 that the Dietary Manual was missing approval by the dietician and governing board.”

“APPLICABILITY CFR(s): 482.30(a) Standard: Applicability. The provisions of this section apply except in either of the following circumstances: (1) A Utilization and Quality Control Quality Improvement Organization (QIO) has assumed binding review for the hospital. (2) CMS has determined that the UR procedures established by the State under title XIX of the Act are superior to the procedures required in this section, and has required hospitals in that State to meet the UR plan requirements under §§456.50 through 456.245 of this chapter. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility documents, it was determined that the provider failed to ensure the facility’s Utilization plan was implemented. This deficient practice poses a potential health and safety risk to the patient when services provided by the facility are not evaluated. Cross reference: A-0043, A00652, A-0654, A-0655, A-0657, A-0658 Findings Include: Phoenix Specialty Hospital Utilization Management Plan 2024, revealed: “I. PURPOSE The purpose of the Utilization Management Plan is to assess and improve the delivery of care to all patients regardless of payment source, in an efficient and cost-effective manner. The plan describes the methods for documenting review of the appropriateness and medical necessity of admissions, continued stays, supportive services, discharge planning assessment/re-evaluation, and allocation of discharge resources. The plan is developed in accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation ...Utilization Management Committee. A. ORGANIZATION ... 3. The Committee shall meet quarterly at a minimum ....” Document Request, Utilization Review Meeting Minutes. The facility has its own UR plan documented, which meets the regulatory requirements. The plan has not been implemented, as evidenced by the facility’s inability to provide any meeting minutes requested-May 2024 through and including September 2025. Employee # 1 confirmed in an interview that the facility is unable to provide any Utilization Review Meeting Minutes.”

“UTILIZATION REVIEW COMMITTEE CFR(s): 482.30(b) A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in §482.12(c)(1). (1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR committee must be one of the following: (i) A staff committee of the institution; (ii) A group outside the institution-- (A) Established by the local medical society and some or all of the hospitals in the locality; or (B) Established in a manner approved by CMS. (2) If, because of the small size of the institution, it is impracticable to have a properly functioning staff committee, the UR committee must be established as specified in paragraph (b)(1)(ii) of this section. (3) The committee or group’s reviews may not be conducted by any individual who-- (i) Has a direct financial interest (for example, an ownership interest) in that hospital; or (ii) Was professionally involved in the care of the patient whose case is being reviewed. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility records, it was determined that the provider failed to ensure the Phoenix Specialty Hospital Medical Staff Bylaws were followed when appointing members to the Utilization Committee. This deficient practice may pose a health and safety risk when all services provided by the facility are not evaluated. Findings Include Phoenix Specialty Hospital Medical Staff Bylaws revealed: “ ...5.9 UTILIZATION MANAGEMENT COMMITTEE 5.9.1 COMPOSITION Representatives from Administration, Medical Records, Case Management, Quality Management, and Nursing shall be members of the Committee ...Committee shall have (sic) include at least 2 physician members, one of which acts a (sic) chair....” Hospital document Governing Body Meeting Minutes dated 08/05/2025 revealed: Utilization Review Committee was appointed. The committee was composed of 4 physicians, the CEO, the CCO, and Case management. No one from Quality or Medical Records was represented. Utilization Review Meeting minutes from May 2024 to current September 2025 were requested. None were provided. Employee # 1 confirmed in an interview dated 09/17/2025, that the facility was unable to provide any meeting minutes. Employee # 1 confirmed in an interview that meeting Governing Body meeting meinutes for 2024 could not be provided.”

“SCOPE AND FREQUENCY OF REVIEW CFR(s): 482.30(c) (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of-- (i) Admissions to the institution; (ii) The duration of stays; and (iii) Professional services furnished including drugs and biologicals. (2) Review of admissions may be performed before, at, or after hospital admission. (3) Except as specified in paragraph (e) of this section, reviews may be conducted on a sample basis. (4) Hospitals that are paid for inpatient hospital services under the prospective payment system set forth in Part 412 of this chapter must conduct review of duration of stays and review of professional services as follows: (i) For duration of stays, these hospitals need review only cases that they reasonably assume to be outlier cases based on extended length of stay, as described in §412.80(a)(1)(i) of this chapter; and (ii) For professional services, these hospitals need review only cases that they reasonably assume to be outlier cases based on extraordinarily high costs, as described in §412.80(a)(1)(ii) of this chapter. This Standard is not met as evidenced by: 46598 Based on a review of documentation and interviews, it was determined that the provider failed to have quarterly meetings of the utilization review committee. This deficient practice poses a potential risk to the health and safety of patients when services provided by the hospital are not evaluated for medical necessity. Findings Include: Phoenix Specialty Hospital Utilization Management Plan 2024, revealed: “I. PURPOSE The purpose of the Utilization Management Plan is to assess and improve the delivery of care to all patients regardless of payment source, in an efficient and cost-effective manner. The plan describes the methods for documenting review of the appropriateness and medical necessity of admissions, continued stays, supportive services, discharge planning assessment/re-evaluation, and allocation of discharge resources. The plan is developed in accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation ...Utilization Management Committee. A. ORGANIZATION ... 3. The Committee shall meet quarterly at a minimum ....” Utilization Review Meeting minutes from May 2024 to current September 2025 were requested. None were provided. Employee # 1 confirmed in an interview dated 09/17/2025, that the facility was unable to provide any meeting minutes.”

“EXTENDED STAY REVIEW CFR(s): 482.30(e) (1) In hospitals that are not paid under the prospective payment system, the UR committee must make a periodic review, as specified in the UR plan, or each current inpatient receiving hospital services during a continuous period of extended duration. The scheduling of the periodic reviews may -- (i) Be the same for all cases; or (ii) Differ for different classes of cases. (2) In hospitals paid under the prospective payment system, the UR committee must review all cases reasonably assumed by the hospital to be outlier cases because the extended length of stay exceeds the threshold criteria for the diagnosis, as described in §412.80(a)(1)(i). The hospital is not required to review an extended stay that does not exceed the outlier threshold for the diagnosis. (3) The UR committee must make the periodic review no later than 7 days after the day required in the UR plan. This Standard is not met as evidenced by: 46598 Based on a review of documentation and interviews, it was determined that the provider failed to have in place an effective utilization review plan to monitor patients’ extended stays. This deficient practice poses a potential risk to the health and safety of patients when the reasons for patient extended stays are not evaluated for medical necessity. Findings Include: Phoenix Specialty Hospital Utilization Management Plan 2024, revealed: “I. PURPOSE The purpose of the Utilization Management Plan is to assess and improve the delivery of care to all patients regardless of payment source, in an efficient and cost-effective manner. The plan describes the methods for documenting review of the appropriateness and medical necessity of admissions, continued stays, supportive services, discharge planning assessment/re-evaluation, and allocation of discharge resources. The plan is developed in accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation ...Utilization Management Committee. A. ORGANIZATION ... 3. The Committee shall meet quarterly at a minimum ....” Utilization Review Meeting minutes from May 2024 to current September 2025 were requested. None were provided. Employee # 1 confirmed in an interview dated 09/17/2025, that the facility was unable to provide any meeting minutes.”

“REVIEW OF PROFESSIONAL SERVICES CFR(s): 482.30(f) The committee must review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services. This Standard is not met as evidenced by: 46598 Based on a review of documentation and interviews, it was determined the provider failed to have in place an effective utilization review plan for the review of services provided by the institution and the members of the medical staff to patients. This deficient practice poses a potential risk to the health and safety of patients when services provided by the hospital may be provided unnecessarily. Findings Include: Phoenix Specialty Hospital Utilization Management Plan 2024, revealed: “ ...II. Utilization Management Committee ...D. RESPONSIBILITIES ...2. To collaborate in monitoring and analyzing the review activities and the effectiveness of the case management staff and the Hospital-appointed Physician Advisor or the Ad Hoc physician ....” Utilization Review Meeting minutes from May 2024 to current September 2025 were requested. None were provided. Employee # 1 confirmed in an interview dated 09/17/2025, that the facility was unable to provide any meeting minutes.”

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 43788 Based on a review of documents, observation, and staff interview, it was determined that the administrator failed to initiate the facility’s emergency plan for a cyber-related emergency when the facility’s internet was down for over five (5) days.This deficient practice poses a risk to the health and safety of patients if authorized personnel and individuals are not able to access internet driven services for the hospital such as the electronic medical record. Cross reference: A-0022, A-0043, A-0431, A-0438 Findings include: Review of the hospital’s Emergency Preparedness Plan revealed a plan was in place for Information Management Infrastructure Downtime. A copy of the plan was requested, but not provided, and it was listed in their Hazard Vulnerability Assessment (HVA) as requiring a policy. The facility was unable to provide documentation describing the establishment of the command structure or the action to be taken to mitigate the effects on the staff and patient population. Review of the hospital policy titled, “Medical Record Emergency Disaster Plan-EHR Downtime”, revealed: “...Purpose: In the event of unplanned, unscheduled downtime, staff will need to be prepared to handle working without computerized technology and be able to transition to a paper process until the EHR functionality resumes ....” Further review of the Medical Record Emergency Disaster Plan-EHR Downtime policy revealed the policy did not address how to access a patient’s electronic medical record if the internet was non-functional. During entrance conference with hospital staff on 09/15/2025, Compliance Officers informed hospital staff that patient medical record chart review would be conducted during the survey process. Staff informed the Compliance Officers that the hospital utilized the electronic medical record (EMR) system “Wellsky”. On 09/15/2025 Compliance Officers requested access to the EMR Wellsky for patient medical record chart review. Employee #1 informed Compliance Officers that the internet service was not working and there was no access to patient medical records. Employee #1 informed Compliance Officers that there was a limited number of mobile hotspots available to staff to use to access the EMR system. Employee #1 provided two (2) staff members with computers and mobile hotspots to access the patient medical records for the Compliance Officers on 09/16/2025. At the end of the survey on 09/17/2025, the hospital ’ s internet service was still non-operational. Employee #3 confirmed on 09/15/2025 that the internet service was not operational, as the hospital ’ s internet bill had not been paid and service was discontinued by the service provider. Employee #3 stated the internet had not been operational since the previous Friday, 09/12/2025. Employee #3 confirmed that the internet service bill had been paid on 09/15/2025 but it could be up to 72 hours before the internet service was operational. Employee #20 confirmed on 09/17/2025 that the facility had not initiated the facility ’ s Emergency Preparedness Plan for a cyber-emergency when the internet service was non-operational. 52995”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 45706 Based on Arizona Administrative Code (A.A.C Title 18 Chapter 13), policy and procedure, observation, and staff interview, it was determined the facility failed to ensure biohazardous waste and sharps bins were stored in a secure manner. This deficient practice poses a risk to patient, staff, and visitor health and safety if used sharps and biohazardous waste or not protected from unauthorized persons resulting in the spread of harmful microorganisms and other diseases. Cross reference: A-0043, A-0748, A-0774, A-0777 Findings include: A.A.CR18-13-1408.B revealed: “ ...B. Once biohazardous medical waste has been packaged for shipment off site, a generator shall provide a storage area for biohazardous medical waste until the waste is collected and shall comply with both of the following requirements: 1. 2. Secure the storage area in a manner that restricts access to, or contact with the biohazardous medical waste to authorized persons ....” Policy titled, “Hazardous Materials and Waste Management Plan 2024” revealed: “ ...The Hazardous Materials and Waste Management Plan implements processes to effectively manage hazardous materials and waste and protect the facility, patients, and staff from these materials while minimizing the risk of harm from exposure. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. This plan is evaluated annually, changed as necessary, based on risk assessment of the environment, changes in conditions, regulations, and standards, and identified needs. The disposal of hazardous waste is contracted out directly to a vendor for hazardous medications waste. (STRICYCLE) ...The program is also designed to assure compliance with the OSHA Hazard Communications Standard and other applicable codes and regulations ...Identify processes used to select, transport, store, use and dispose of hazardous materials, and to separate, segregate, transport, store, package and dispose of hazardous waste ....” Observation of the hospital on 09/15/2025 revealed the following: First floor: (2) sharps containers in room #110 not secure. Main entrance nursing station (1) sharp container not secure. Medication room #1 (1) sharps container located on counter top not secure and (1) not in use located on the floor just to the right of the entrance. Biohazard storage rooms located on first floor ICU, Med Surg, and Tele units were unlocked and unsecured. Biohazard storage room located on second floor was unlocked and unsecure. Employee #1 and #20 confirmed on 09/16/2025 the above-mentioned biohazardous waste was not stored in a secure manner. 52995 Citation #1 Based on document review, observation and staff interviews it was determined that the administrator failed to ensure: 1.Sterile medical supplies that were expired were removed from use and discarded 2.Laboratory specimen tubes expired were removed from use and discarded 3.Multi use ultrasound gel was marked with an open date and discard date This deficient practice poses a risk to the health and safety of patients exposing the patient to ineffective, dangerous or contaminated supplies used in procedures and treatments. Cross reference A0043, A0700 Findings include: Policy titled: “Infection Prevention Plan 2025” revealed “... Mission: To maximize the safety and wellness of staff and patients through proactive prevention and risk mitigation of infectious agents...” “... Regularly conducting inspections of the facility to ensure that risks for the transmission of infections or occupation hazards are minimized....” 1. Observation on 09/15/2025 in the Intensive Care Unit (ICU) revealed Two (2) Peripherally Inserted Central Catheter (PICC) insertion trays with expired dates of 03/31/2025 and 05/31/2025. Employee #2 and employee #6 confirmed 09/15/2025 that the items were expired. 2. Observation on 09/15/2025 of second floor medical supply room revealed three (3) Discofix (stop cock) had expired dates of 03/01/2025. Employee #21 confirmed on 09/15/2025 that the items were expired. Observation on 09/15/2025 of second floor, medical supply room revealed: expired lab specimen tubes. Green top (11 items) expired 03/31/2025, red top (5 items) expired 04/30/2025, purple top (2 items) expired 02/28/2025, gray top (2 items) expired 02/28/2025, yellow and red marble top (47 items) expired 03/31/2025. 3. Product review revealed, manufacture recommendation for Aquasonic Ultrasound Transmission gel, Parker Laboratories, Inc. (2014), “...Reusable bottles should be marked with the date filled and then discarded after one month. Cracked or damaged bottles should be discarded immediately....” Observation on 09/15/2025 first floor ICU and second floor medical surgical unit revealed ultrasonic scan gel on bladder scanner cart did not have open date or discard dates on multiuse bottles. Employee #2 confirmed on 09/15/2025 that the item was not labeled with open date and discard date. On 09/15/2025 expired and unmarked products in ICU was confirmed by employee #2, employee #6 On 09/15/2025 Employee #11 and employee #21 confirmed that items on second floor medical supply were expired. Citation #2. Based on policy and procedures, observation, and staff interview, it was determined the Administrator failed to ensure: 1.linen was not touching the floor while being stored on (1) linen cart; 2.the shower room floor tiles were securely affixed to the floor and grout was free of stains and mold-like substances; 3.patient supplies were not next to the hand washing sink located in the second-floor medication storage room. This deficient practice poses a risk to patient health and safety increasing the healthcare associated infections as well as cross contamination between patients and the environment. Cross reference: A-0043, A-0748, A-0774, A-0777 Findings include: Policy titled, “Infection Prevention Plan” revealed: “...The Infection Prevention and Control Program is designed to improve the quality of care for patients while reducing the risk of acquired Healthcare Associated Infections (HAIs) for patients, staff and visitors. The Infection Prevention Program coordinates prevention, surveillance, investigation and control of infectious agents and reports information to external agencies as required...Surveillance: Regularly conducting inspections of the facility to ensure that risks for the transmission of infections or occupation hazards are minimized....” 1. During a tour of the second-floor on 09/15/2025, directly across from the shower room, one linen cart was observed with linens stacked on the top of the cart, as well as on the third shelf, where linens were hanging down and making contact with the floor. Employee #18 confirmed on 09/15/2025 the linens were touching the floor as well as the top shelf was left uncovered. 2. During a tour of the second-floor showering room on 09/15/2025, an area approximately 4 feet by 4 feet of the shower floor was observed to have multiple cracked tiles and loose tiles that were not properly affixed. A black substance was also noted in the grout lines of this section. Employee #20 confirmed on 09/17/2025 the tiles were not properly affixed and there was a black substance in the grout lines. 3. During a tour of the second-floor medication storage room, multiple wall-mounted hanging bins containing various patient care supplies and nutrition packets were observed next to the handwashing sink, within the splash contamination zone. Employee #21 confirmed patient supplies and nutrition was located next to the hand washing sink and within a splash contamination area.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 46598 Based on a review of hospital records and an interview, it was determined that the provider failed to have an Infection Preventionist trained in infection control practices and procedures. This deficient practice poses the risk of infectious organisms not being identified, contagions spreading throughout staff and patient populations, the inability to track trends throughout the hospital, and no monitoring of infection control mitigation. Cross reference: A-0043, A-0774, A-0777 Findings Include: Hospital document titled “Phoenix Specialty Hospital Infection Prevention Plan 2025”, revealed: “ ...RESPONSIBILITIES AND AUTHORITY ...Governing Board. The Governing Board of Phoenix Specialty Hospital has the final authority and responsibility for the Infection Prevention Program and the delivery of optimal quality and safe patient care. The Governing Board has delegated oversight for the development and implementation of the organization-wide Infection Prevention Program to the Director of Quality and Risk, Infection Control Coordinator, and to the Infection Prevention Committee ... Organization-wide performance improvement activity will be reported at least quarterly to the Governing Board. The Infection Prevention Plan and program will be evaluated and approved annually by the Governing Board. Hospital document titled “Phoenix Specialty Hospital Job Description Evaluation Infection Control Coordinator/ Employee Health Nurse” revealed “ ... Qualifications 3. Continued Education in the area of Infection Control/Epidemiology preferred ....” Employee # 1 confirmed in an interview that the facility did not have Infection Control Policies, only a plan. Employee # 1 confirmed in an interview that the facility’s infection preventionist is not qualified through training and education. “It is on her list to do” .”

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility records the provider failed to ensure that the Infection Preventionist was responsible for the communication and collaboration with Quality Assurance, Performance & Improvement related to Infection Control issues. This deficient practice poses the risk of hospital leadership being unaware of infectious risks in the hospital, the outcome of infection control activities, and the spread of communicable diseases or hospital-acquired infections among patients and staff. Cross reference: A-0043, A-0748, A-0777 Findings Include: Infection Control meeting minutes dated May 2024 to current September 2025 requested. Infection Control Meeting minutes dated 07/29/2025 were provided. Quality Council meeting minutes dated May 2024 to current September 2025 requested. Quality Council meeting minutes dated 07/29/2025 were provided. Employee # 1 confirmed in an interview dated 09/16/2025 that the facility is unable to provide additional meeting minutes for the date of May 2024 through current September 2025. Unable to show communication and collaboration between the two committees.”

“IC PROFESSIONAL COLLABORATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (vi) Communication and collaboration with the antibiotic stewardship program. This Standard is not met as evidenced by: 46598 Based on staff interviews and facility records the provider failed to ensure that the Infection Preventionist was responsible for the communication and collaboration with Antibiotic Stewardship related to Infection Control issues. This deficient practice poses the risk of hospital leadership being unaware of infectious risks in the hospital, the outcome of infection control activities, and the spread of communicable diseases or hospital-acquired infections among patients and staff. Cross reference: A-0043, A-0748, A-0777 Findings Include: Hospital document titled “Phoenix Specialty Hospital Infection Prevention Plan 2025”, revealed: “ ...Infection Prevention Process Cycle ...Prevention Related Activities ...Collaborating with all disciplines and departments of the organization to develop and update area-specific policies and procedures ...Communication/Consultation ...Maintaining active committee participation (such as Infection Prevention, Quality Improvement, Pharmacy and Therapeutics, safety product evaluation, construction and renovation) ....” Infection Control meeting minutes dated May 2024 to current September 2025 requested. Infection Control Meeting minutes dated 07/29/2025 were provided. Antibiotic Stewardship/Pharmacy Committee Meeting minutes requested dated May 2024 to current September 2025 requested. ASP and Pharmacy and Therapeutics Committee Minutes dated 07/29/2025 were provided. Hospital document titled “ASP and Pharmacy and Therapeutics Committee Meeting minutes” dated 07/29/2025, revealed communication and collaboration with antibiotic stewardship. Item # 4 in the minutes. Program to include ASP-ID Restricted Abx review, Antimicrobial Stewardship Program overview, restricted antibiotics, Carbapenem-resistant organisms, and Antibiotics and financials. Employee # 1 confirmed in an interview dated 09/16/2025 that the facility is unable to provide additional meeting minutes for the date of May 2024 through current September 2025. Unable to show communication and collaboration between the two committees.”

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 50367 Based on a review of hospital record and staff interview, it was determined that the administrator failed to ensure medical records accompany two (2) patients (Patient #7 and Patient #9) during transfer. This deficient practice may result in various detrimental outcomes, including delay or duplication of care and unsafe decisions. Cross reference: A-0043, A-0431 Findings Include: Policy titled, “Transfers,” revealed: “...COPY To provide guidelines to nursing personnel upon transferring patients to other facilities. A physician order is needed for transfer. The responsibility for the transfer rests with the transferring physician and facility. Policy: 1. A change in condition resulting in service or care that cannot be provided at Phoenix Specialty Hospital will result in the transfer of a patient:...· Send appropriate documentation with the accompanying paperwork to assist the receiving hospital in the continuum of care ....” Further review of Patient #7 ’ s medical record failed to reveal documentation of the medical record accompanying the patient during the transfer. Further review of Patient #9 ’ s medical record failed to reveal documentation of the medical record accompanying the patient during the transfer. Employee #1 confirmed during an interview conducted on 09/17/2025, patients are transferred with the needed documents of the medical record. Employee #1 confirmed during an interview conducted on 09/17/2025, Patient #7 and Patient #9 did not have documentation of the medical record accompanying during the transfer.”