Kindred Hospital Westminster

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40483 Based on observation, interview, and record review, the hospital failed to ensure nursing services were provided for four of nine sampled patients (Patients 1, 2, 6, and 7) as evidenced by: 1. For Patient 6: a. The nursing staff failed to follow the hospital’s P&P and physician positioning order for turning Patient 6 and Patient 7 at least every two hours. b. The nursing staff failed to follow the hospital’s P&P for labelling Patient 6’s tube feeding with name, date and time started. c. The nursing staff failed to follow Patient 6’s physician order for the application of topical medication and dressing application. 2. For Patient 7, the nursing staff failed to follow the hospital’s P&P and physician positioning order for turning Patient 6 and Patient 7 at least every two hours. 3. For Patient 1: a. The nursing staff failed to apply zinc paste for the patient as per the physician’s order. b. The nursing staff failed to provide soft boots (heel protectors) to the patient as per ordered. c. The nursing staff failed to ensure the patient was turned and repositioned as per the hospital’s P&P and failed to ensure the patient was not on supine position. 4. For Patient 2, the nursing staff failed to ensure the patient was turned and reposition as per the hospital’s P&P and failed to ensure Z-Flo pillow was provided to the patient. These failures posed the increased risk of substandard health outcomes for the patients. Findings: In 2016, the NPUAP defined the following: * A pressure injury (ulcer) is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device. * Stage 3 pressure injury is defined as a full-thickness skin loss in which fat tissue is visible in the ulcer. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur. The subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. * Stage 4 pressure injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. * Unstageable Pressure Injury is defined as an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of the hospital’s P&P titled Guidelines - Patients with Wounds and at Risk for Wounds, release date 3/2026, showed * All patients are considered at risk for pressure injuries. * Each patient should have an individualized plan of care created around the identified risk level. * Standard interventions for all patients can include ... repositioning orders (minimum of every two hours turns). * Additional interventions to consider: repositioning devices and heel offloading. * The frequency of wound dressing changes is dependent upon various clinical indicators, including physician order. 1. On 7/2/26, review of Patient 6’s medical record was initiated. Review of the H&P dated 1/25/26, showed Patient 6 was admitted to the hospital with diagnosis of sacral decubitus ulcer. Review of the nursing skin assessment flowsheet dated 1/24/26 at 2206 hours, showed a Braden Score of 9 with a sensory perception as very limited, moisture as moist, activity as bedfast, mobility as completely immobile, nutrition as probably inadequate, and fiction and shear as problems. Review of the Wound Care physician’s note dated 3/13/26, showed Patient 6 had been diagnosed with a Stage 4 sacral pressure injury, with a wound vac in place. a. On 1/27/26, Patient 6 had a repositioning order which included turning the patient every two hours, from side to side. Review of Patient 6’s turning flowsheet showed the following: - On 3/14/26, Patient 6 was documented in the supine position at 0823 hours. - On 3/16/26, Patient 6 was documented in the supine position at 0835 hours, and at 1819 hours Patient 6 was documented in the left side position and not documented in a different changed position until 2232 hours. - On 3/17/26, Patient 6 was documented in the right-side position at 1715 hours and not documented in a different changed position until 2000 hours. - On 3/18/26, Patient 6 was documented in the left-side position at 2000 hours and not documented in a different changed position until 3/19/26 at 0200 hours. - On 3/20/26, Patient 6 was documented in the right -side position at 0600 hours and not documented in a different changed position until 1000 hours. Patient 6 was also documented at 1000 hours in the left position and not documented in a different position until 1413 hours. - On 4/16/26, Patient 6 was documented in the supine position at 1200 hours. - On 4/17/26, Patient 6 was documented in the left-side position at 1706 hours and not documented in a different changed position until 2200 hours. - On 4/20/26, Patient 6 was documented in the left-side position at 0000 hours and not documented in a different changed position until 0400 hours. - On 4/22/26, Patient 6 was documented in the supine position at 0400 hours. And then not documented to a change in position until 0836 hours. - On 6/27/26, Patient 6 was documented in the left-side position at 0800 hours and not documented as changed position until 1229 hours, and that documented position was supine, not side to side as ordered. - On 6/29/26, Patient 6 was documented in the left-side position at 0000 hours and not documented as changed position until 0400 hours. Patient 6 was then documented on the left side position at 0600 hours and not changed position until 1003 hours. Patient 6 was then documented in the left side position at 2016 and no positioned into a different position until 6/30/26 at 0158 hours. - On 6/30/26, Patient 6 was documented in the left-side position at 0422 hours and not documented as changed position until 1000 hours. Patient 6 was then documented in the right-side position at 2200 hours and not documented as changed position until 7/1/26 at 0200 hours. - On 7/1/26, Patient 6 was documented in the left-side position at 2200 hours and not documented as changed position until 0200 hours on 7/2/26. - On 7/2/26, Patient 6 was documented in the right-side position at 0549 hours and not documented as changed position until 1000 hours. On 7/7/26 at 0800 hours, a concurrent review and interview was conducted with the Wound Care Coordinator. The Wound Care Coordinator reviewed and verified the initial H&P and the Wound Care physician’s progress note showed the patient had a pressure injury to the sacral region of the body. The Wound Care Coordinator verified Patient 6 had a physician’s order to turn him every two hours and to turn Patient 6 side to side only, to the left side or right side only. The Wound Care Coordinator stated the purpose of turning the patient every two hours was to relieve pressure and to prevent the wound from worsening. The Wound Care Coordinator stated the purpose of turning the patient to the left side or the right side only, rather than the supine position was to prevent the patient from being sat on their pressure injury. The Wound Care Coordinator reviewed and verified the above findings from turning flow sheet. The Wound Care Coordinator also stated the expectation was for the nursing staff to follow the physician’s order which stated patient was be turned every two hours. The Wound Care Coordinator reviewed and verified Patient 6 was documented as placed in supine position and was also not documented as turned every two hours per order. b. Review of the Resource Title: Procedure-Administration of Enteral Nutrition, last reviewed 1/2026, showed in general how to provide a patient enteral nutrition ...gather and prepare the necessary equipment. Label formula bag with two patient identifiers, feeding rate, and hang date and time. Review of the Glucerna order dated 4/13/26, showed a rate of 70 ml/hr via gastrostomy tube,/PEG, continuous feeding. On 7/3/26, at 0850 hours, a tour of hospital commenced with the Wound Care Coordinator. During this observation on 2 West, the telemetry floor with the Wound Care Coordinator, Patient 6 was observed with a kangaroo style tube feeding pump and a carton of a diabetic 1.5 Cal enteral nutrition formula (Glucerna 1.5) hanging from an IV pole. The diabetic enteral nutrition formula hanging had no label with two patient identifiers, feeding rate, and no hanging date and time. On 7/3/26 at 0920 hours, the Wound Care Coordinator also reviewed the tube feeding pump and the carton of diabetic 1.5 Cal enteral nutrition formula (Glucerna 1.5) hanging from the IV pole. The Wound Care Coordinator verified the carton had no label, no date or time of when it was opened, and no date/time when it needed to be changed. The Wound Care Coordinator stated the expectation was for the diabetic 1.5 Cal enteral nutrition formula (Glucerna) needs to have a label with the patient’s information, the date and time of hanging and initials of who opened and started it. The Wound Care Coordinator stated the rationale for labeling was due to the tube feeding only being safe for consumption for approximately 24 hours. The Wound Care Coordinator stated without the date/time label, the nurse would have no idea if the Glucerna was still safe for consumption. The Wound Care Coordinator stated the expectation was for the nurses to follow the policy for administering a patient tube feeding. This expectation included writing the date when opened and when the tube feeding was no longer safe for consumption and ready to be discarded. On 7/3/26 at 0940 hours, RN 1 was interviewed. RN 1 verified she was the day shift nurse caring for Patient 6. RN 1 stated she had received report from the nightshift nurse but had not cared for this patient previously. RN 1 entered Patient 6’s room and verified the tube feeding container was unlabeled. RN 1 stated she did not know the tube feedings hanging date and time and when it needed to be replaced. RN 1 stated she had not looked at the tube feeding and was not aware it was unlabeled. RN 1 stated the expectation was for the nurse who opened the tube feeding to label, date and time the tube feeding. RN 1 stated the current handing tube feeding without the hang date and time would need to be replaced for safety concerns. RN 1 stated she could check in the computer for the documentation of when the previous shift had documented its replacement. However, RN 1 stated she did not feel comfortable labeling it herself as she simply did not know when it was opened. RN 1 was observed replacing the tube feeding and completing the handing tag and applying it to the newly administered Glucerna 1.5 c. Review of the Wound Care Nurse’s (WCN) wound notes dated 3/13/26, showed an acquired skin tear to Patient 6’s the right lateral knee. Review of the physician’s order dated 3/13/26, showed mupirocin (an antibiotic ointment) topical ointment, apply to right lateral knee, cover with wound dressing, BID (two times a day) 0900 and 1800 hours. Review of the medication application showed the following: - On 3/26/26 at 0900 hours, the application of mupirocin to the right lateral knee was completed. No documentation of an application of a wound dressing. No documentation of a second 1800 hours medication application and wound dressing application was documented as completed as ordered. - On 3/27/26 at 0918 hours, the application of mupirocin to the right lateral knee was completed. No documentation of an application of a wound dressing. No documentation of a second 1800 hours medication application and wound dressing application was documented as completed as ordered - On 4/2/26 at 1707 hours, the application of mupirocin was documented as completed to Patient 6’s nostrils. No documentation of an application of a wound dressing. - On 4/3/26 at 1800 hours, the application of mupirocin was documented as completed to Patient 6’s nostrils. No documentation of an application of a wound dressing. - On 4/7/26 at 0900 hours, the application of mupirocin was documented as completed to Patient 6’s nares (nostrils). No documentation of an application of a wound dressing. - On 4/7/26 at 1917 hours, the application of mupirocin was documented as completed to Patient 6’s nares (nostrils). No documentation of an application of a wound dressing. On 7/7/26 at 0800 hours, a concurrent review and interview was conducted with the Wound Care Coordinator. The Wound Care Coordinator reviewed and verified the acquired skin tear to Patient 6’s right lateral knee. The Wound Care Coordinator reviewed and verified mupirocin order BID to right lateral knee which showed to apply foam dressing (0900 and 1800). The Wound Care Coordinator reviewed and verified the ordered wound dressing was a foam dressing. The Wound Care Coordinator reviewed and verified no documentation of the application of the foam dressing, only documentation was location of the application of the mediation. The Wound Care Coordinator reviewed and verified the above medicine applications. The Wound Care Coordinator stated the medication mupirocin was used as a topical antimicrobial for infection control and for protection of the wound. The Wound Care Coordinator stated the expectation was for the floor nurse to carry out the application of the topical mupirocin medication and foam dressing change two times a day as ordered. The Wound Care Coordinator stated if there was a rationale for not performing the dressing change, the physician would need to be contacted and documentation in Patient 6’s chart would need to be done. The Wound Care Coordinator stated the charting system could not show in the documentation where a wound dressing was applied as the documentation only showed the application of the medication. The Wound Care Coordinator verified no documentation was made for not applying the medication and dressing on 3/26/26 at 1800 hours and on 3/27/26 at 1800 hours. The Wound Care Coordinator verified the location of the medication was the right lateral knee and not the nostrils (nares) as documented on 4/2/26 at 1707 hours, 4/3/26 at 1800 hours and on 4/7/26 at both 0900 hours and 1917 hours. On 7/8/26 at 1630 hours, all of these findings were shared and acknowledged by the DQM. 2. On 7/7/26, review of Patient 7’s medical record was initiated. Review of the H&P dated 5/8/26, showed Patient 7 was admitted to the hospital with diagnosis of acute hypoxemic respiratory failure, a history of CVA with hemiparesis, and diabetes mellitus type 2. Review of the nursing skin assessment flowsheet dated 5/8/26 at 0323 hours, showed a Braden Score of 11 with a sensory perception as very limited, moisture as moist, activity as bedfast, mobility as very limited, nutrition as adequate and friction and shear at problem level Review of the wound care nurse initial assessment dated 5/8/26 at 0745 hours, showed the patient required assistance with bed repositioning, had pressure injuries to the right ischium, left ischium, right hip, right heel on admission. Patient remained at risk for skin integrity issues due to bedbound state, incontinence and co-morbidities. On 5/8/26, Patient 7 had a repositioning order which included turning the patient every two hours. Review of Patient 7’s turning flowsheet showed the following: - On 5/26/26, Patient 7 was documented in the right-side position at 0200 hours and in the same position at 0400 hours. - On 5/28/26, Patient 7 was documented in the right-side position at 2200 hours and not documented as changed position until 5/29/26 at 0200 hours. - On 5/29/26, Patient 7 was documented in the supine position at 0600 hours and not documented as changed position until 1000 hours. - On 5/31/26, Patient 7 was documented in the supine position at 0600 hours and not documented as changed position until 1000 hours - On 6/1/26, Patient 7 was documented in the right-side position at 0600 hours and not documented as changed position until 1000 hours On 7/7/26 at 0800 hours, a concurrent medical record review and interview was conducted with theWound Care Coordinator. The Wound Care Coordinator reviewed and verified the initial H&P and the Wound Care physician’s progress note showed the patient had several pressure injuries to their bilateral legs on admission. The Wound Care Coordinator verified Patient 7 had a physician’s order to turn him every two hours. The Wound Care Coordinator verified the documentation showing Patient 7 was bedbound and unable to turn without assistance from staff. The Wound Care Coordinator stated the purpose of turning the patient every two hours was to relieve pressure and to help prevent the current wounds from worsening and new ones from forming. The Wound Care Coordinator also stated the expectation was for the nursing staff to follow both the hospital policy and the physician’s order which stated Patient 7 was to be turned every two hours. The Wound Care Coordinator reviewed and verified the above findings from turning flow sheet. 22553 3. On 7/3/26, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 3/9/26 and discharged on 4/6/26. a. Review of the physician’s order dated 3/9/26 at 1159 hours, showed a physician ordered the primary floor nurse to apply zinc paste to the perineum and buttocks and leave open to air every shift. On 7/7/26 at 1030 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 2. RN 2 confirmed that treatment was performed according to orders on the following dates: 3/13/26 at 0946, 1524, and 2118 hours; 3/16/26 at 1804 and 2243 hours; 3/22/26 at 1110 hours; 3/25/26 at 1556 hours; and 3/30/26 at 2030 and 2324 hours. However, documentation showed on 3/30/26 at 2030 hours, the wound dressing was “intact” rather than open to air. RN 2 stated there were no further entries documenting justification if the treatment for other days was provided or omitted. b. Patient 1’s medical record showed an order on 3/23/26, for soft boots (heel protectors) to be worn at all times to offload the lower extremities. On 7/7/26 at 1030 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 2. RN 2 found documented evidence of soft boot used on 3/23/26 at 0957 hours; 3/25/26 at 2350 hours; 3/27/26 at 0941 and 1949 hours; and 3/31/26 at 1112 hours. RN 2 further noted there were no additional entries regarding rationale for provision or omission of the soft boot intervention. c. An interview and concurrent review of Patient 1’s medical record was conducted with the DQM on 7/3/26 at 1340 hours. Review of the Risk of Impaired Skin/Tissue Integrity dated 3/23/26 at 0952 hours, showed turning the patient only to the left and right sides. The DQM confirmed Patient 1’s repositioning as follows: * Patient 1 was on supine position on 3/24/26 at 1956 hours; 3/25/26 at 0207 hours; 3/26/26 at 0600 hours; 3/27/26 at 1200 and 1819 hours; 3/28/26 at 0400 hours; and 3/29/26 at 0600 hours, * No position change for Patient 1 every two hours as per the hospital’s P&P. - The patient was on the left side on 3/24/26 from 0400-0800 hours. - The patient was on the right side on 3/26/26 from 1000-1348 hours - The patient was on the left side on 3/26/26 from 1349-1807 hours - The patient was on the right side on 3/27/26 from 0600-1059 hours - The patient was on the left side on 3/29/26 from 1800-2159 hours. 4. On 7/2/26 at 1550 hours, Patient 2 was observed being repositioned with the Wound Care Coordinator present. CNA 1 assisted with turning the patient, indicating that the patient was on his left side and would be moved to the right. The Wound Care Coordinator confirmed that no pillows were placed on the patient’s back. The patient’s left leg made contact with the bed linen, while the right heel rested on a pillow. The patient’s lower extremities exhibited contractures. No pressure-relief boots were observed on the patient’s heels or within the room, which was inconsistent with hospital protocol for pressure injury prevention. A Z-Flo Fluidized Pillow, was found at the left shoulder. The patient’s sacral wound dressing was positioned directly on the mattress without any gap. On 7/3/26 at 1427 hours, Review of Patient 2’s medical record was conducted with the DQM. Patient 2’s medical record showed the patient had been admitted to the hospital on 5/14/26. Review of the Impaired Skin/Tissue Integrity .... Plan of Care dated 6/26/26, showed a weekly wound care reassessment showing: - The patient was not able to follow simple commands and requiring assistance for bed repositioning. The patient had * Stage 4 pressure injury on the sacrococcygeal area * Stage 4 pressure injury on the occiput * Stage 4 pressure injury on the left lateral lower leg * Stage 3 pressure injury on the frontal region * Unstageable pressure injury on the right heel * a pressure injury on the left lateral foot * Abrasion on the left ankle * Extensive moisture-associated skin damage to the left back, buttock, and perineal area - Continue plan of care including the use of a pressure relieving mattress, frequent turning and repositioning, and offloading of heels and bony prominences Review of the nursing notes dated 7/2/26, showed interventions included maintaining a Z-Flo pillow under the left hip when turned left, placing a second Z-Flo pillow between the feet to offload pressure, and repositioning the patient to the right or left side only if possible to offload the sacral bone. Review of the repositioning flowsheet showed the following: * On 7/2/26, from 0000 to 0424 hours, the patient was on the right side * On 7/2/26 at 1800 hours, the patient was on left side and repositioned happened at the same time.”

“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: 40483 Based on observation, interview, and record review, the hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital as evidenced by: 1. The hospital failed to follow the hospital’s P&P related to Donning and Doffing Personal Protective Equipment and Transmission Based Precautions for one of nine sampled patients (Patient 6). 2. The hospital failed to ensure the patient care device was cleaned for one sampled patient’s room ( Room A). These failures posed the increased risk of substandard health outcomes for the patients. Findings: 1. Review of the hospital’s P&P titled Donning and Doffing Personal Protective Equipment last reviewed 6/2022 showed to utilize PPE when there is a potential for contamination and/or when transmission-based precautions dictate. Review of the hospital’s P&P titled Transmission Based Precautions approval date 4/2/26, showed the purpose of the policy is to establish requirements for patients with documented or suspected infection or colonization with epidemiologically important pathogens for which additional precautions are needed to prevent transmission .... All healthcare team must follow transmission-based precautions when entering a patient’s room ...Failure to comply with this policy will result in appropriate performance management ...Transmission-based precautions including contract precautions that are a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact. On 7/2/26, a review of Patient 6’s medical record was initiated. Review of Patient 6’s medical record showed an order dated 1/24/26, for contact precautions for Multiple Drug-Resistant Organisms (MDRO) isolated in the axilla, groin and tracheal aspirate. Contact precautions were further updated for the additional cultured organism, Candida auris (C. auris) in the tracheal aspirate on 3/29/26. On 7/3/26 at 0850 hours, a tour of hospital commenced with the Wound Care Coordinator. During this observation on 2 West, the telemetry floor with the Wound Care Coordinator, Patient 6 was observed receiving care in his room. The room was observed with a sign outside the room for contact isolation. The sign was in both pictogram and English language words, denoting the expectation for performing hand hygiene, applying a gown and gloves prior to entering Patient 6’s room. Observed outside the room, was also a container with prepackaged isolation gowns and boxes of gloves in small, medium and large. On 7/3/26 at 1015 hours, NP 1 was observed entering Patient 6’s room in their scrubs without performing hand hygiene and applying the posted contact isolation personal protective equipment (PPE) including both provided gown and gloves. This observation was verified by the Wound Care Coordinator and NP 1. On 7/3/26 at 1020 hours, NP 1 was interviewed. NP 1 stated they were aware of the contact isolation sign outside Patient 6’s room but stated they were just coming in to review Patient 6’s tracheotomy. NP 1 acknowledged that a tracheotomy could have aspirate which could contain infective, spreadable organisms. NP 1 verified they did not apply the required PPE as shown on the sign outside Patient 6’s room. NP 1 stated they were aware they should have applied the required PPE of gown and gloves prior to entering Patient 6’s. NP 1 stated the purpose of wearing PPE was to protect both himself and his other patients from spreading infective organisms. NP 1 acknowledged he did have training for the application of PPE and transmission-based precautions. On 7/8/26 at 1038 hours, the Infection Preventionist (IP) was interviewed. The IP stated patients were tested for infective organisms. The IP stated once the patient tested positive for the infective organisms, an order for transmission-based precautions was obtained from the provider. Then, the signage, denoting the type of transmission-based precautions to be used prior to entering the room, was posted outside of a patient’s room. The signage showed photos of the required PPE and also stated in English. The IP verified staff, including members of the medical staff, were expected to follow the posted transmission-based precautions outside a patient’s room. The IP stated the posted signage was not meant to be ignored. The signage was for the protection of both the patients and the staff. IP stated infection prevention was everybody’s concern at the hospital. On 7/8/26 at 1630 hours, these findings were shared with the DQM. 22553 2. On 7/2/26 at 1550 hours, Room A was inspected in the presence of the Wound Care Coordinator. Patient 2 was found resting on a Citadel 200 mattress with a white linen on top, the mattress exhibited colored spot residue and water marks on its surface. A staff member subsequently removed these residues using disinfectant wipes.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the abuse-allegation process was followed as required by the hospital’s P&P, for two of two sampled patients (Patients 1 and 2). This failure created the risk of delaying investigations into the abuse. Findings: During a review of the hospital’s P&P titled “Abuse & Neglect,” dated 2/25, the P&P showed for Suspected Abuse: First Responder/Supervisor Responsibilities: 1. The employee who first becomes aware of a patient who is said to be abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient. Immediate action measures shall include but are not limited to suspension of an employee involved in the abuse allegation, reassignment of other staff not involved in an allegation, review of patient’s care plan, and restriction of visitors. 2. If the allegation is conveyed by a family member, legal representative or visitor, assure the individual that the hospital treats any allegation seriously. Thank the individual for conveying their concerns and explaining that the supervisor will be notified promptly. 3. The first person to receive the allegation of abuse should enter an event report. The Investigation Guidelines showed...Interview witnesses, including the charged individual(s) and obtain signed statements when appropriate. ... Reports that are taken from patients and/or families and logged on the Complaint and Grievance Form will be responded to, in writing, with findings and recommendations resulting from investigation... 1. During a review of Patient 1’s medical records on 4/29/26, the medical record showed Patient 1 was admitted to the hospital on 1/24/26. During a review of the Patient/Family Support dated 3/12/26 at 1418 hours, the Patient/Family Support showed Patient 1’s family member disclosed Patient 1’s new bruise on his body that was not there previously. Patient 1’s family member stated she immediately spoke with Patient 1’s primary RN. Patient 1’s family member stated that in the presence of Patient 1’s primary RN, the patient alleged he had been “beat up” by staff members. During a concurrent interview and record review on 4/30/26 at 0917 hours, with the Director of Quality Management, the Director of Quality Management stated RN 2 received abuse allegation on 3/11/26. However, RN 2 did not escalate to the supervisor. 2. During a review of Patient 2’s medical records on 4/29/26, the medical record showed Patient 2 was admitted to the hospital on 5/9/25 and was discharged on 4/24/26. During a review of the Change of Condition dated 3/10/26 at 1239 hours, the Change of Condition showed Patient 2’s family member reported HD Nurse and LVN 1 twisted Patient 1’s arm. During a review of the Employee Timecard for LVN 1 dated 3/10/26, the Employee Timecard showed LVN 1 clocked in at 0652 hours clocked out at 1746 hours for the shift (five hours and seven minutes after the allegation was made at 1239 hours). During an interview on 4/29/26 at 1134 hours, with the Director of Quality Management, the Director of Quality Management stated they were not aware of the abuse allegation past 1500 hours and close to 1730 hours. The Director of Quality Management stated the HD Nurse did not have any other case and the allegation was made at the end of the HD treatment. During an interview and concurrent hospital record review on 4/30/26 at 0917 hours, with the Director of Quality Management, the Director of Quality Management showed the HD Nurse’s statement in a Word document. However, the statement did not contain a signature. In addition, documentation of interviews with RN 2 and LVN 1 consisted only of the interviewer’s summary. There were no signed statements for RN 2 or LVN 1 as required by the hospital’s P&P. During an interview with the Director of Quality Management on 4/30/26 at 1015 hours, the Director of Quality Management acknowledged the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff followed the provider’s medication-administration orders for one of two sampled patients (Patient 2). This failure posed a risk of adverse health outcomes to the patient. Findings: During a review of Patient 2’s medical records on 4/29/26, Patient 2’s medical record showed Patient 2 was admitted to the hospital on 5/9/25 and was discharged on 4/24/26. During a review of the Orders dated 2/20/26 at 2200 hours, the Orders showed to administer metoprolol (medication used to lower blood pressure), 50 mg per tube feeding, every eight hours, holding the dose for systolic blood pressure (SBP) less than 110 mmHg or heart rate (HR) less than 50 bpm. During a review of the Orders dated 3/9/26 at 2100 hours, the Orders showed to administer diltiazem (medication used to lower blood pressure) 60 mg per feeding tube every 12 hours, holding the dose for SBP less than 100 mmHg or HR less than 45 bpm. During a review of the Vital Signs/I&O/unit labs dated 3/10/26, the Vital Signs showed the following: * At 0200 hours, blood pressure was 112/56 mmHg * At 0730 hours, blood pressure was 112/70 mmHg, HR was 68 bpm * At 1402 hours, blood pressure was 152/82 mmHg, and HR was 71 bpm Review of the MAR dated 3/10/26, the MAR showed the following: * At 0554 hours, metoprolol was not administered due to scheduled HD. * At 1250 hours, metoprolol was not administered per MD’s order. * At 1250 hours, diltiazem was not administered per MD’s order. During a review of the medical record, the medical record failed to show MD’s order to hold metoprolol and diltiazem due to HD. During an interview on 4/30/26 at 1015 hours, with the Director of Quality Management, the Director of Quality Management acknowledged the above findings.”

“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: 26756 Based on observation, interview and record review, the hospital failed to ensure the GB was responsible for the conduct of the hospital as evidenced by: 1. The hospital failed to ensure the medical staff requirements were met. Cross reference to A044. 2. The hospital failed to ensure the medical staff was accountable to the GB for the quality of care provided to patients. Cross reference to A049. 3. The hospital failed to ensure that contracted services were evaluated in accordance with the hospital’s P&P. Cross reference to A083. 4. The hospital failed to ensure the patients received care in a safe setting. Cross reference to A144. 5. The hospital failed to ensure an ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program was implemented and maintained. Cross reference to A263. 6. The hospital failed to ensure an active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Cross reference to A747. The cumulative effect of this systemic failure resulted in the hospital’s inability to provide quality healthcare in a safe environment to the patients.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure an ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program was implemented and maintained as evidenced by: 1. Failure to collect and use data to monitor the quality and appropriateness of patient care. Cross-reference to A0273. 2. Failure of the GB or responsible leadership to ensure the QAPI program was fully implemented and effective. Cross-reference to A0309. 3. Failure to ensure adequate resources were allocated to support and sustain the hospital’s internal practice. Cross reference to A0315. The cumulative effect of these systemic failures resulted in the hospital’s inability to ensure safe, high-quality patient care, thereby creating an unsafe patient care environment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 22553 Based on observation, interview, and record reviews, the hospital failed to ensure an active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship as evidenced by: 1. The hospital failed to ensure the infection prevention standard precautions were implemented by medical staff, RN, and contracted service staff as per the hospital’s P&P. Cross reference to A750. 2. The hospital failed to develop and provide a job description for the hospital’s ASP Pharmacist. Cross reference to A760. 3. The hospital failed to be able to provide a current antibiogram for the calendar year 2025 and the hospital had failed to put a system in place for having any proposed antibiogram to go through the hospital’s established review process up through to the hospital’s governing body. Cross reference to A761. 4. The hospital failed to ensure the hospital-wide infection surveillance, prevention, and control protocol titled the blood cultures criteria form being enforced by the hospital’s IP and administration had documented references to nationally recognized guidelines. Cross reference to A772. 5. The hospital failed to ensure the I WATCH project had data collected, reported analyzed for a quality care activity as per the hospital’s P&P. Cross reference to A774. 6. The hospital failed to ensure the reference material was available as per the hospital’s P&P and failed to promote communication of HAI relevant information between medical staff and nursing staff as per the hospital’s P&P. Cross reference to A775. 7. The hospital failed to ensure all of the hospital’s P&Ps and Company 1 guidelines had been followed and implemented. Additionally, the hospital’s Antibiotic Stewardship team failed to provide competency-based training and education for all of the hospital’s medical staff, contracted staff, and pharmacy staff. Cross reference to A781. The cumulative effect of these systemic practices resulted in the hospital’s inability to minimize the risk of the spread of infections in the hospital and created an unsafe patient care environment for their inpatients.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 49419 Based on observation, interview, and record review, the hospital failed to ensure the medical staff requirements were met, as evidenced by: * The hospital did not provide the survey team with medical staff bylaws for Kindred Westminster Long Term Acute Care Hospital. * The hospital did not provide the survey team with medical staff bylaws for Kindred Westminster approved by the Governing Body. * The hospital did not provide the survey team with medical staff rules and regulations; and, therefore, there is no evidence the Governing Body approved any medical staff rules and regulations. * The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff to create a Policy or Procedure regarding when to order acetaminophen prn for a fever greater than 99 degrees and how the clinical staffs were to interact if there was an order by the medical staff for acetaminophen prn at a temperature higher than 99 F. * The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a Policy or Procedure regarding ordering blood cultures and that clarified whether any non-physician could effectively cancel a doctor’s order by holding the drawing of the blood for the culture. * The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a policy, procedure, or guideline regarding the surveillance of healthcare infections, and Infection Control Plan * The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the Medical Staff was responsible for approving an Infection Prevention and Control Program Plan. These failures had the potential for adverse patient outcomes due to the lack of established medical staff governance, inadequate clinical guidance, and insufficient oversight of critical care processes. Findings: 1. During an interview on 3/6/2026 at 1630 hours, with the Chief of Staff, Medical Staff, the Chief of Staff, Medical Staff stated the recommendation to prescribe acetaminophen (Tylenol, an over-the-counter medication used for fevers, aches and pains) as needed up to every four hours for fever greater than 99 degrees Fahrenheit (99 F) was made “sometime before November in 2025. The Chief of Staff, Medical Staff stated he learned about it verbally and the recommendation came from “Corporate Kindred.” The Chief of Staff, Medical Staff stated his usual practice when ordering Tylenol (acetaminophen) as needed for an initial fever, was when the temperature was 100.4 degrees Fahrenheit (100.4 F) or higher. The Chief of Staff, Medical Staff stated nurses or the Infection Preventionist would call or text him and ask if he would change the temperature for as needed to greater than 99 F. The Chief of Staff, Medical Staff stated he almost always said no; but sometimes he would say if greater than 100 degrees Fahrenheit. The Chief of Staff, Medical Staff stated that he was trained that a fever was 100.4 F or higher. The Chief of Staff, Medical Staff stated ordering Tylenol for a temperature greater than 99 F was “Not like anything I have experienced at any other hospital.” The Chief of Staff, Medical Staff stated he received a complaint from Physician 1 that someone changed an order for acetaminophen PRN for his patient without his knowledge. The Chief of Staff, Medical Staff stated he went around to “Various departments and individuals” asking how this had happened and who had changed the order. The Chief of Staff, Medical Staff stated that “no one professed knowledge.” The Chief of Staff, Medical Staff stated an Adhoc meeting of the Medical Executive Committee (MEC) was held on 11/4/2025. The Chief of Staff, Medical Staff agreed the “Adhoc MEC Minutes” for “11/4/25 at 1400 hours” included a final bullet that stated, in its entirety, “MEC also brought up a concern regarding Tylenol being ordered and given to patient with a temperature of 99 F without the doctor’s knowledge. The order was for temperature of 100.4 and not 99. That practice is not supported by the MEC though open for review if there is evidence or science to support it.” The attendance sheet was signed by the CEO, CCO/COO, DON, DQM, Pharmacy Director and three physicians, including the Chief of Staff, Medical Staff . During the interview when asked who could change an order for a given patient, the Chief of Staff, Medical Staff stated only the attending and any physician consultants to the patient may do so. The Chief of Staff, Medical Staff stated no other doctors could, such as a Medical Director, a pharmacist couldn’t, and a nurse couldn’t. The Chief of Staff, Medical Staff stated the Adhoc MEC meeting’s decision that the practice of acetaminophen PRN for a temperature greater than 99 F was not supported, was not communicated to the Medical, Nursing or Pharmacy staff, only to Physician 1. The Chief of Staff, Medical Staff stated he was not sure whether anyone else was informed. The Chief of Staff, Medical Staff was not sure whether there had been an investigation by any committee or person related to who had changed a doctor’s order, how it could have happened, had it happened previously, and whether this patient or other patients had been harmed. During an interview on 3/5/2026 at 1500 hours, with Pharmacist 1 and the Director of Pharmacy (DOP), for which the Director of Quality Management (DQM) was present, the DOP stated corporate had asked the hospital to treat 99 F degrees temperatures as a fever for acetaminophen PRN orders. The DOP was not sure when that request was made; was not sure about the rationale other than patient comfort; was not sure if 99 F was used by any doctor prior to the recommendation; and, was not sure exactly what nurses tell doctors or how the nurse words the conversation. During an interview on 3/6/2026 at 1505 hours, the Infectious Disease Medical Director (MDIC) stated he first became aware of orders for acetaminophen PRN for fever greater than 99 F in November 2025, when one of the Infectious Disease doctors informed him that someone changed his order for acetaminophen PRN for temperature 100.4 F or greater to 99 F or greater. MDIC stated his response was, “That’s weird.” His response was to text the COO/CCO, DON and IP asking if there “was some rule now about Temperature of 99 degrees.” The COO/CCO sent him some articles from corporate and that he would get back to him. He was not involved with any earlier “decision making with things from above.” The MDIC stated he is a member of the Stewardship, Infection Control, Patient Safety and Pharmacy and Therapeutics committees and the meetings for “all get kind of lumped together.” He was also a member of the MEC, which has a separate meeting The acetaminophen PRN for fever greater than 99 F was not a Policy or Procedure. The MDIC stated if it had been a Policy or Procedure he would have been involved. The MDIC then stated, “The funny thing is they don’t ask me anything or involve me. They ask if they want to.” The MDIC also stated “I don’t do a lot of things that one thinks of for a director.” The MDIC stated his role is no advisory, and he was “a lot more involved years ago” when there were two IPs. The MDIC stated they would talk regularly and did things together, including water testing. Now is “in the background,” as the Infection Preventionist (IP) has her own boss. The MDIC stated the one thing he is still involved in is Formulary review and updating. The MDIC stated the Infection Preventionist (IP) is through a contracted group and this is the 5th group to be contracted. The MDIC stated he is not sure” why they change.” The MDIC stated he has had no input into hiring any of the new groups and is not a participant in peer review. The MDIC stated he is aware the nurse calls are still going out to doctors and described the nurse conversations as “more like opting out,” explaining the nurse tells the doctor to accept 99 F or else state they do not want to accept it and then provide a different parameter. The MDIC stated he is only at the hospital about once a month, when he rounds, and for some of the committee meetings. The MDIC stated he is cc’d on texts that go to doctors about acetaminophen PRN orders. The MDIC stated he was trained that a fever was 100.4 F or greater. When asked what he had been told was the rationale for prescribing a medication with a black box warning to some one with a “fever greater than 99 F, the MDIC stated there was “none.” The MDIC stated risks included elevated liver function tests and allergies and that he was not aware of any benefit. During an interview on 3/6/2026 at 1405 hours, the CEO stated he was present at the 11/4/2025 Adhoc MEC meeting. CEO stated the issue that no doctor providing care gave the order to change the temperature from 100.4 to 99 to use to give Tylenol “was taken very seriously.” CEO stated there was an assessment that included review of other people, medical staff and, etc. CEO stated he remembered the MEC voted not to adopt the threshold. The CEO stated he did not remember who did the assessment and what the findings were and to ask the DQM. The CEO stated that from what he understood, the recommendation for the order for acetaminophen PRN fever greater than 99 F came from a corporate recommendation. the CEO remembers the recommendation “was not in writing”, “was not a policy, was not a procedure or a standing order.” The CEO stated he met with Nursing and the IP and they felt it was a reasonable request to make. The group discussed making the recommendation a procedure and decided not to, that is was “a clinician’s choice.” During the interview when asked what was the rationale, as he understood it, for prescribing a medication with a black box warning (for its severe risks) to someone without a fever by the standard medical definition,the CEO stated maybe there was a team call and that Medical staff are always included in these discussions. The CEO stated the RN was to ask the doctor and “would follow what they said.” When asked what communication there was with the Medical, Nursing and Pharmacy staffs about the recommended protocol for nurses asking doctors, the CEO stated there was no education to the medical or pharmacy staff and that such education wasn’t needed because the recommendation was “not a policy.” CEO stated the nursing staff was educated verbally through the brief and debrief meetings for each shift and when huddles were held. The CEO stated he wasn’t sure about when the recommendation was implemented, but within the past year. The CEO stated that doctors’ general response to the recommendation was greeted the way any “new process for them is,” “with lots of questions and concerns.” The CEO proceeded to state the “Doctors have all been wonderful and said ‘just call me.” The CEO stated nurses were still calling doctors; although he didn’t know of any data about how many, and how many agree with 99 F or don’t. During a document review of an e-mail from the Market Director of Pharmacy - Orange County (who is also the DOP for the hospital), dated 7/30/2025 and timed at 11:16 hours, reportedly to his pharmacies staffs, with, “Subject: Orders for Tylenol for temp!!!!!!,” the complete text was: “Please remember: When you have a PRN order for Tylenol for temp, Use: “PRN temperature > 99 degrees!!!!!” During an interview on 3/6/26 at 1315 hours, with RN 5, RN 5 stated she worked night shift and usually worked in the ICU. RN 5 stated on night shift, the ICU staff take telephone orders. RN 5 stated she was aware of the Tylenol 99 protocol being used at the facility. RN 5 wasn’t certain when it started, but thought it was a few months ago. RN 5 stated the new protocol was for the Nurse, when they noticed a PRN acetaminophen order, to tell the physician in person or by telephone, the facility wants to use PRN above 99 F for fever and can they add that parameter. RN 5 stated some doctors don’t want it and prefer the previously used 100.4 F. RN 5 stated the doctor must tell us “no” and what parameters to use or we use the greater than 99 F. We are instructed to do this and follow up is done by our charge nurse or the supervisor. During the interview, RN 5 stated she was informed about the protocol by the CNO during a routine huddle during her shift and that the CNO did not give the staff anything in writing at the huddle. RN 5 stated she was not given a reference or anything to read or refer to for questions, clarification or understanding the new facility protocol regarding the medication Acetaminophen (Tylenol) at the huddle. RN 5 verified the nursing ICU staff were still asking for this parameter at the time of interview. RN 5 was asked if the CNO or any charge nurse/supervisor from her department had, since the huddle, provided them with any policies, procedures or rationale for the new protocol. RN 5 stated no. RN 5 also stated she had not been informed to stop doing this protocol. RN 5 stated every time we take an order of PRN Tylenol the house supervisor or charge nurse will remind us to get the Tylenol for 99 F parameter and then the House Supervisor or charge nurse also follows up to see it was done. During the interview, RN 5 was asked if she had any safety concerns about the new protocol and that the ICU Nursing staff had not been given a rationale for its use. RN 5 stated she did have safety concerns. RN 5 stated she had worked at other hospitals in the area and those used greater than 100.4 F for their parameter with the medication Acetaminophen. RN 5 stated she had three concerns: - RN 5 stated one safety concern they had was regarding possibly giving patients with liver problems additional acetaminophen (Tylenol). RN 5 stated the nurses had to carefully monitor the amount of Acetaminophen (Tylenol) a patient with liver disease could receive. RN 5 stated this parameter made nurses have to do extra monitoring for some patients who have certain contraindications for acetaminophen. - The second concern was regarding patients who had different temperature set points. RN 5 stated 98.6 F is just an average temperature for people and that means some patients will always be higher and some patients will be lower. RN 5 thought over 99 F was too close to some patient’s normal temperature and the patient might not truly have a fever. RN 5 thought the parameter might cause some patients to be taking unneeded medication. - RN 5 gave a third example of concern regarding a patient she had previously cared for with an autoimmune disease. One of the symptoms often associated with auto-immune diseases was when the patient was reactive, the patient had an elevated temperature. RN 5 stated the elevated temperature was not due to infection, but due to the patient’s immune system response to their disease. RN 5 stated she had to advocate for her patient and get a PRN Acetaminophen (Tylenol) order with the parameter for her of 101 F and not 99 F. During an interview on 3/10/2026 at 1800 hours with Physician 2, Physician 2 stated he was an active member of the medical staff at the hospital and one time the CCO/COO sent a text to Physician 2 asking if the facility could do “sort of like a standardized order set for my patients that acetaminophen would be PRN if temperature was greater than 99 F.” Physician 2 said no, had “never heard of such a practice.” Physician 2 stated always wanted to know from a nurse if a patient had a change of conditions such as spiking a fever. Physician 2 stated “99 is not a fever.” The lowest temperature Physician 2 had ordered a PRN medication for fever for was 100.4 F. Physician 2 stated was told be the CCO/COO that the rationale was for patient discomfort and. or malaise for high temp and fever. That was the only contact. Physician 2 stated no one had ever changed an order. Physician 2 stated nothing like this had ever been done at any other facility. Physician 2 stated had never received any communication about the process of a nurse asking what temperature a doctor will accept as a fever. Physician 2 stated had never talked with any other doctor about the communication with the CCO/COO. The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a Policy or Procedure regarding when to order acetaminophen PRN for a fever greater than 99 degrees and how the clinical staffs were to interact if there was an order by the medical staff for acetaminophen PRN at a temperature higher than 99 F. 2. The hospital delayed a physician ordered blood culture draw for Patient 10. Review of the Blood Culture Criteria form being used at the facility showed no authors, no documented references for its criteria and requirements, no original release date; no review date; and no revision dates. The Blood Culture Criteria form instructions stated if the criteria for at least two of the items in Box 1 and at least one item in Box 2 was not met, to “STOP and CONSULT MD as to “Why we need a blood culture?” and consult with the Director of Nursing & Clinical Services or Staff 1. Review of Patient 10’s medical record showed Physician 5’s order for blood cultures to rule out fungemia or bacteremia, WBC 16, hypotensive. Start ASAP and then every 15 minutes, stop after 2 exec, not renewable, unit to notify ancillary to draw on 7/11/25 at 0723. Lab results showed a blood culture specimen was collected on the next day, 7/12/25 at 1030 hours. During an interview on 3/5/2026 at 1500 hours, with Pharmacist 1 and the Director of Pharmacy (DOP), for which the Director of Quality Management (DQM) was present, Pharmacist 1 stated his role is to review non-formulary drugs and restricted antifungals, beta lactams, those listed in the agenda for the Stewardship Committee meetings. He reviews patient charts daily, looking for signs of fever, labs, flowsheets, reads the doctors and nurses notes, and looks at imaging results of patients at the hospital and three other facilities. Pharmacist 1 stated he “determines appropriateness” of the anti-infectious medications and if is not appropriate he performs an intervention (reaches out via phone either voice or text if they don’t answer, sometimes in person). Pharmacist 1 does not confer with others, such as the IP. If the doctor agrees with Pharmacist 1’s recommendation, then he makes the change, usually as a verbal order. If the attending disagrees the patient’s regime doesn’t change. If the attending disagrees he contacts the DQM so the case will be brought up to the peer review committee. Pharmacist 1 stated he talks with the MDIC if the recommendation is questionable as there are gray areas. When asked about the process in general as to who decides there is to be an “intervention,” Pharmacist 1 stated when the RN receives the Blood Culture results, the RN notifies the susceptibilities, they contact the attending. Pharmacist 1 sometimes notices the results before the RN receives them and then would call either the RN or the attending. Pharmacist 1 enters all “contacts attempts” in his excel spreadsheet. During the interview, when asked what criteria is used for his decisions and if there was a P&P, Pharmacist said there were none, it was his knowledge. Pharmacist 1 stated the criteria were the FDA indications per the package insert and IDSA guidelines (three IDSA guidelines were provided to the survey team later). Pharmacist 1 stated there was no P&P referencing the IDSA guidelines. The DOP stated none of the hospitals had such a policy. The DOP stated that each doctor is “expected to keep up with evidence” themselves and that there is a newsletter that is sent out when there are changes. During a concurrent observation and interview on 3/6/26 at 1357 hours, the Lead Lab Tech stated he was the one who received the physician’s order and verified the lab had record log sheet titled blood culture log. Lead lab tech stated this record was kept for the blood culture orders approval process. Lead Lab tech stated before he could have a phlebotomist draw the blood cultures, he had to receive approval from the Infection Preventionist (IP). Lead Lab tech stated the Infection Preventionist (IP) was in charge of the approval for blood cultures. The Lead Lab Tech stated he would receive a text message from the Infection Preventionist (IP) and once the IP sent approval of the physician’s ordered blood cultures, the Lead Lab Tech would notify the phlebotomist to draw the blood. Lead Lab tech stated he could also receive approval from the CNO or the DON. The Lead Lab tech was asked what happens if the physician’s order is not approved by the IP, CNO or DON. The Lead Lab tech stated, then they are not drawn. The Lead Lab tech was asked to verify the cultures were not drawn, even with the physician’s order for patient treatment? Lead Lab tech stated all ordered blood cultures had to be approved, before the lab could draw it and send it off to the satellite lab. The Lead Lab tech was asked if this process slowed down care. Lead lab tech stated this was the process currently. All blood culture orders were held until the lab got permission from the Infection Preventionist (IP), CNO or the DON. The Lead Lab tech agreed there was no physician involvement in this approval to draw process. Review of text messages dated 7/11/2025 at 1129 hours from Infection Preventionist (IP) to Physician 4 and 5 showed “Hi Doctors 4 and 5, This is the IP and CEO at the facility. I am reaching out regarding the blood culture order on Patient 10. I see that the order is for hypotension and WBC’s of 16 which does not meet the facility approved blood culture criteria. Can we cancel or collect after CL vacation? CEO: Yes, we should.” Doctor 4 responded on 7/11/25 at 1342 hours and stated Doctor 5 may have ordered it. No text message was received from Doctor 5. During an interview on 3/6/2026 at 1405 hours, with the CEO, the CEO stated his name is put on the cc for the text each time a doctor is called about a Blood Culture, but he doesn’t really read them or respond. The CEO stated he has never reached out to a doctor himself. During an interview on 3/6/2026 at 1505 hours with the MDIC, the MDIC stated he was aware the IP and facility have a blood culture criteria form and it was shown to him a few weeks ago. The MDIC replied, “You cannot be so stringent” and provided some reasons why patients may not have an elevated temperature or “may not mount leukocytosis.” The MDIC stated there is no protocol as to when blood cultures are drawn while a patient is receiving antibiotics. The MCID stated sometimes the DON and/or IP ask his advice and sometimes they agree. The MDIC stated he does get cc’d on texts from the IP to the “primary attending” asking about an order for blood cultures, “Hey, is there a way we can hold off doing them right away?” The MDIC stated he sometimes reviews the charts. The MDIC stated he is not aware of any reason to delay past a specific date and time. The MDIC stated sometimes the doctors complain to him about the blood cultures not being performed when ordered because of the blood culture criteria form. The MDIC is aware that some attendings have had blood cultures “denied” (not performed) and sometimes have been recommended to put the patient on wide-spectrum antibiotics. MDIC stated when a doctor is “pressing to do it (obtain blood cultures),” he tells them to do it (write the orders). The MDIC is not aware as to what QAPI “is or isn’t doing” related to the blood culture criteria form use. The MDIC stated, “There should be changes to the way it is now. Not heavy handed. This is not like any acute care hospital I work at. Or have.” The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a Policy or Procedure regarding ordering blood cultures; and, which, clarified whether any non-physician could effectively cancel a doctor’s order by holding the drawing of the blood for the culture. 3. During a review of the two-page document the facility presented as the Guideline for Healthcare Associated Infection at Kindred Westminster on 3/11/2026, dated June 2022, the document was from “ScionHealth.” It was titled “Resource Title: Guideline-Surveillance of Healthcare Associated Infection” and with Last Review Date: 06/2022. The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a policy, procedure, or guideline regarding the surveillance of healthcare infections. 4. During a review of the four-page document the facility presented as the current Healthcare Infection Prevention and Control Program Plan (IP&CP) at the hospital on 3/11/2026, the document was from “ScionHealth,” it was titled “Resource Title: Guideline-Infection Prevention and Control Program Plan” and with “Last Review Date: 12/2024” Copyright is held by ScionHealth Support Center. Section 5.q. showed, “Infection Prevention and Control Program is reviewed a least annually and revised as indicated.” Section 8 showed “The facility’s Infection Prevention and Control Program monitors the elements of the infection prevention and control program as designated by the Strategic Quality Plan, The Quality Council, the Medical Executive Committee and the Governing Body. Infection Prevention and Control Program presents QAPI data to the Performance Safety and Reliability Committee at least quarterly.” The Section 9 showed Membership may include the collaborative elements of and had a table ten job titles and then “other appropriate facility staff.: Section 10 showed the Infection Prevention and Control Committee are (sic) chaired by an appointed physician who hopefully is and then the sentence continues in Section 11, that is, “Infectious Disease Specialist. The physician will:” “Section 11. a. showed the IP&CP was chaired by an appointed physician who preferably is an Infectious Disease Specialist. Section 11.. showed the physician, “Provides guidance, advice and support for the IP in all her/his assigned responsibilities.” Section 11.. showed, “Provide oversight and consultation for all facility specific Infection Prevention and Control. Section 11. d. showed, “Communicate infectious prevention and control related issues to the Medical Executive Committee.” Page 4 contains sections 16 and 17 and then 14 references. Two references are to CMS and Federal Code of Regulations with the first being to §482.42. Most are Internet addresses, thus not dated. There was no signature or approval page. The document did not contain any hospital information. The hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to patients when it did not ensure the medical staff created a policy, procedure, or guideline regarding the surveillance of healthcare infections.”

“MEDICAL STAFF CFR(s): 482.12(a)(1) [The governing body must] determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff. This Standard is not met as evidenced by: 49419 Based on interview and record review, the hospital failed to ensure the GB determined, in accordance with State law, which categories of practitioners were eligible for appointment to the medical staff, as the hospital could not provide medical staff bylaws identifying which practitioner types the GB had approved for medical staff membership. This failure had the potential to result in unqualified or unauthorized practitioners providing patient care. Findings: Cross reference to A-044”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 26756 Based on interview and record review, the hospital failed to ensure the GB approved the medical staff bylaws and the medical staff rules and regulations, as the hospital was unable to provide any bylaws or rules and regulations that had been approved by the GB. This failure had the potential to result in the medical staff operating without the required oversight and authorization from the GB. Findings: Cross reference to A0044”

“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: 26756 Based on interview and record review, the hospital failed to ensure the medical staff was accountable to the GB for the quality of care provided to patients when: * A medication order was changed without a physician’s verbal or written order or consent. * Physician orders were held rather than executed. * The hospital provided a healthcare-associated infection policy, procedure, or guideline that had not been approved by the Medical Executive Committee or the GB. * The hopsital provided an Infection Prevention and Control Plan that had not been approved by the Medical Executive Committee or the GB. This failure had the potential to compromise patient safety and the hospital’s ability to ensure proper oversight of medical care. Findings: Cross reference to A044”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure that contracted services were evaluated in accordance with the hospital’s P&P, resulting in insufficient information being provided to the GB for oversight and decision-making. This failure resulted in incomplete oversight of contracted clinical services and lack of evidence that the GB was provided with required information for review to show sufficient documentation for evaluating the contracts followed the hospital P&P. Findings: During a review of the hospital’s P&P titled “Core: Contract Evaluations,” issued in June 2021, showed its purpose is to establish clear guidelines for evaluating contracts. Clinical service contracts listed on the Physician and Clinical Contract list are overseen by the Leadership Committee, including an annual review based on the criteria outlined within each agreement. The Chief Executive Officer (CEO) or designated representative conducts the annual evaluation in collaboration with Clinical Department Directors, Medical Staff, and other relevant personnel. Each contract must specify clinical and performance indicators, which serve as the basis for assessment. These indicators are monitored throughout the year by an assigned committee-such as Leadership, Patient Care and Safety-and results are summarized accordingly. At the end of each calendar year, all physician and clinical service contracts are reviewed using the “Contract Services Evaluation Form,” with each performance dimension receiving a score from one to five. Upon completion, the CEO documents general comments and recommendations informed by data analysis. The Quality Council and Medical Executive Committee (MEC) are expected to finalize their reviews so evaluations can be presented during the Governing Board’s annual meeting. During a concurrent interview and review of the Contracts on 3/12/26 at 1544 hours with the DQM, the DQM provided a document titled “Contracts” along with the 2025 Contract Services Tracking and Reporting Tool for review. The documents was reviewed and confirmed that nine (9) contracts were monitored but were not included in the official Contract list, while eight (8) contracts on the list were not monitored. The Contract Services Tracking and Reporting Tool lacked defined indicators and scoring criteria. Review of the MEC 2025 Q1-Q4 summaries showed that the Leadership Committee’s dashboard and the Tracking and Reporting Tool contained the same statement for all 4 quarters “it was motioned, seconded and carried to concur with the recommendations and actions taken by the leadership committee.” The summary did not include evidence of physician contracts evaluation. There was no documentation of contract evaluation results, no performance indicator review, and no evidence that physician contracts were evaluated by MEC as required by policy. During an interview with the DQM on 3/12/26 at 1555 hours, the DQM confirmed there was no scope of contract available for all the contracts.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the patients received care in a safe setting as evidenced by: 1. The hospital failed to develop and maintain complete, current, and comprehensive P&Ps in accordance with the hospital’s established P&P process. 2. The hospital’s GB failed to provide oversight of MEC actions, including failure to ensure and document follow-up on an MEC meeting decision. 3. The hospital’s GB failed to ensure the Patient Safety and Relationship committee structure and duties were followed as per GB Bylaw, including an incomplete committee membership list and missing review dates. 4. The hospital failed to ensure timely implementation of a physician ordered intervention, specifically a delayed blood culture draw for one of 15 sampled patients (Patient 10). 5. The hospital failed to provide documented training/rationale to the nursing staff for the use of their new (Tylenol for temperature 99 F) nursing protocol. 6. The hospital failed to ensure medication orders were not changed without a physician’s written or verbal order, placing patients at risk for receiving care without appropriate practitioner authorization. These failures create the risk of unsafe patient care environment for the hospital patients. Findings: 1. On 3/5/26 1406 hours, during an interview with the CEO, CEO stated the DQM was assigned for the hospital P&P development and implementation. During interviews on 3/5/26 1154 hours and on 3/13/26 at 1328 hours with the DQM, the DQM stated after the hospital was acquired by Company 1 two years ago, corporate P&Ps were gradually adopted. However, ongoing corporate revisions prevented the hospital from finalizing its own P&Ps. The DQM stated the hospital had been utilized all of Company 1 Resource, Enterprise Policy, Corporate policy, Division Policy, and former hospital’s for operational guidance but has no ownership for all. The DQM stated the current P&Ps could be confused and difficult use in the hospital. During an interview on 3/13/26 at 1328 hours, with the DQM, the DQM acknowledged that the current collection of P&Ps was fragmented, potentially confusing, and difficult for staff to use effectively. During a review of GB meeting minutes documentation, the documentation showed on 2025 2nd quarter meeting showed policy and Resource revision released in July on Patient Care, Management and Leadership and Isolation and Cohorting Guidelines for review and approval. On 2025 3rd quarter meeting minutes documented showed Governing Board reviewed and approved only “Patient Care Policy.” During a review of the hospital’s P&Ps, the following policies were found to be past due for the required triennial review: * Core: E-Prescribing - last reviewed June 2022 * Core: Contract Evaluations - last reviewed June 2022 * Core: Availability of Resource Materials - last reviewed June 2022 * Company 1 Resource Guideline: Surveillance of Healthcare-Associated Infections - last reviewed June 2022 2. During a review of the hospital Bylaw, Article III 3.04 Manner of Acting, the act of a majority of the members presents at a meeting at which a quorum is present shall be the act of the GB. During a concurrent interview and documentation review on 3/5/26 at 1330 hours, the DQM provided the 2024 and 2025 MEC and GB minutes for review. The 2024 MEC Quarter 4 Summary documented in the Peer Review section for identified one Infectious Disease (ID) provider had ordered blood culture and antibiotics within guidelines. The MEC determined the ID provider would undergo FPPE. (Focused Professional Practice Evaluation, a time -limited process used by healthcare organization to evaluate practitioner’s privilege-specific competence). In addition, those five (5) medical records were reviewed by two physicians to evaluate medical management. The summary showed the results of the review were to be forwarded to the MEC. The 2025 MEC minutes showed no documentation of the required follow-up. During a review of the 2025 Governing Board Report first quarter showed no evidence of GB review or recommendation regarding the event. During an interview on 3/5/26 at 1330 hours, with DQM, the DQM stated after that MEC meeting, the MEC determined the issue was a provider-specific decision and chose not to take further action. However, this final MEC decision was not documented, as required for follow-up. 3. During a review of the Bylaws Article V Committee 5.03 the Board although having no named committee other than MEC, may have a discretion of the Chairperson of the Board, designate and appoint from time to time, such other special and /or standing committees, each of which shall consist of one or more GB members. The duties/charges and authority of the committee were defined by written resolution signed by the Chairperson of the GB. During an interview on 2/27/26 at 1334 hours with the DQM, the DQM presented a graphic diagram illustrating the hospital management and leadership reporting structure. The DQM stated that this was the hospital’s organizational chart encompassing all services. Within the chart, a designated box contained nine services: laboratory, radiology, respiratory, pharmacy, food and nutrition services, infection control, rehabilitation, surgical services, and dialysis. The DQM stated those services were collectively represented in the PSNR committee, which reported directly to the CCO/COO. During an interview on 3/4/26 at 0834 hours, with the DQM, the DQM provided an updated version of the reporting graphic organizational chart that reflected the addition of Case Management within the PSNR section. The DQM confirmed that the organizational chart was complete and accurately listed the leadership committees. The DQM stated the PSNR committee met quarterly to report data. These reports were then presented at the MEC quarterly meeting for approval, after which the MEC’s quarterly report was submitted to the GB as part of their quarterly review. When inquired about the hospital documentation regarding this subcommittee PSNR if its membership list and responsibilities, the reporting position, the DQM stated that no such document exists. 40483 4. Review of the hospital’s Blood Culture Criteria Form showed no documented references for its criteria and requirements. There was no original release date, no review date and no updates. Further review of the Blood Culture Criteria Form showed the listed criteria for screening showing: * Box 1: two of these criteria: a. Systemic Inflammatory Response (SIRS)- two or more must be present: - Temperature >100.4 degrees F or <96.5 degrees F - Heart Rate > 100 bpm - New-onset altered mental status - Respiratory rate > 22 breaths per minute (or higher than baseline) - WBC > 12,000 cells/lux or < 4,000 uL - Systolic blood pressure < 90 mmHg or Mean Arterial Pressure (MAP) < 65 mmHg * Box 2: 1 of these criteria b. History or signs suggestive of new infection. For example: - Cough/sputum/chest pain (chills, c/o hot or cold) - Wound infection (foul or purulent drainage) - Dysuria (decreased urine output) - Abdominal pain/diarrhea - Cellulitis (skin warm to touch) - Line or device in place * Steps: - 1st, from criteria: Box 1 must meet at least 2 or more and Box 2 must meet at least 1 or more. - 2nd, meet all criteria as above then OK to do blood culture. If not meet criteria as above, STOP and CONSULT MD as to “Why we need a blood culture?” and consult to the Director of Nursing & Clinical Service or Staff 1. Review of Patient 10’s medical record showed Physician 5’s order for blood cultures to rule out fungemia or bacteremia, WBC 16, hypotensive; start ASAP and then every 15 minutes, stop after 2 exec, not renewable, unit to notify ancillary to draw on 7/11/25 at 0723. Lab results showed a blood culture specimen was collected on the next day, 7/12/25 at 1030 hours. During the tour of the hospital’s laboratory, the lab blood cultures log book was reviewed. The blood cultures log sheet showed the following: * box for the date and time, * box for the patient ’ s name, ordered by, * box Agreed Y or N. * box Reason not approved * box Done sampling by/time During a concurrent tour of the hospital’s laboratory and interview on 3/6/26 at 1357 hours, with the Lead Lab Tech, the Lead Lab Tech stated that the hospital did not have the ability to run cultures. The Lead Lab Tech stated that all cultures, including blood, urine, stool, and catheter-tip swabs, had to be sent to another Lab. The Lead Lab Tech stated the hospital had a working blood bank and urinalysis (U/A) department. The Lead Lab Tech stated the blood culture orders were documented in a blood cultures logbook. The Lead Lab Tech described the process for blood cultures. He stated he received the physician’s order and verified that the lab maintained a record log sheet titled “Blood Culture Log.” He stated this record was kept for the blood culture order approval process. The Lead Lab Tech stated that before he could have a phlebotomist draw the blood cultures, he had to receive approval from the IP. The Lead Lab Tech stated the IP was responsible for the approval of blood cultures. The Lead Lab Tech stated he received a text message from the IP, and once the IP sent approval of the physician’s ordered blood cultures, the Lead Lab Tech notified the phlebotomist to draw the blood to be sent to another lab. The Lead Lab Tech stated he could also receive approval from the CNO or the DON. The Lead Lab Tech stated that if the physician’s order was not approved by the IP, CNO, or DON, then the cultures were not drawn. When asked whether cultures were not drawn even with a physician’s order for patient treatment, the Lead Lab Tech stated that all ordered blood cultures had to be approved before the lab could draw them and send them to the satellite lab. The Lead Lab Tech stated this was the current process. All blood culture orders were held until the lab received permission from the IP, CNO, or the DON. There was no physician involvement in this approval-to-draw process. During a review of text messages dated 7/11/2025 at 1129 hours, the text messages showed the text message sent from IP to Physician 4 and 5 showing “Hi Doctors 4 and 5, This is the IP and CEO at the facility. I am reaching out regarding the blood culture order on Patient 10. I see that the order is for hypotension and WBC’s of 16 which does not meet the facility approved blood culture criteria. Can we cancel or collect after CL vacation? CEO: Yes, we should. Doctor 4 responded on 7/11/25 at 1342 hours and stated Doctor 5 may have ordered it.” There was no text message from Doctor 5. During a concurrent interview and review of the hospital’s documentation, with the IP on 3/11/26 at 1500 hours, the IP verified she was not employed by the hospital but employed by third-party contract service to the hospital known as Vendor 1. The IP stated she had her Certification in Infection Control but was not a licensed medical doctor in the United States. The IP stated she did not have a DEA number and could not prescribe medications in the United States. The IP reviewed and verified the text messages. The IP stated the text message was sent to the two different physician phones with the expectation the physicians would be able to respond at any given time. The IP stated the blood culture orders that did not meet the criteria form would be held until the physician responded. The IP stated the physician in question did not respond so the order for Patient 10’s blood cultures was held and not completed when ordered. The IP stated this physician very often refused to answer her text messages and did not agree with the form. The IP stated the blood culture was drawn the next day when the physician rounded on the patient. The IP reviewed the hospital’s document titled Blood Culture Criteria Form and stated she was familiar with the form. The IP stated the blood culture criteria form was created before her time working at the hospital, but was being used and enforced when the hospital physicians ordered blood cultures for patients by herself and the hospital administration. The IP was asked what enforced meant. The IP stated the hospital was currently enforcing the form and that meant if a physician ordered a blood culture for a patient and the patient did not meet 2 criteria from box A (Box 1) and 1 additional criterion from box B (Box 2), for a 3 criteria total) of the criteria listed in this Blood Culture Criteria form the physician’s order for a patient was held, and not completed as ordered. The IP stated the determination of meeting criteria was assessed and completed by the IP, the hospital DON or the hospital House Supervisor. The IP stated the physician was then texted by the IP or the administrators and questioned about their blood culture order not meeting the form criteria and was asked to cancel the order. The IP stated the physician’s order would not be filled and the blood cultures were not drawn by the lab staff until the physician responded to the text message sent to their phone. The IP stated the physicians were required to respond to the text message asking them to cancel their order if it did not meet the form’s criteria. The IP was asked if they could outright alter or cancel the physician’s order, the IP stated that she was not a physician and could not prescribe or alter the physician’s order but would hold the order until the physician responded to her text messages. The IP state the physicians could say no to the cancellation of their order but were encouraged not to. 5. Review of the document titled Adhoc MEC meeting minutes dated 11/4/25 at 1400 hours, showed a concern regarding Tylenol being ordered and given to patients with a temperature of 99 degrees F without the doctor’s knowledge. The order was for 100.4 degrees F and not 99 degrees F. This practice was not supported by the MEC though open for review if there was evidence or science to support it. On 3/6/26 at 1315 hours, an interview was conducted with RN 5. RN 5 stated they worked night shift and usually worked in the ICU. RN 5 stated on night shift, the ICU staff took telephone orders, especially at night. RN 5 stated they were aware of the Tylenol 99 protocol being used at the hospital. RN 5 stated acetaminophen (Tylenol) was one of the more common PRN medication orders they received from the practitioners on their unit. RN 5 stated the hospital recently had a new protocol for Tylenol. RN 5 stated they were not certain when it started, but thought it was a few months ago. RN 5 stated the new protocol was to tell practitioners when they were ordering a PRN acetaminophen with an indication for fever, the hospital used above 99 degrees F for fever, and asked if they could add that parameter. RN 5 stated some practitioners did not want it and preferred the previously used 100.4 degrees F. RN 5 stated the practitioner had to tell them no and what parameters to use or they used the greater than 99 degrees F. RN 5 stated they were instructed to do this and follow up was done by the charge lead or the supervisor. RN 5 stated they were told the (Tylenol 99) nursing protocol in a huddle by the hospital clinical leader at the end of their shift. RN 5 stated they were not aware of any hospital policy for this protocol. RN 5 could not recall the rationale provided by the clinical leader for the new instructions. RN 5 stated the clinical leader did not give the staff anything at the huddle. RN 5 stated they were not given a reference or anything to read or refer to for questions, clarification or understanding of the new hospital protocol regarding acetaminophen (Tylenol). RN 5 verified the ICU staff were still asking for this parameter at the time of interview. RN 5 was asked if the clinical leader or any charge lead/supervisor from their department had, since the huddle, provided them with any policies, procedures or rationale for the new protocol. RN 5 stated no. RN 5 also stated they had not been informed to stop doing this protocol. RN 5 stated every time they took an order for PRN Tylenol, the house supervisor or charge lead reminded them to get the Tylenol for 99 degrees F parameter and then the house supervisor or charge lead also followed up to see it was done. RN 5 was asked if this new protocol was considered a standing order, but stated they were not sure, because they still had to ask for it from the practitioner. RN 5 was asked if she had any safety concerns about the new protocol and that the ICU nursing staff had not been given a rationale for its use. RN 5 stated they did have safety concerns. RN 5 stated they had worked at other facilities in the region and those used greater than 100.4 degrees F for their parameter with acetaminophen. RN 5 stated she did have safety concerns. * RN 5 stated the staff had to carefully monitor the amount of acetaminophen (Tylenol) an individual with liver disease could receive. RN 5 stated this parameter made staff had to do extra monitoring for some individuals who had certain contraindications for acetaminophen. RN 5 stated one safety concern they had was regarding possibly giving individuals with liver problems additional acetaminophen (Tylenol). * The second concern was regarding individuals who had different temperature set points. RN 5 stated 98.6 degrees F was just an average temperature for people and that meant some individuals would always be higher and some individuals would be lower. RN 5 thought over 99 degrees F was too close to some individual’s normal temperature and might not truly have indicated a fever. RN 5 thought the parameter might have caused some individuals to take unneeded medication. * RN 5 gave a third example of concern regarding an individual they had previously cared for with an autoimmune disease. One of the symptoms often associated with autoimmune diseases was when the individual was reactive, the individual had an elevated temperature. RN 5 stated the elevated temperature was not due to infection, but due to the individual’s immune system response to their condition. RN 5 stated they had to advocate for the individual and obtain a PRN Acetaminophen (Tylenol) order with the parameter for them of 101 degrees F and not 99 degrees F. 49419 6. During an interview on 3/6/26 at 1630 hours, the Chief of Staff stated the recommendation to prescribe acetaminophen (an over-the-counter medication used for fevers, aches and pains) as needed (PRN) up to every four hours for fever greater than 99 degrees Fahrenheit (99 F) was made “sometime before November in 2025. Chief of Staff stated he learned about it verbally and “sometime, probably October 2025.” The Chief of Staff stated the recommendation came from “Corporate Company 2.” the Chief of Staff stated his usual practice when ordering acetaminophen PRN for an initial fever, was when the temperature was 100.4 degrees Fahrenheit (100.4 F) or higher. Chief of Staff stated whenever he was asked by a nurse or the Infection Preventionist (IP) if he would change the temperature for PRN acetaminophen to greater than 99 F, he almost always said no; but sometimes would say if greater than 100 degrees F. The Chief of Staff stated ordering acetaminophen for a temperature greater than 99 F was “not like anything I had experienced at any other hospital.” The Chief of Staff stated he received a complaint from Physician 1 that someone changed an order for acetaminophen PRN for his patient without his knowledge. The Chief of Staff stated he went around to various departments and individuals asking how this had happened and who had changed the order. The Chief of Staff stated that “no one professed knowledge.” The Chief of Staff did not remember the name of the patient. The Chief of Staff stated he was the Chairperson of the Clinical Executive Committee (CEC) and they remembered calling for an Adhoc meeting of the CEC in November 2025. The meeting was called to discuss ventilator alarm settings. The complaint from Practitioner 1 was added to the meeting. The Chief of Staff agreed the “Adhoc CEC Minutes” for “11/4/25 at 2:00 pm” included a final bullet that stated, in its entirety, “CEC also brought up a concern regarding Tylenol (brand name for generic medication named acetaminophen) being ordered and given to a patient with a temperature of 99.0 without the practitioner’s knowledge. The order was for temperature of 100.4 and not 99. The practice was not supported by the CEC though open for review if there was evidence or science to support it.” The attendance sheet was signed by the Executive Leader, Clinical Operations Leader, Nursing Director, Quality Director, Pharmacy Director and three practitioners, including the LCO. When asked who could change an order for a given patient, the Chief of Staff stated only the attending practitioner and any consulting practitioners could. LCO stated no other clinicians could, such as a Medical Director, a pharmacist, or a nurse. The Chief of Staff stated the Adhoc MEC meeting’s decision that the practice of acetaminophen prn for a temperature greater than 99 F was not supported, this was not communicated to the Medical, Nursing or Pharmacy staff, only to Physician 1. The Chief of Staff was not sure whether anyone else was informed. The Chief of Staff was not sure whether there had been an investigation by any committee or person related to who had changed a doctor’s order, how it could have happened, had it happened previously, and whether this patient or other patients had been harmed. During an interview on 3/5/26 at 1500 hours, with Pharmacist 1 and the Director of Pharmacy (DOP), for which the Director of Quality Management (DQM) was present, the DOP stated corporate had asked the hospital to treat 99 F degrees temperatures as a fever for acetaminophen prn orders. The DOP was not sure when that request was made; was not sure about the rationale other than patient comfort; was not sure if 99 F was used by any doctor prior to the recommendation; and, was not sure exactly what nurses tell doctors or how the nurse words the conversation. During an interview on 3/6/26 at 1405 hours with the CEO, the CEO stated he was present at the 11/4/25 Adhoc MEC meeting. The CEO stated the issue that no doctor providing care gave the order to change the temperature from 100.4 to 99 to use to give Tylenol “was taken very seriously.” The CEO stated there was an assessment that included review of other people, medical staff and, etc. The CEO stated he remembered the MEC voted not to adopt the threshold. The CEO stated he did not remember who did the assessment and what the findings were and to ask the DQM. During a document review of an e-mail from the Market Director of Pharmacy - Orange County (who was also the DOP for the hospital), dated 7/30/2025 and timed at 11:16 AM, reportedly to the pharmacy staffs, with,”Subject: Orders for Tylenol for temp!!!!!!,” the complete text was: “Please remember: When you have a PRN order for Tylenol for temp, Use: “PRN temperature greater than 99 F degrees!!!!!” “”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff obtained physician’s order to place mitten restraints for one of 15 sampled patients (Patient 1). This failure could lead to inappropriate use of restraints and unsafe care for the patient. Findings: During a concurrent interview and review of Patient 1’s medical records on 2/25/26 at 1528 hours, with the DQM, Patient 1’s medical record showed Patient 1 was admitted to the hospital on 2/3/26. During a review of the Restraint Initiation/Order (Non-Violent Non-Self-Destructive Behavior) dated 2/23/26, the Restraint Initiation/Order (Non-Violent Non-Self-Destructive Behavior) showed Patient 1 was placed in mitten restraints on both hands due to self-injury risk and impaired orientation or understanding. RN 2 applied the mittens on 2/23/26 at 0000 hours and recorded an assessment 30 minutes after application. There was no documented evidence that RN 2 obtained a physician’s order for the restraint, and the telephone order section remained blank. Review of the Physician/LIP/AHP Assessment/Restraint Order Confirmation section included the statement: “I have completed a comprehensive assessment of this patient, including potential medical issues contributing to their present behavior. I have determined that the restraints are medically necessary for a limited period.” The fields for identifying restraint reasons were not checked. Signature and date documentation indicated review on 2/23/26 at 1030 hours. During an interview with the DQM on 2/25/26 at 1528 hours, the DQM confirmed the above findings.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) program incorporated quality indicator data for the “I WATCH” monitoring the process to evaluate the effectiveness and safety of services and the quality of patient care provided in the hospital. This failure had the potential for negative outcomes affecting the quality and safety of patient care Finndings: The hospital failed to ensure the I WATCH project had data collected, reported, analyzed for a quality care activity as per the hospital’s P&P. Cross reference to A774.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the GB and the MEC monitored the ongoing I WATCH project as part of the hospital’s quality improvement activities. This created the risk of performance issues not addressed by performance improvement activity. Findings: During an interview on 3/6/26 at 1505 hours, with the Medical Director of Infection Control, the Medical Director of Infection Control stated he was not aware as to what QAPI “is or isn’t doing” regarding the use of the Blood Culture Criteria Form use. The Medical Director of Infection Control stated, “There should be changes to the way it is now. Not heavy handed. This is not like any acute care hospital I work at, or have.” During an interview on 3/11/26 at 1459 hours, with the DQM regarding I WATCH, the DQM stated although she was technically invited to participate, she was not actively involved in the initiative. The I WATCH team consisted of hospital leadership members including the CEO, CCO, DON, HS, as well as the representatives from pharmacy and phlebotomy. Additional participants included wound care specialists, HD services, providers, and consultants. The meetings were conducted three times per week, with frequency adjusted based on the number of patients requiring review. The DQM stated the I WATCH team assessed patients’ clinical conditions, fever status, central line days, central line vacations, blood cultures, and the necessity for antibiotics. The project was presented to both the MEC and GB, who subsequently endorsed it. When questioned about the existence of any policies, programs, documentation, or evaluations related to I WATCH, the DQM confirmed that none were in place. During a review of the Company 1 Resource Section -14 Infection Prevention document showed the forms, guidelines, procedures, and tools-specifically the I WATCH and the Blood Culture Criteria Form-were not included among the forms, guidelines, procedures, or tools listed in the resource section. The hospital failed to ensure the I WATCH project had data collected, reported, analyzed for a quality care activity as per the hospital’s P&P. Cross reference to A774.”

“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: 22553 Based on record review and interview, the hospital’s GB failed to ensure adequate resources were allocated to support and sustain the hospital’s internal practice of requiring or encouraging PRN acetaminophen orders for temperatures greater than 99°F, a nursing practice, despite the absence of a written policy or supporting evidence. The GB also failed to ensure adequate resources were provided to support and sustain the Blood Culture Criteria Form used by clinical staff members. These failures created the increased risk of unrecognized poor health care practices. Findings: 1. The hospital failed to ensure the reference material was available as per the hospital’s P&P. Cross reference to A775, example # 1. 2. The hospital failed to promoting communication of HAI relevant information between medical staff and nursing staff per P&P. Cross reference to A775, example # 2.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40483 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P and positioning order for turning one of 15 sampled patients (Patient 9) at least every two hours from side to side. This failure posed an increased risk of substandard health outcomes to Patient 9. Findings: In 2016, the NPUAP defined the following: * A pressure injury (ulcer) is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device. * Stage 4 pressure injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. Review of the hospital’s P&P titled Core: Clinical Guidelines for Pressure Injury release date 6/2022, showed the purpose of the policy is to establish guidelines for the RN’s role in preventing and treating pressure injuries. Standard interventions for all patients can include... repositioning orders (minimum of every two-hour turn). On 2/27/26, a review of Patient 9’s medical record was initiated. Patient 9’s medical record showed the patient was admitted to the hospital on 11/4/25. Review of the H&P dated 11/4/25, showed Patient 9 was admitted to the hospital with a stage IV pressure injury. On 11/8/25, Patient 9 had a repositioning order which included turning the patient every two hours, from side to side. Review of Patient 9’s turning flowsheet showed the following: - On 11/7/25, Patient 9 was documented in the right-side position at 0800 hours and not documented as changed position until 1217 hours (documented as in the same position for 4 hours and seventeen minutes). - On 11/10/25, Patient 9 was documented in the left-side position at 0626 hours and not documented as changed position until 1109 hours (documented as in the same position for 4 hours and 43 minutes). - On 11/10/25, Patient 9 was also documented in the right-side position at 1109 hours and not documented as changed position until 2200 hours (documented as in the same position for 10 hours and 51 minutes). On 2/27/26 at 1000 hours, an interview and concurrent record review was conducted with the DQM. The DQM verified side to side meant changing the side the patient was on from left side to right side every two hours and not repositioned onto their back. The DQM stated the purpose of turning a patient every two hours, side to side, was to help keep pressure off a patient’s bony prominences especially when they have any pressure injuries on their back. The DQM provided the above policy. The DQM verified it applied to Patient 9’s care. The DQM stated the purpose of repositioning a patient was to help prevent pressure ulcers from starting or progressing. The DQM stated the expectation was for the nursing staff to follow the orders and the policy regarding the turning of Patient 9. The DQM reviewed Patient 9’s turning documentation and verified the above concerns.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 40483 Based on interview and record review, the hospital failed to ensure the nursing staff received training and competence to care for one of 15 sampled patients (Patient 9). A LVN who provided care for Patient 9, did not have the current, documented competency for caring for a patient with a Gastro-Jejunostomy (G-J) tube. This failure to provide the necessary education and competency for the care of the patients to whom they were assigned had the potential for poor outcomes to the patients receiving services in the hospital. Findings: Review of the Procedure-Administration of Enteral Nutrition last reviewed January 2026, showed in general how to provide a patient enteral nutrition, but not regarding the different types of feeding tubes and their individual use and requirements for patients. Review of the Procedure-Evaluation and Verification of Competency Guidelines last reviewed March 2025, showed the department supervisors, managers and/or directors are responsible for enduring staff competency. Nursing is required to successfully complete standardized competency assessment examinations prior to unsupervised direct patient care. Annual Competency Validation...specific departmental competencies will be selected annually and as needed for revalidation. Annual skills are ongoing and should be completed throughout the year. On 2/27/26, a review of Patient 9’s medical record was initiated. Patient 9’s medical record showed the patient was admitted to the hospital on 11/4/25. Review of the H&P dated 11/4/25, showed Patient 9 was admitted to the hospital with a gastrojejunostomy. On 2/27/26 at 1321 hours, an interview was conducted with the Nurse Education Manager. The Nurse Education Manager verified he was the Nurse Manager for the education department, who provided the training for the nursing staff. The Nurse Education Manager stated several types of enteral feeding tubes existed and many were single lumen. However, Nurse Education Manager stated a Gastrojejunostomy Tube GJ tube) was a different type of feeding tube. A GJ tube is double lumened with 1 lumen to the stomach (gastro) and 1 lumen to the jejunum. A GJ tube is a feeding tube used for enteral nutrition, water flushing, and medication. The gastro lumen is for medication and the jejunal lumen is for enteral feeding and water flushes. On 2/27/26 at 1400 hours, a review of the nursing staff’s schedule and Patient 9’s medical record showed LVN 1 provided g-j tube care. The hospital policies regarding enteral nutrition, care of patients with GJ tubes and nursing staff competencies were requested. A policy on the enteral nutrition/feeding procedure was provided. No policy on nursing staff competencies on the use and care of patients with GJ tubes was provided. On 3/13/26, a review of LVN 1’s competencies for nursing care was conducted. Review of the provided hospital nursing competencies did not show a documented 2025 competency for the care of a patient with a Gastrojejunostomy tube (GJ tube). On 3/13/26 at 1336 hours, an interview was conducted with the Nurse Education Manager. The Nurse Education Manager verified there were a general guideline as reviewed above, but which described the specific nursing staff competencies and no specific policy on the care of patients with GJ tubes. The Nurse Education Manager stated every year the nursing staff had an annual skills fair, typically in the fall. The Nurse Education Manager stated he was the one who selected the yearly training and competencies for the nursing staff. The Nurse Education Manager stated the topics, training and competencies were selected based on the topics he thought the nurses needed and on feedback of events throughout the year. The Nurse Education Manager verified he had not provided training or competencies at the skills fair to the nursing staff last year (2025) regarding the care of patients with a GJ tube. The Nurse Education Manager stated that based on this current event, he should probably do training competency with the nursing staff at their annual skills fair for this year, 2026.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 22553 Based on observations, interviews, and record review, the hospital failed to ensure the infection prevention standard precautions were implemented by medical staff, RN, and contracted services staff as per the hospital’s P&P, creating the increased risk of spreading infection to the patients. Findings: Review of the corporate policy titled “Standard Precautions,” effective November 2024 showed its purpose is to establish requirements for Standard Precautions as the minimum infection prevention measures applied to all patient care. Facility healthcare staff are required to wear Personal Protective Equipment (PPE), which includes specialized gear designed to provide protection from infectious materials. The type of PPE selected should correspond to the nature of patient interaction and the risk of exposure to blood, body fluids, or infectious agents. PPE items may include gloves, masks or procedure masks, gowns, face shields, or goggles. On 2/27/26 at 1023 hours, the telemetry unit and ICU were visited with the CCO and NEM. The following was observed: * In the telemetry unit, a contact precautions sign was posted on a patient’s room instructing all individuals to use alcohol rub, don an isolation gown, and wear gloves before entering. Physician 2 was observed entering this room without performing hand hygiene or wearing PPE; subsequently, a staff member entered to provide PPE, after which Physician 2 exited the room and entered another room with similar precautions, again without PPE. * In the ICU, one contracted services staff member presented in a patient room with posted contact precaution sign, not wearing any PPE, who left without utilizing alcohol rub. Additionally, another RN was seen in a patient room with contact precautions who donned PPE, but the back of the gown remained exposed in a contaminated environment. A concurrent interview with the CCO, the CCO confirmed that the CCO holds responsibility for ensuring medical staff compliance with hospital infection control policies and procedures.”

“ANTIBIOTIC STEWARDSHIP PROGRAM CFR(s): Antibiotic stewardship program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership, This Standard is not met as evidenced by: 13095 Based on record review and through emails with the hospital’s Nurse Education Manager (NEM), the hospital failed to develop and provide a job description for the hospital’s ASP Pharmacist. This deficiency had the potential to demonstrate that the hospital’s ASP Pharmacist was, qualified to do his job. Findings: On March 12, 2026 at 1125 hours, a request was made by the hospital’s survey team to review the hospital’s personnel file for the hospital’s ASP pharmacist. The email from the survey team leader read: “Hi, please help the survey team for review the personal file of (ASP pharmacist), including: the job description, competency, health screen. Please forward the file to (CDPH pharmacist’s email address).” The hospital’s NEM responded in an email dated 3/12/2026 at 1230 hours “Hello, pharmacy is aware and processing this request and will email the documents including health files asap. Thank you.” In an email from the hospital’s NEM dated 3/12/2026 at 1523 hours, the NEM wrote: “Hello, please see attached Education Files for (AS pharmacist). Thank you”. In an additional, email exchange with the hospital’s NEM on 3/12/2026 at 1601 hours, the CDPH Pharmacist surveyor asked the hospital’s NEM, “Does the facility have a current job description for your ASP pharmacist?” In a third email from the hospital’s NEM dated 3/13/2026 at 1055 hours, the hospital’s NEM wrote for both of the surveyor’s inquiries, regarding the hospital’s Infection Control Pharmacist position and the ASP pharmacist position: “There is no (Hospital) Job Description, but the (DOP) will provide one by the end of the day.” Neither of these job descriptions were ever provided to the survey team. National HR professional bodies which includes SHRM (Society for Human Resource Management (SHRM): Recommend defining essential functions, standardizing structure, and obtaining upper management approval. The core function of any job description is to: Sets Expectations: Eliminates confusion regarding what needs to be done. Provides Structure: Defines organizational hierarchy. Identifies Skill Sets: Outlines necessary training or qualifications A clearly defines the role’s responsibilities, duties, required skills, and performance expectations, acting as a foundational tool for recruitment, hiring, onboarding, and performance management. It ensures alignment between employee and employer, sets compensation, and helps protect companies legally. Job descriptions are an essential part of the evaluation process for knowing whether an employee is capable of being successful/ or unable to do their job.”

“ANTIBIOTIC STEWARDSHIP COORDINATION CFR(s): §482.42(b)(2) The hospital-wide antibiotic stewardship program: (i) Demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; This Standard is not met as evidenced by: 13095 Based on review of the hospital’s P&Ps, interview with the hospital’s Chairman for Antibiotic Stewardship ID physician, and interview with the hospital’s corporate Antibiotic Stewardship Pharmacist (ASP Pharmacist) and the corporate Director of Pharmacy (DOP), the hospital failed to be able to provide a current antibiogram for the calendar year 2025 and the hospital had failed to put a system in place for having any proposed antibiogram to go through the hospital’s established review process up through to the hospital’s governing body. The failure of the hospital to not have a current antibiogram and to no use the hospital’s established review process had the potential to cause the hospital’s patients to not receive the hospital’s optimal antibiotic treatment available. Findings: During an interview on 3/5/2026 at 1610 hours, with the hospital’s corporate ASP Pharmacist and the corporate DOP, the corporate DOP indicated that the hospital did not have a current 2025 Antibiogram and that the hospital’s contracted laboratory (in Rancho Cucamonga) was still gathering and aggregating the hospital’s culture and sensitivity data for the hospital’s, for bacteria and other organisms. An Antibiogram is a periodic, aggregated report summarizing the antimicrobial susceptibility patterns of local bacterial isolates to specific drugs within a healthcare facility. It is updated annually, as it guides clinicians in choosing effective empirical antibiotic therapy and helps track local resistance trends to support antimicrobial stewardship programs. “The National Institute for Health”, (which is a National Standard) in 2021 defined an antibiogram as: “The antibiogram is an essential resource for institutions to track changes in antimicrobial resistance and to guide empirical antimicrobial therapy.” As stated above, it is essential that the hospital has a system in place to track any changes in antimicrobial resistance which will guide the hospital’s medical staff in the decision-making process for choosing empirical (prior to test results returning) antibiotic therapy for the hospital’s patients. During a concurrent interview with the corporate DOP on 3/5/2026 at 1610 hours revealed that the raw data which was being collected by the hospital’s contracted laboratory had not been reviewed by the hospital’s normal review process, which includes the hospital’s Pharmacy and Therapeutics Committee, Medical Executive Committee, and the hospital’s Governing Body.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 40483 Based on interview and record review, the hospital failed to ensure the hospital-wide infection surveillance, prevention, and control protocol titled the blood cultures criteria form being enforced by the hospital’s IP and administration had documented references to nationally recognized guidelines. This failure created the increased risk of transmission of infections and further compromised acutely ill patients’ clinical conditions. Findings: Review of the hospital’s Blood Culture Criteria Form showed no documented references for its criteria and requirements. No documented approval date or hospital board approval, no original release date, no review date, and no updates to the form. Further review of the Blood Culture Criteria Form showed the listed criteria for screening showing: * Box 1: two of these criteria: a. Systemic Inflammatory Response (SIRS)- two or more must be present: - Temperature >100.4 degrees F or <96.5 degrees F - Heart Rate > 100 bpm - New-onset altered mental status - Respiratory rate > 22 breaths per minute (or higher than baseline) - WBC > 12,000 cells/uL or < 4,000 uL - Systolic blood pressure < 90 mmHg or Mean Arterial Pressure (MAP) < 65 mmHg * Box 2: 1 of these criteria b. History or signs suggestive of new infection. For example: - Cough/sputum/chest pain (chills, c/o hot or cold) - Wound infection (foul or purulent drainage) - Dysuria (decreased urine output) - Abdominal pain/diarrhea - Cellulitis (skin warm to touch) - Line or device in place * Steps: - 1st, from criteria: Box 1 must meet at least 2 or more and Box 2 must meet at least 1 or more. - 2nd, meet all criteria as above then OK to do blood culture. If not meet criteria as above, STOP and CONSULT MD as to “Why we need a blood culture?” and consult to the Director of Nursing & Clinical Service or Staff 1. A request was made for a list of all the Infection Preventions P&Ps currently in use at the hospital. The DQM provided Company 1 list of Table Contents, Infection Prevention last reviewed date 8/2025, showed a listing of the current Company 1 forms and guidelines used at this hospital. The provided list did not include the Blood Culture Criteria form. On 3/4/26 at 1530 hours, an interview and document review was conducted with the IP. The IP verified she was not employed by the hospital but employed by third-party contract service to the hospital known as Vendor 1. The IP stated she had her Certification in Infection Control but was not a licensed medical doctor in the United States. The IP stated she did not have a DEA number and could not prescribe medications in the United States. The IP reviewed the hospital document titled Blood Culture Criteria Form and stated she was familiar with the Blood Culture Criteria Form. The IP stated the Blood Culture Criteria Form was being used and enforced when the hospital physicians ordered blood cultures for patients by the IP and the hospital administration. The IP stated she thought it had been approved for use by the hospital Medical Executive Committee (MEC) but was uncertain of the date. The IP was also uncertain if any changes, reviews or updates had been made to the form. The IP verified the form did not provide any of this information, and stated it was created before she started working at the hospital. The IP was asked what enforced meant. The IP stated the hospital was currently enforcing the form and that meant if a physician ordered a blood culture for a patient and the patient didn’t meet 2 criteria from box A (Box 1) and 1 criteria from box B (Box 2) or 3 criteria of the criteria listed in this Blood Culture Criteria Form, the physician’s order for a patient was held, and not completed as ordered. The IP stated the determination of meeting criteria was assessed and completed by the IP, the hospital DON or the hospital House Supervisor, not the ordering physician. On 3/4/26 at 1540 hours, the DQM entered the interview room and reviewed the provided Company 2’s Blood Culture Criteria Form. The DQM verified this form as presented by the DQM, was currently in use at the hospital. The DQM reviewed and verified the form as presented had no documented national-guideline references for its criteria listed on the form. The DQM verified no approval date or approval board, original release date, no documented review date and no documented updates. The DQM also stated she thought the form had been reviewed and approved by the hospital MEC sometime in the year 2024 but could not provide an exact date. A review of the MEC committee meeting minutes Q1-Q4 for the year 2024 was conducted. This review did not show committee approval, review, or update of the use and enforcement of the Blood Culture Criteria Form. On 3/5/26 at 1500 hours, an interview was conducted with the ID Pharmacist and the Director of Pharmacy. The ID Pharmacist and the Director of Pharmacy were asked if they were familiar with the Blood Culture Criteria Form. The ID Pharmacist responded, stating Pharmacy did not complete the blood draws. That was the laboratory responsibility. On 3/6/26 at 1500 hours, an interview was conducted with the Medical Director of Infection Control. The Medical Director of Infection Control stated he had seen the Blood Culture Criteria Form. The Medical Director of Infection Control stated as far as he knew there was no protocol for blood cultures. The Medical Director of Infection Control stated this form originally approved though the MEC because of a physician’s misuse of ordering lots of blood cultures. The Medical Director of Infection Control stated Blood Culture Criteria form should be used as guidelines and more nuanced. The Medical Director of Infection Control stated after review, he thought the criteria on the Blood Culture Criteria form was too restrictive. The Medical Director of Infection Control stated physicians sometimes needed to do blood cultures for other reasons not included on this form. The Medical Director of Infection Control stated nuances and cannot be captured in a form. The Medical Director of Infection Control stated there was no input from a physician, was too strict, and had limitations for use. On 3/12/26 at 1000 hours, a follow up interview was conducted with the Medical Director of Infection Control. The Medical Director of Infection Control verified he had a current contract with the hospital to provide these services. The Medical Director of Infection Control stated his role was advisory. The Medical Director of Infection Control stated the Infection Control meetings were led by the IP who provided information and things to approve. The Medical Director of Infection Control stated that infection control information was presented to him, and he was not asked for his input. The Medical Director of Infection Control stated he was made aware of the concerns physicians had regarding the hospital use of the Blood Culture Criteria form. The Medical Director of Infection Control stated it was very frustrating for his group of providers, especially the Infectious Disease (ID) providers. These providers were upset for several reasons. The ID physicians’ concerns were regarding the holding of their ordered blood cultures and having to justify their clinical judgement to a non-physician, which to them caused a delay of care due to the back and forth with the IP. This was not what you wanted to do and delays in patient care serve no one and the going back and forth was frustrating for the medical staff. There needs to be a good medium or use of some other source, but it was hard to get everyone the same page. The ID providers were upset cause their clinical judgement was being challenged by non-doctors. The Medical Director of Infection Control stated these criteria needed to be used more like guidelines. The Medical Director of Infection Control stated patients with blood stream infections were more critically ill and the criteria could not be rigid. The Medical Director of Infection Control stated the provider with the license and training rounds on these patients. The provider who saw them a month before at another facility knew the patient better than someone with this form.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the I WATCH project had data collected, reported, analyzed for a quality care activity as per the hospital’s P&P, creating a substandard patient care environment. Findings: Review of the hospital’s P&P titled Core: Quality of Care Issues Identified Internally released June 2023 showed the policy is to ensure the following: - The system allows data to be collected, reported, analyzed, and disseminated based on identified quality of care issues. - Identified quality of care issues include but are not limited to hospital key indicators (benchmark data). The hospital document for IC Plan Year: Year 2025 was reviewed on 3/5/26 at 1010 hours. The IC Plan Year: Year 2025 showed: * The purpose of the infection prevention program is to identify and reduce the risk of acquiring and transmitting infections among the patients, staff, physicians, LIPs ... .... It is maintained to provide a safe, sanitary, and comfortable environment that involves each department. The reduction of the risk and/or prevention of Healthcare Associated infections (HAI) are addressed through the utilization of established systems of collection, aggregation, analysis, presentation of facility specific data along with strategies to improve patient outcomes. The infection and control program use this information to seek opportunities for improvement; and then plans, implements. and evaluates control strategies. * The Summary of 2024 Data section showed Company 1 CLABSI goal was not met in 2024. The items identified as barriers for prevention of CLABSI included inconsistent central line dressing change practices with nursing staff especially dialysis line; physician discontinuing PICC lines when they no longer meet criteria, patient /family refuse PICC line to be removed; and high percentage of blood culture contamination rate. * The Prioritized Risk Per Annual Risk Assessment section showed CLABSI was the first priority. * The Summary Surveillance Plan section showed the Strategies to Mitigate Risk for CLABSI included a daily assessment of patients for necessity of CVC, downgrade or D/C when appropriate. On 3/5/26 at 1010 hours, during an interview, the IP reported that since 2024, the hospital has strengthened enforcement of its existing infection control program to reduce BSIs. Communication between the IP and hospital leadership has been facilitated through forms and text messages, enabling prompt action to ensure patient safety for inpatients. On 3/5/26 at 1504 hours, the Quarter 1, 2025 (January-March) Governing Board Report was reviewed with the DQM. The Quarter 1, 2025 (January-March) Governing Board Report showed the Executive Summary section showing “In addition to performance improvement activities regarding CLABSI and CAUTI, I watch has been fully implemented and showed effective results,” the nurse-driven protocol for Foley catheter discontinuation was being reinforced among nursing and medical staff, the hospital would continue engagement with medical staff that had high utilization rates. Additional efforts needed to be explored in removing Foley catheters. On 3/10/26 at 1426 hours, during an interview with the CCO/CNO, the CCO explained that the I WATCH project was launched in 2024 as part of BSI prevention efforts, initiated by the nursing staff. Daily, the House Supervisor (HS) collected information from bedside nurses, which was reported to nursing leadership, the IP, and the CEO. For patients who met criteria on the blood culture criteria Sheet, the team reviewed relevant medical records including central lines, catheters, antibiotic usage, and laboratory reports and engaged providers for follow-up actions as appropriate. Team reports and discussions were communicated via individual phone text messages. The CCO affirmed that I WATCH was approved by the Medical Executive Committee (MEC) and Governing Board (GB), and noted some provider feedback indicating disagreement regarding patient care decisions. In such cases, the team consulted with the Medical Director of Infection Control. On 3/11/26 at 1459 hours, during an interview regarding the I WATCH with the DQM, the DQM stated that she was invited to participate but was not actively involved in the initiative. The I WATCH team included hospital leadership, CEO, CCO, DON, HS as well as representatives from pharmacy, phlebotomy, wound care, hemodialysis services, providers, and consultants. Meetings were held three times per week, with frequency adjusted based on the number of patients requiring review. The team evaluated clinical conditions, fever, central line days, central line vacation, blood cultures, and antibiotic necessity. Both MEC and GB had approved the I WATCH. When asked about policies, procedures, or documentation evaluating the I WATCH, DQM indicated that none currently exist. Additionally, review of the Company 1 Resource Section -14 Infection Prevention document showed that the I WATCH program and Blood Culture Criteria Form were not listed among infection prevention forms, guidelines, procedures, or tools. The hospital delayed a physician ordered blood culture draw for Patient 10. Cross reference to A044, example # 2. During an interview on 3/6/26 at 1505 hours with the Medical Director of Infection Control, the Medical Director of Infection Control stated when a doctor was “pressing to do it (obtain blood cultures),” he tells them to do it (write the orders). The Medical Director of Infection Control was not aware as to what QAPI “is or isn’t doing” related to the blood culture criteria form use.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the infection preventionist was responsible for providing training and education of hospital personnel and staff, including medical staff as evidenced by: 1. The hospital failed to ensure the reference material was available as per the hospital’s P&P. 2. The hospital failed to promote communication of HAI relevant information between medical staff and nursing staff as per the hospital’s P&P. These failures created the potential of substandard care environment for their patients. Findings: 1. Review of the hospital’s P&P titled Core: Availability of Resource Materials released August 2022 showed this policy established guidelines to assure that all hospital personnel have access to a current copy of all policy and procedures manual, clinical and non-clinical reference materials. The policy is to ensure the following: * One copy of each clinical manual and reference materials will be accessible twenty-four (24) hours a day, seven days a week for clinical staff and leadership. * Provide policy and procedure manuals (e.g. Patient Care, Infection Prevention and Control) to serve as hospital division reference for clinical staff and leadership regarding division wide clinical policy, procedures, protocols and guidelines. * Resources include but are not limited to core Policy and Procedure Manuals, facility specific policies and addendums. * An original copy of the core policy and procedures manuals and reference materials shall be maintained in the facility’s administrative suite. * Core policy and procedure manuals are available electronically on the intranet system. * Each facility shall designate a responsible person to assure that all new policies, procedures and updates are placed in the respective policies and procedure manuals located in the nursing station. * At no time will policies and procedures to be unavailable to hospital staff. On 3/6/26 at 1125 hours, during an interview with the IP, it was noted that the NEM referenced acetaminophen administration for low-grade fever, as previously communicated to nursing staff during their huddle. On 3/10/26 at 1426 hours, during an interview with the CCO, the CCO stated that the IP had provided an article indicating that administering acetaminophen to patients with a fever of 99°F or higher can decrease mortality rates. This information was disseminated to the nursing staff through huddles. Nurses were instructed to request PRN acetaminophen orders for fevers of 99°F or greater. The CCO also provided a reference link for further review. On 3/12/26 at 1349 hours, during an interview, the NEM reported that on 11/11/25, Company 1 sent reference material to the CCO about administering PRN acetaminophen to patients with fever or temperatures of 99°F or higher to reduce mortality rates. The NEM clarified that the reference material was not accessible to clinical staff and leadership 24 hours a day, seven days a week as per the hospital’s P&P. 40483 2. Review of Company 1 Resource Title: Guideline-Infection Prevention and Control Program Plan dated December 2024 showed the Infection Prevention and Control Program is designed and implemented to identify and reduce the risk of acquiring and transmitting infections. It is maintained to provide a safe, sanitary and comfortable environment that involves each department. The Infection Prevention and Control Program includes processes to minimize healthcare associated infections through an organization-wide program. These processes include but are not limited to the: - Achieving an appropriate system of communication within the healthcare system to deliver information about infection prevention control and risks to patients, visitors and staff. - Plan includes promoting communication of HAI relevant information between healthcare providers. Review of Company 1 Resource Table of Contents Section - 14 Infection Control last updated August 2025 did not show a policy, procedure, form, guideline, tool or protocol listed for the Nursing Protocol (Tylenol 99 F) Review of the referenced website https://www.cdc.gov/nhsn/pdfs/pscmanual/pscmanual_current.pdf was also conducted. The website was shown to be a manual of over 450 pages. Review of the Medical Director of Infection Control Services Agreement showed the medical directors duties included: review of infection control policies and procedures; conduct in-service education for hospital personnel, including pertinent education regarding infection control procedures within the hospital. On 3/6/26 at 1011 hours, an interview was conducted with the IP. The IP verified she was not employed by the hospital but employed by third-party contract service to the hospital known as Vendor 1. The IP stated she was aware of the nursing protocol (Tylenol 99 degrees F). The IP stated the nursing protocol (Tylenol 99 F) was from their Corporate (Company 1) head IP who recommended using the lower fever threshold for administering acetaminophen (Tylenol). The IP was asked if the Corporate IP was available for interview regarding this new nursing protocol. The IP stated no and the Corporate IP she referenced had already retired and was unavailable for interview. The IP stated she had the information about nursing protocol (Tylenol 99 F). The IP stated the purpose of giving patients Tylenol for fevers greater than 99 degrees F was to reduce the incidence of CAUTI’s at the hospital. The IP stated the rationale for the implementation of this nursing protocol (Tylenol 99 F) instruction was to catch an infection early before the patient became septic. The IP stated the nursing staff was instructed to ask the ordering doctor for the parameters of administer with a temperature of greater 99 degrees F when acetaminophen (Tylenol) was ordered as a PRN (as needed) for the hospital patients. The IP was asked if any training, or documented rationale was provided to the nursing staff for this nursing protocol. The IP stated the training was conducted during nursing huddles. The IP was asked to provide a document or copy of the training provided during these nursing huddles. The IP stated there was no documentation of the training given to the nursing staff. The IP stated they did not document the training provided in huddles. The IP was asked if any desk reference material or access to online material was provided to the nursing staff (especially night shift) if they had concerns or questions. The IP stated the nurse staff had access to the document via the website its NHSN CDC website. The IP was asked if the hospital physicians were made aware of this nursing protocol. The IP stated the Corporate IP spoke with the hospital IP and not the Director of Infectious Disease in the hospital. The IP stated the CNO sent the article reference to the Director of Infectious Disease. The IP stated she had communicated with him regarding the nursing protocol. The IP stated it was his responsibility to inform and teach the physicians. On 3/6/26 at 1315 hours, an interview was conducted with RN 5. RN 5 stated she worked night shift and usually worked in the ICU. RN 5 stated on night shift, the ICU staff took telephone orders, especially at night. RN 5 stated she was aware of the Tylenol 99 F protocol being used at the hospital. RN 5 was asked what the nursing protocol was called and stated she did not know. RN 5 stated she was unaware of the name of the protocol. RN 5 stated it had not been provided to her by the CNO. RN 5 stated acetaminophen (Tylenol) was one of the more common prn medication orders they got from the physicians on her unit. RN 5 stated this hospital recently had a new protocol, for Tylenol. RN 5 wasn’t certain when it started, but thought it was a few months ago. RN 5 stated the new protocol was to tell physicians when they were ordering a PRN acetaminophen with an indication for fever, the hospital was used above 99 degrees F for fever, and can they add that parameter. RN 5 stated some doctors did not want it and preferred the previously used 100.4 degrees F. RN 5 stated the doctor must tell us no and what parameters to use or we used for the temperature greater than 99 degrees F. We were instructed to do this and follow up was done by our charge nurse or the supervisor. RN 5 stated she was told about the (Tylenol 99 F) nursing protocol in a huddle by the hospital CNO at the end of her shift. RN 5 defined this huddle as an informal meeting by the CNO, given to the nursing staff at the beginning of one shift and the end of the other, the overlap. It was done to get the information out to both day and night shifts. RN 5 stated she was not aware of any hospital’s policy for this protocol to look up information later. RN 5 could not recall the rationale provided by the CNO for the new instructions. RN 5 stated she was not aware if the new information or protocol had a name. RN 5 stated she was not given a reference or anything to read or refer to for additional or later questions, clarification or understanding the new hospital protocol regarding the medication acetaminophen (Tylenol) at the huddle. RN5 stated she was unaware of any paper or online resources for this protocol. RN 5 stated it was new information provided to them verbally by the CNO at the end of her night shift. RN 5 verified the nursing ICU staff were still asking for this parameter at the time of interview. RN 5 was asked if the CNO or any charge nurse/supervisor from her department had, since the huddle, provided them with any new or updated policies, procedures or rationale for the new protocol. RN 5 stated no. RN 5 also stated she had not been informed to stop doing this protocol. RN 5 stated every time they took an order of PRN Tylenol the house supervisor or charge nurse would remind them to get the Tylenol for 99 degrees F parameter and then the House Supervisor or Charge Nurse/Supervisor also followed up to see it was done. On 3/12/26 at 1000 hours, an interview was conducted with the Medical Director of Infection Control. The Medical Director of Infection Control verified he had a current contract with the hospital to provide these services. The Medical Director of Infection Control stated his role was advisory. The Medical Director of Infection Control stated the infection control meetings were led by the IP who provided information and things to approve. The Medical Director of Infection Control stated that infection control information was presented to him, and he was not asked for his input. The Medical Director of Infection Control stated he was now aware of the nursing protocol and was told about it by another physician. The Medical Director of Infection Control stated he was asked where the information came from, and was informed, it was a directive from the corporation. The Medical Director of Infection Control stated the CCO/CNO provided him with a reference for the nursing protocol and had educated the nursing staff to request from the physicians for the 99 degrees F parameter for Tylenol. The Medical Director of Infection Control stated he had little input with this nursing protocol. The Medical Director of Infection Control stated higher authorities at the corporate dictated this protocol; and the Medical Director’s voice did not carry that much weight.”

“ABX STEWARDSHIP LEADERSHIP TRAINING CFR(s): [The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 13095 Based on review of the hospital’s P&Ps, interview with the hospital’s corporate ASP Pharmacist, corporate DOP, and ID physician, the hospital failed to ensure that: 1. All of the hospital’s P&Ps and Company 1 guidelines had been followed and implemented. 2. The hospital’s Antibiotic Stewardship team also failed to provide competency-based training and education for all of the hospital’s medical staff, contracted staff, and pharmacy staff. These failures had the potential to result in less-than-optimal care for the patients in the hospital. Findings include: 1. Review of the hospital’s Antibiotic Stewardship (AS) policy, entitled: “Core: Antimicrobial Stewardship”, which had been dated 6/2023, read: “Purpose: This procedure establishes guidelines for antimicrobial stewardship. The mission of any Antimicrobial Stewardship Program (ASP) is to optimize clinical outcomes while minimizing unintended consequences ... of antimicrobial therapies. Therefore, Kindred ASP involves a multidisciplinary team that is comprised of a complementary group of health care personnel ...”. Additional review of this policy and procedure revealed under the procedure section: “1. The hospital will have in place an Antimicrobial Stewardship Team .....b. This team will meet routinely (at minimum monthly) to review select antimicrobial regimens for appropriate: i. Drug, ii. Dose, iii. Duration ...etc. During an interview with ID physician on 3/12/2026 at 1005 hours, ID physician stated that the hospital’s AS Committee only meets once a quarter and not monthly as outlined in the hospital’s P&P. During an interview with the hospital’s ASP pharmacist on 3/5/2026 at 1610 hours, the ASP pharmacist stated in regards to the hospital’s contracted laboratory, “the data from the laboratory is presented at the facility’s Antibiotic Stewardship Committee on a quarterly basis”, which confirmed/verified that the hospital’s Antibiotic Stewardship Committee, only meet on a quarterly basis and not on the monthly basis as outlined in the hospital’s P&Ps. Additional review of the same P&P above read: “2. A hospital antibiogram will be developed and presented to the Medical staff annually.” During a concurrent interview with ID physician on 3/12/2026 at 1005 hours, ID physician stated that he was not aware of a 2025 antibiogram being developed or presented to the hospital’s medical staff. During an earlier interview on 3/5/2026 at 1610 hours with the hospital’s corporate ASP Pharmacist and the corporate DOP, the corporate DOP indicated that the hospital did not have a current 2025 Antibiogram and that when the Antibiogram will be developed, it is shared with select “invited” physicians only. No one was able to tell the survey team, when the 2024 Antibiogram had been shared with medical staff, as the facility did not maintain any records of when it had last presented the 2024 Antibiogram with the hospital’s medical staff. Further review of the hospital’s P&P above read: “6. The antimicrobial stewardship team will support education for all clinicians.” Yet during an interview with ID physician on 3/12/2026 at 1005 hours, ID physician stated that he was not aware of the hospital’s Antibiotic Stewardship Committee as a whole, providing any educational training to all of the hospital’s clinicians (Nursing, Pharmacists, Medical Staff, contracted staff, etc.). Review of the hospital’s Company 1: “Guideline-Surveillance of Healthcare Associated Infection”, dated 6/2022, read: “13. The Infection Preventionist reviews the antibiogram report for any trends and a report ...The antibiogram is shared with the Medical Staff and Pharmacy committee to ensure appropriate antibiotic therapy is implemented”. Yet the hospital was unable to share/provide any evidence that the 2024 or the 2025 hospital antibiograms had been shared with either medical staff or the hospital’s Pharmacy Committee. 2. During an interview with ID physician on 3/12/2026 at 1005 hours, ID physician stated that he was not aware of anyone from the hospital’s AS Committee who had provided any type of Antimicrobial Stewardship competency-based training to any of the hospital’s medical staff, contracted staff, or to any of the hospital’s pharmacy staff. After the interview with ID physician, the hospital’s DOP, decided to provide two copies of a corporate pharmacy generated newsletter from the Kindred hospital system, which included the following facilities: La Mirada, Santa Ana, San Gabriel Valley, and Westminster, all of which would have very different antibiograms). Neither of the newsletters provided evidence of competency-based antimicrobial stewardship training. The documents were not specific to the location being surveyed, Westminster’s antimicrobial stewardship committee and these newsletters were not examples of competency-based education/training, which Westminster’s AS committee, was responsible for providing under this requirement.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care and services to two of nine sampled patients (Patients 1 and 7) as evidenced by: 1. For Patient 1: a. Failed to notify the physician when the patient was refusing BIPAP at night for 5 days. b. Failed to reassess the patient after a change in condition and failure to notify the physician of change in condition when Patient 1 had respiratory distress; and failed to monitor oxygen saturation while the patient was on oxygen therapy and BIPAP. 2. For Patient 7: a. Failure to perform wound care to Patient 7 as ordered by the physician. b. Failed to photograph Patient 7’s wounds within 48 hours of discharge as per the hospital’s P&P. These failures posed the increased risk of substandard health outcomes to the patient. Findings: 1. During a review of the hospital’s P&P titled, “Procedure-Non Invasive Positive Pressure Ventilation (NIPPV),” reviewed on 6/2023, the P&P showed the patients should also have a continuous pulse oximeter with appropriate alarm settings and functioning alarm to call system preferred. The P&P showed to set up the ventilator to the order setting and apply it to the patient adjusting for minimal leak and patient comfort. For BIPAP .... adjust the fraction of inspired oxygen (FIO2) as ordered, and set the initial expiratory positive airway pressure (EPAP) at 4 cm H2O or as ordered. Increase EPAP in 1-2 cm H2O increments (to a maximum of 8 cm H2O) to achieve a SPO2 of 92% or higher or as ordered. - Set the ventilator alarms appropriate for the patient’s current condition. These alarms alert the staff to potential life threatening event; make sure the alarms are turned on, functioning properly and audible to staff. - Assess patient’s vital signs and respiratory status, observing for chest expansion and auscultating for bilateral breath sounds, to ensure adequate ventilation. - Update care plan with preventive intervention. - Monitor patients as scheduled while patient is on the NIPPV unit. - Patients should have continuous pulse oxymetry with functioning alarm, connection to the nurses call system preferred. - Assess the pulse, respiratory rate, auscultate breath sounds, SPO2 (titrate to maintain SPO2 more than 92%), use of accessory muscles, restfulness or agitation. Documentation: Update care plan to address preventive interventions for risk of breakdown. Chart alternating of mask type or O2 delivery device in efforts to offload pressure on nose, cheeks or forehead. Cleaning: any shared patient care equipment is cleaned after each patient use according to manufacturer’s instructions During a review of hospital’s P&P titled, “Assessment and Reassessment,” release date 06/2023, the P&P showed the goal of the Assessment /Reassessment process is to provide an interdisciplinary approach for assessment and ongoing reassessment of individual patient care needs and for planning and implementing patient specific interventions. Coordination of care by sharing patient information internally and externally with other care givers. Nursing Department: A RN directs the nursing care of every patient through delegation and supervision to other nursing and non-nursing personnel. A collaborative assessment and individualized Patient Care Treatment Plan is discussed by the Interdisciplinary Care Transitions (ICT) during the patient Care Conference. The recommended ICT review of each patient will occur at least seven days of admission and no less than weekly there after during the interdisciplinary Patient Care Conference. Respiratory Therapist (RT): The RT will notify and discuss with the attending physician, those patients identified with high risk clinical indicators for difficult intubation or airway and a plan of care will be developed to include interventions to maintain airway patency. The initial assessment include HR, SPO2, FIO2, Communication airway devices, breathing pattern, RR, breath sounds. Patients receiving RT services are reassessed each shift and when there is a significant change in respiratory status or condition to determine response to treatment. Appropriate care plans will be entered based on diagnosis, assessment, symptomatology. Care plans will be updated as needed based on patient’s condition. During Patient 1’s record review on 1/6/26 at 0825 hours, Patient 1’s medical record showed Patient 1 was admitted on 6/27/25 at 2149 hours, with diagnoses of non-traumatic intracranial hemorrhage, for rehabilitation, and hypoxemic respiratory failure. During a review of the SBAR and Off Tool dated 6/27/25, the SBAR and Off Tool showed Patient 1 had history of CVA with left side droop, CABG, Afib, pneumonia and was on contact isolation for ESBL in the sputum. Patient 1 was alert, and oriented to person, place, time and events. Patient 1 was on BIPAP at night from 11 pm to 7 am with FIO2 25 %, IPAP 14, EPAP 8. a. During a review of the physician’s orders dated 6/28/25 at 0311 hours, the physician’s orders showed the telephone orders, entered by a RT, for Patient 1, as follows: - BiPAP: IPAP level 14, EPAP level 8, FIO2 25 % at night and as needed every 4 hours (0000, 0400, and 0800.... 2000 hours start on 06/28/25 at 0400 hours. - Oxygen therapy, nasal cannula flow rate 3 liters per minute to titrate for O2 saturation of 92% every shift. (1000 hours, 2200 hours) to start on 6/28/25 at 1000 hours stop after 90 days, renewable. - On 7/10/25 at 0152 hours, another order was entered in the EMAR by RT for Patient 1, showed oxygen therapy, type of device: BIPAP, FIO2 40% continuously titrate to maintain saturation of 92% every 4 hours (00, 04, 08, .... 20 hours) and to stop after 90 days, renewable. During a review of RTs care data for Patient 1, the care data showed the patient refused to wear the BIPAP on 7/3/25, 7/9/25, 7/10/25, 7/11/25, and 7/12/25, and there was no documentation to show the physician was notified or that the RN was aware of these refusals. The DQM confirmed the lack of documentation, and stated that an order dated 7/14/25 (after 5 times/days the patient refused the BIPAP) call the patient’s family member to talk to the patient if the patient continues to refuse the BIPAP at night. The DQM confirmed the lack of documentation and stated that an order dated 7/14/25 directed staff to call the patient’s family member to encourage compliance if the patient continued to refuse BIPAP at night, which occurred only after five prior refusals. b. During a concurrent interview and record review on 1/6/26 at 1507 hours, with the DQM and PT, Patient 1’s PT notes were reviewed. The PT notes dated 7/1/25, showed Patient 1 walked 100 feet with contact guard assistance during the initial evaluation. The PT notes dated 7/21/25 at 1209 hours, showed Patient 1 required maximum assistance, and the PT stated the patient had “definitely declined” compared to previous assessments and performance of activities. The DQM stated the physician was informed of the change in condition and ordered an MRI of the head. During a concurrent interview and record review on 1/6/26 at 1508 hours with the DQM, RN 1’s neurological assessment notes dated 7/21/25 were reviewed. The RN 1 assessments notes showed at 0727 hours, (documented at 1420 hours) Patient 1 had a GCS of 14, the patient obeyed commands, opened eyes spontaneously, and was confused for verbal response, but able to express ideas clearly, and easy to understand speech. At 1815 hours (documented at 2025 hours), the patient was lethargic following 45 minutes post-BIPAP removal, desaturated to 70% on 6 liters NC, and required RT intervention to resume BIPAP, after which saturation improved to 97% Patient 1 became alert and responsive, with HR 77 and saturation 99%. The patient’s family member was at the bedside and was notified the patient was not appropriate to eat at that time. The DQM did not provide documentation showing RN 1 completed a neurological reassessment of Patient 1 after the PT documented a decline in the patient’s condition. During a concurrent interview and record review on 1/8/26 at 1310 hours with RN 1, RN 1 stated she teamed up with an LVN and CNA for team nursing. RN 1 stated the RT was responsible for the BIPAP machine, but for nursing care, she or the RN was responsible for the patient on BIPAP. RN 1 did not provide documentation of reassessment of vital signs and O2 saturation when Patient 1 had a change in condition on 7/21/25. RN 1 stated the night shift nurse called the physician at 2020 hours. During a review of RN 1’s assessment dated 7/21/25 at 2000 hours (documented at 2333 hours), RN 1’s assessment showed Patient 1’s GCS was 8, opened eyes spontaneously, flexion to pain, and nonverbal. RN 1’s assessment showed at 2000 hours the patient’s family member called expressing concerns regarding lack of care and communication from physicians. The RN called the physician at 2020 hours and received orders. The family member arrived, requested transfer to another hospital, and spoke to the physician about concerns. RN 1’s assessment showed RN oversight of patient care signed every shift as leader of the care team, reviewed the impact of care on the patient, and concurred with the current plan. During a concurrent interview and review of the RT assessments on 1/8/26 at 2000 hours with the RT Manager, review of RT assessments showed Patient 1 refused BIPAP on 7/6, 7/9, 7/10, and 7/11/25 (only wore it for 15 minutes), and on 7/12 the patient requested BIPAP but removed it soon after. There was no documentation to show the nurses or the physician were notified of the patient’s refusing BIPAP. The RT Manager stated the expectation was for RTs to notify the physician and nurses, when a patient refused BIPAP and that nocturnal assessments included checking BIPAP and O2 saturation at least twice per shift, typically at 2300 and 0300 hours. The RT assessments dated 7/21/25 at 1451 hours, showed RT 2 received Patient 1 on 4 liters NC, responsive but somewhat confused, and the physician ordered ABG. After results, the patient was placed back on BIPAP (I/E 14/8, FIO2 35%) for four hours with O2 saturation 93-100% and no respiratory distress. At 1829 hours, the patient completed under four hours of BIPAP and was returned to 4 liters NC per physician request. RT 3 documented at 1855 hours that the patient was returned to BIPAP due to desaturation; however, there was no documentation of the O2 saturation level during desaturation, no documentation of the BIPAP settings when reapplied, and no documentation that the physician was notified of the change in condition and care. The findings were shared with DQM. 45560 2. On 4/13/16, the NPUAP defined the following: - A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. - Deep Tissue Pressure Injury is an injury to the skin and underlying soft tissue resulting from intense or prolonged pressure and shear forces. It is characterized by intact or non-intact skin with a persistent, non-blanchable discoloration (deep red, maroon, or purple) or a blood-filled blister. During a review of the hospital’s P&P titled, “CORE: Skin and Wound Care Program Overview,” dated 6/2023, the P&P showed documentation standards used to measure quality outcomes includes, reassessment of wound characteristics is completed with each dressing change; skin assessment/inspection at the time of admission and each shift. During Patient 7’s medical record review on 1/12/26 at 1015 hours, the medical record showed Patient 7 was admitted to the hospital on 10/6/25. During a review of Patient 7’s Pressure Injury Assessment dated 10/7/25, the Pressure Injury Assessment showed Patient 7 was admitted to the hospital with a deep tissue pressure injury to their sacrococcygeal area. During a review of Patient 7’s Weekly Wound Care note dated 10/7/25, the Weekly Wound Care note showed Patient 7 had an abrasion to their mid back. a. During a review of the physician order dated 10/9/25, the order showed wound care to the sacrococcyx, cleanse wound with normal saline (a wound cleansing solution) and pat dry, apply zinc paste (a medicated paste used to treat and prevent skin irritations) and cover with foam dressing 3 times a week (Tuesday, Thursday, and Saturday at 0900 hours). During a review of the physician order dated 10/9/25, the order showed for wound care to the mid back, apply skin prep and cover with foam dressings 3 times a week (Tuesday, Thursday and Saturday at 0900 hours). During a concurrent interview and record review on 1/12/26 at 1015 hours, with the Director of Wound Care, Patient 7’s wound care flowsheet dated 10/18/25 was reviewed. The wound care flowsheet showed wound care to Patient 7’s mid-back wound and sacrococcyx wound was not completed as ordered. The Director of Wound Care was also unable to locate documentation showing wound care was completed as ordered for Patient 7 on 10/18/25. During an interview on 1/12/26 at 1100 hours with the Director of Wound Care, the Director of Wound care acknowledged the above findings. b. During a review of the hospital’s P&P titled, “CORE: Photography of wounds for Non-ProTouch Facilities,” dated 6/2021, the P&P showed photographs should be retaken at a minimum as the wound(s) change(s), monthly, and within 48 hours prior to discharge. During a review of Patient 7’s physician orders dated 10/22/25, the order showed to transfer Patient 7 to Hospital A’s ER. During a concurrent interview and record review on 1/12/26 at 1015 hours, with the Director of Wound Care, the Director of Wound Care was unable to locate photographs of Patient 7’s sacrococcygeal wound taken within 48 hours of discharge. During an interview on 1/12/26 at 1100 hours, with the Director of Wound Care, the Director of Wound care acknowledged the above findings.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff developed a plan of care to address Patient 1’s CVA, atrial fibrillation, and diastolic heart failure for one of nine sampled patients (Patient 1). This failure had the potential to impact overall patient outcomes. Findings: During a medical record review on 1/6/26 at 0825 hours, the medical record showed Patient 1 was admitted to the hospital on 6/27/25 at 2149 hours, with diagnosis of non traumatic intracaranial hemorrhage. The reason for admission was for rehabilitation and hypoxemic respiratory failure. During a review of the SBAR and Off Tool dated 6/27/25, the SBAR and Off Tool showed Patient 1 had history of CVA with left side droop, CABG, Afib, pneumonia and was on contact isolation for ESBL in the sputum. The patient was alert, and oriented to person, place, time and events. Patient 1 was using BIPAP at night with FIO2 at 25 %, IPAP 14, EPAP 8 from 11 pm to 7 am. During a review of Patient 1’s H&P dated 6/27/25, the H&P showed Patient 1 had a past medical history of diastolic heart failure, CAD, s/p CABG, atrial fibrillation, presented to a hospital of generalized weakness, and was diagnosed with right middle cerebral artery stroke. The plan was to consult a cardiologist and for rehabilitation. During a review of Patient 1’s initial admission assessment dated 6/27/25 at 2348 hours, Patient 1’s initial admission assessment showed the patient was forgetful, extremity strength on the left arm and left hand grasp were moderate (decreased). Patient 1 was for physical therapy and occupational therapy screening, patient had upper extremity weakness or decrease coordination and bladder incontinence. Review of Patient 1’s Care Plan did not show plan of care to address the CVA, atrial fibrillation, and diastolic heart failure. The DQM was asked to show the plan of care for physical effects of CVA and address the cardiovascular problems of the patient. The DQM could not show care plan to address the CVA with left side weakness and cardiovascular problems of the patient.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review the hospital failed to ensure the nursing staff implemented the hospital’s P&P for two of nine sampled patients (Patients 1 and 3) as evidenced by: 1. The dialysis RN did not wear appropriate PPE during the dialysis procedure for Patient 3 according to the hospital’s PPE P&P. 2. EKG strips were missing from the medical record for Patient 1 on 7/21/25, as required by the hospital’s documentation policy. These failures increased the risk of substandard health outcomes for the affected patients. Findings: 1. During an observation on 1/7/26 at 1307 hours, on the Telemetry floor with the DQM, Patient 3 was receiving dialysis in Room B. Patient 3 was tracheostomized and connected to a ventilator. RN 3 was observed performing dialysis without wearing personal protective equipment (PPE). At 1432 hours, RN 3 was observed at the patient’s bedside without a PPE holding a gauge on the patient’s right upper arm and then placed a plastic clamp. RN 3 was asked if he needed to wear a PPE during dialysis. RN 3 stated the patient finished the dialysis and he was trying to stop the bleeding on the upper arm dialysis access. RN 3 was asked what PPE he should be wearing, RN 3 stated the patient was not on isolation, he would be wearing PPE only when the patient was on isolation. Review of Patient 3’s H&P dated 12/4/25 showed Patient 3 was admitted to the hospital on 12/4/25, with diagnosis of end stage renal disease and on hemodialysis. During an interview with the DQM on 1/7/26 at 1308 hours, the DQM stated the hospital used the dialysis company’s P&Ps. During a review of the hospital’s P&P title, “Dialysis,” effective date 6/2024, the P&P showed all dialysis nurses are required to wear a gown for the whole duration of the treatment. All hemodialysis nurses are required to wear goggles or face shields granulation of AVF or AVG as well as needle removal. Eye protection (goggles or face shields) should also be worn when the risk arises (such as manipulating blood lines or access device). All hemodialysis nurses are required to wear gloves when touching the machine, access sites and patient. Findings were shared with the DQM. 2. During a review of Patient 1’s EKG strips from 6/27/25 to 7/21/25 on 1/8/26 at 1510 hours, the EKG strip dated 7/21/25 was recorded at 0807 hours. However, there was no record of the EKG strips on 7/21/25 after 0807 hours and for the night shift. The DQM stated the Telemetry technician ran and recorded EKG strips, and the RN would interpret the initial strip and initial the rhythm strip once a shift. During a review of the hospital’s P&P titled, “Procedure - Continuous Cardiac Monitoring,” reviewed date 1/8/25, the P&P showed monitoring, recording, interpreting, and documenting cardiac rhythms: Cardiac rhythms will be recorded, interpreted, and documented on the initiation of telemetry monitoring with each nursing shift assessment and more frequently as indicated by the patient’s condition and or physician’s order. A qualified staff member competent in cardiac rhythm interpretation will interpret each strip and measure and record the rate, rhythm, PR interval, QRS width, and QT interval. A qualified and competent RN will validate the rhythm strip. Nursing personnel will notify the central monitoring station of any of a change in the patient’s condition necessitates the recording of cardiac activity. Print a strip for any patient who was transferred to a higher level of care and experienced a change in condition while on telemetry or whose death was not expected. Findings were shared with the DQM.”

“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: 37663 Based on observation, interview, and record review, the hospital failed to maintain an acceptable level of safety and quality in accordance with its P&Ps as evidenced by: 1. Failure to maintain the kitchen and cafeteria in sanitary condition; flooding and a sewer odor were present in the cafeteria where food was served to staff and the public. 2. Failure to ensure the work order for the dishwasher in the kitchen was completed in a timely manner. 3. Failure to maintain the kitchen wall in acceptable condition. 4. Failure to maintain the corridor between the dietary area and the loading dock door in a sanitary condition. 5. Two carts at the loading dock were full of black plastic trash bags. 6. The Environmental Services (EVS) room at the loading dock was not maintained in a clean and sanitary condition. 7. In Room A, the shower was tagged “Do not use, don’t drain.” These failures increased the risk of unsafe conditions and potential harm to patients. Findings: On 1/7/26 at 1200 hours, a tour of the hospital was conducted with the DQM and the Dietary Director. 1. The cafeteria where food was served had a collection of gray-colored water on the floor and a sewer odor. In the kitchen, at the cold food preparation area in front of the dietary office, gray-colored water was observed pooling. The Dietary Director stated the water came from the dietary office and was swept out. The water came out yesterday from underneath when it rained. Discolored gray and black tiles under the dishwashing area table and around the ice machine had white discoloration. The dietary office floor was observed to be wet with a warped baseboard and a rag on the floor. 2. The dishwashing machine was observed with handles tied together. The Dietary Director was asked about the dishwashing machine. The Dietary Director stated the dishwashing machine has been broken since 1/1/26. Review of the work order showed a dishwasher activity log dated 1/5/26 at 1028 hours. Record review and interview with the Facilities Manager and DQM was conducted on 1/8/26 and verified the dishwasher was reported on 1/2/26 during their meeting. However, the work order was submitted on 1/5/26. 3. The kitchen wall was observed to have uneven edges with brown and gray stains. The DQM stated the wall was repaired; however, the repair was not completed. 4. The corridor between the kitchen and the loading dock door (outside the hospital) had black stains on the floor. 5. Two carts were observed overflowing with black plastic garbage bags. The garbage dumpster was full to the brim. The Facilities Manager stated they were garbage bags to be placed in the main dumpster. The main dumpster pickup days were Wednesday and Saturday. 6. A small room at the loading dock had a yellow mop bin with a long metal rod. The floor was wet with a black powdery substance, and rusted metal was observed on the wall. The Facilities Manager stated the EVS had used the room. 7. During the tour at 2 West Unit on 1/7/26, at 1450 hours, Room A’s shower room was tagged “Do not use, don’t drain.” The DQM stated she spoke to the Facilities Manager about what needed to be fixed; the shower was spraying everywhere and needed a new showerhead. However, the work order was not provided. Findings were shared with the CEO and COO/CCO.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45560 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff implemented their P&Ps for the medication administration via injection for one of three sampled patients (Patient 1) as evidenced by: 1. The nursing staff did not change Patient 1’s IV bag after 24 hours as per the hospital’s P&P. 2. The nursing staff did not label Patient 1’s IV tubing as per the hospital’s P&P. These failures had the potential to increase the risk of substandard healthcare outcomes and safety to the patient. Findings: 1. Review of the hospital’s P&P titled CORE: Administration of Medications via Injection, release date June 2022 showed under procedure, the 7 “R’s” of administering medications will be followed with each medication administration: “Right” patient, “Right” medication, “Right” dose, “Right” time, “Right” route, “Right” reason, and “Right” documentation. On 6/10/25 at 0839 hours, a medication pass observation was conducted for Patient 1, with RN 3. During the observation, a 250 ml bag of NS (normal saline, a mixture of water and salt with a salt concentration of 0.9%) was observed infusing at a TKO rate for Patient 1. The label on the IV bag showed “EXPIRES 24 HRS AFTER HANG TIME”. The same label also showed that the bag was hung on 6/8/2025 at 2331 hours (approximately 33 hours from the initial hang time). On 6/10/25 at 0900 hours, an interview was conducted with RN 3. RN 3 acknowledged the bag of NS for Patient 1 should have been changed 24 hours after the initial hung. 2. Review of Lippincott Manual of Nursing Practice revised August 19, 2024, provided by the hospital, showed to change a primary intermittent administration set every 24 hours. The same document also showed to label the administration set at the proximal and distal end to prevent dangerous misconnections. On 6/10/25 at 0839 hours, during the same medication pass observation was conducted with RN 3. During the medication pass an observation was made, the IV tubing connected to the bag of NS running at a TKO rate was unlabeled. On 6/10/25 at 0900 hours, an interview was conducted with RN 3. RN 3 acknowledged there was no way to identify when the IV tubing for Patient 1’s was initiated and confirmed it should have been labeled. On 6/10/25 the Director of Quality Management was notified and acknowledged the above findings.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 37663 Based on an interview and record review, the hospital failed to ensure the hospital’s P&P for Transfusion Therapy was impertinent for one of the seven sampled patients (Patient 2) when Patient 2’s vital signs were not checked at 15 minutes after the start of the transfusion as per the hospital’s P&P. This failure created an increased risk of substandard health outcomes to the patient. Findings: Review of the hospital’s P&P titled Transfusion Therapy dated June 2023 showed the vital signs will be observed and documented at minimum at the following intervals or times: * Check pre -transfusion’s baseline vital signs immediately prior to initiation of transfusion. * Check the vital signs 15 minutes after the start of transfusion. * Thereafter, check the vital signs hourly until the transfusion is completed. * Check the vital signs 30 minutes after the transfusion is completed. * Immediately when a transfusion reaction is suspected or change in clinical condition occurs. On 1/8/25 at 0940 hours, an interview and concurrent review with Patient 2’s medical record was conducted with the Director of Quality Management. Review of Patient 2’s medical record showed Patient 2 was admitted to the hospital on 12/24/24. Review of the Blood/Blood Component Transfusion Record dated 12/30/24, showed the following: * Patient 2 received blood transfusion started at 1535 hours and ended at 1830 hours. * The Vital Signs section showed the patient’s vital signs were taken as follows: - At 1535 hours, the pre-transfusion’s vital signs showed the patient’s temperature was 98.7 degrees F, the patient’s pulse was 85 beats per minute, the patient’s BP was 106/66 mmHg, and the patient’s RR was 25 breaths per minute. - At 1615 hours (or 40 minutes after the start of the blood transfusion), the patient’s temperature was 98.6 degrees F, the patient’s pulse was 81 beats per minute, the patient’s BP was 110/60 mmHg, and the patient’s RR was 20 breaths per minute. The vital signs were taken at 40 minutes instead of 15 minutes after the start of the blood transfusion. - At 1700 hours, the patient’s temperature was 98.7 degrees F, the patient’s pulse was 83 beats per minute, the patient’s BP was 121/97 mmHg, and the patient’s RR was 21 breaths per minute. - At 1800 hours, the patient’s temperature was 98.6 degrees F, the patient’s pulse was 79 beats per minute, the patient’s BP was 146/79 mmHg, and the patient’s RR was 22 breaths per minute. - At 1830 hours, the patient’s temperature was 98.8 degrees F, the patient’s pulse was 70 beats per minute, the patient’s BP was 120/65 mmHg, and the patient’s RR was 20 breaths per minute. - At 1900 hours (or 30 minutes post transfusion), the patient’s temperature was 98.7 degrees F, the patient’s pulse was 72 beats per minute, the patient’s BP was 118/61 mmHg, and the patient’s RR was 19 breaths per minute. On 1/8/25 at 0940 hours, an interview was conducted with the Director of Quality Management. The Director of Quality Management was asked about the patient’s vital signs recorded for 15 minutes after the start of the blood transfusion. The Director of Quality Management verified the vital signs recorded at 1615 hours.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the type and location of the restraint was documented accurately for one of six sampled patients (Patient 1). This failure posed the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed the physical restraint devices include hand mittens or mitts; and soft limb restraints (wrist and ankle). On 11/13/24, Patient 1’s closed medical record was reviewed with the Director of Quality Management. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24. Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed on 3/2/24 at 2100 hours, a soft limb restraint was placed on Patient 1’s left hand. Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed on 3/6/24 at 0800 hours, a soft limb restraint was placed on Patient 1’s left wrist. Patient 1’s closed medical record showed Patient 1 was on restraint on 3/7/24, for 24 hours. On 11/13/24 at 1438 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the Assistant Administrator. When asked, the Assistant Administrator stated if a restraint was applied to the patient’s hand, the type of restraint should have been a mitten, not a soft limb restraint. On 11/13/24 at 1501 hours, an interview was conducted with the Director of Quality Management. When asked, the Director of Quality Management stated if the soft limb was used for restraint, the location of the restraint should have been the wrist. On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the monitoring and assessment were consistently performed as per the hospital’s P&P for two of six sampled patients (Patients 1 and 3). This failure posed the risk of substandard outcomes to the patients. Findings: Review of the hospital’s P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed to perform ongoing safety checks and monitoring (at least every two hours or as noted on the designated forms) by the patient’s clinical team of the patient’s response to the restraint, including any condition changes for non-violent behavior restraints. 1. On 11/13/24, Patient 1’s closed medical record was reviewed with the Director of Quality Management. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24. Review of Patient 1’s closed medical record showed Patient 1 was on restraint on 3/7/24, for 24 hours. Review of the safety checks and monitoring (Q2 hours) form dated 3/7/24, showed the following safety checks and monitoring were performed every two hours except at 1400 hours: * Range of motion offered/provided * Food/fluids offered/provided * Toileting offered/provided * Dignity/comfort/hygiene maintained * Managed safety/no injury * Mental status unchanged * Skin integrity unchanged * Temporary release during care (direct observation maintained) * Circulatory status of restrained extremities unchanged * Pain managed per policy 2. On 11/13/24 at 1000 hour, a tour of the Intensive Care Unit was conducted. Patient 3 was observed to be restrained with the soft two-points restraints on both wrists. On 11/13/24, Patient 3’s medical record was reviewed with the Director of Quality Management. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 10/21/24. Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed the soft limb restraints were applied to the patient’s left and right wrist on 11/11/24 at 0001 hours. Review of the safety checks and monitoring (Q2 hours) form dated 11/12/24, showed the safety checks and monitoring were performed during the restraints. However, the following was missing: * On 11/12/24 at 2000 hours, the section of Pain Managed per Policy was left blank. * On 11/12/24 at 2200 hours, the sections of Circulatory Status of Restrained Extremities Unchanged and Pain Managed per Policy were left blank. On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure RN 3 had been validated for competency for the restraint use as per the hospital’s P&P. This failure posed the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed upon hire and periodically as determined by the hospital’s hospital care and safety quality council, all staff having direct patient care responsibilities shall be trained on the restraint freedom program along with the proper and safe use of restraints and seclusion used in the hospital. This should include how to recognize and respond to signs of physiological or psychological distress. On 11/13/24, Patient 1’s closed medical record was reviewed with the Director of Quality Management. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24. Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed RN 3 applied soft limb restraints to Patient 1’s left hand on 3/2/24 at 2100 hours. Review of RN 3’s Self-Assessment for Restraints, showed RN 3 rated RN3’s proficiency as 4 (expert-serve as a resource) and Frequency as 4 (daily or weekly). When requested for RN 3’s validated competency for restraints other than the self-assessment, the hospital was not able to provide the requested document. On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff clarified with the physician about the use of BiPAP and metoprolol (a medication used to treat high blood pressure) PRN and failed to ensure the legibility of medical record for one of six sampled patients (Patient 6). These failures posed the risk of poor health outcomes for the patient. Findings: Review of the hospital’s P&P titled Physician’s Orders dated October 2022 showed if the medication or treatment is an “as-needed” or PRN, specify the condition for which the medication or treatment is to be used. Review of the hospital’s P&P titled Core: Corrections to the Medical Record dated June 2022 showed the purpose is to ensure a consistent and legal mechanism for maintaining the integrity of the medical record when corrections are necessary. The Procedure section showed making corrections to a Paper Medical Record as follows: * In black ink, draw a single line through the incorrect data. * Writes “error” above the incorrect data. * Write the correct data below the lined-out material. * Sign and date the correction. On 11/13/24 at 1239 hours, Patient 6’s closed medical record review was conducted with the Director of Quality Management. Patient 6’s closed medical record showed the patient was admitted to the hospital on 10/24/24. a. Review of the Physician Order form showed RN 3 wrote a telephone order for BiPAP, PRN for SOB only, RT was aware. The form showed the Telephone Order Read Back to the physician’s name and dated 11/8/24. The time section was blank. On 11/13/24 at 1239 hours, during an interview with RN 2, RN 2 was asked to review the order for when the patient would need this PRN treatment. RN 2 stated the SOB would be presented differently from patient to patient. It would depend on each patient’s medical history and/or clinical condition. It would include the oxygen level, the patient’s respiratory rate, and the patient’s clinical presentation. RN 2 stated based on this written order, the RN would need to clarify with the physician for the parameter or criteria to implement this PRN order for the patient. The Director of Quality Management stated there was no a documented evidence RN 3 clarified with the physician about the SOB. b. Review of the Physician Order form dated 11/9/24 at 0730 hours, showed the telephone order read back was hand-written as follows: * Hydralazine (a medication used to treat high blood pressure) which was lined-out. There was no the word of error or signature was written as per the hospital’s P&P. * Metoprolol 25 mg IVP, BID, PRN every six hours for HR greater than 120 bpm, SBP 150 mmHg. The number “5” of the 150 mmHg was overwritten by the number “1.” Review of the physician’s order dated 11/9/24 at 1519 hours, showed metoprolol, 25 mg IVP every six hours, prn, hold for HR below 60 bpm and for SBP less than 110 mmHg. On 11/13/24 at 1239 hours, an interview and concurrent record review was conducted with RN 2. RN 2 reviewed the physician’s order and stated there were two written orders which should be available for review in the EHR. RN 2 reviewed the EHR and stated there was no another order for metoprolol BID written in EHR. During a follow-up interview with the Director of Quality Management, the Director of Quality Management confirmed the parameter for the use of metoprolol PRN written in EHR was not consistently with the parameter for the use of metoprolol PRN hand-written on the Physician Order form. The Director of Quality Management could not locate document to show the physician was clarified about the discrepancy.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure Patient 5 or the patient’s family member received the Patient Guide to Blood Transfusion pamphlet before a blood transfusion. This failure could lead to violate the patient’s rights. Findings: On 11/13/24, Patient 5’s medical record was reviewed with the Director of Quality Management. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 10/18/24. Review of the Blood/Blood Component Transfusion Record dated 11/10/24, showed Patient 5 received blood transfusion started at 1000 hours and ended at 1315 hours. Review of the Informed Consent for Transfusion form showed a telephone consent was obtained from Patient 5’s family member on 11/10/24 at 0800 hours, for the blood transfusion. The form showed the physician signed on 11/10/24 at 1000 hours. However, the box of “I hereby certify that the patient has received a copy of the California Department of Health Care Services information pamphlet, A Patient’s Guide to Blood Transfusion. (CA only)” was unchecked. On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.”

“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: 22553 Based on record review and interview, the hospital failed to ensure the licensed nurse-to-patient ratios on the Medical/Surgical units were maintained during staffing meal breaks. This failure had the potential to contribute to inadequate patient supervision and unsafe patient care. Findings: Review of the hospital’s P&P titled CORE: Plan for the Provision of Patient Care dated June 2023 showed the leadership of the hospital recognizes its role in providing the framework for directing health care services that are responsive to patient needs and that result in positive patient care outcomes. The Chief Clinical Officer is responsible for ensuring the hospital’s plan for Provision of Care is complete and up-to-date. Review of the hospital’s P&P titled CORE: Patient Classification System dated June 2023 showed this policy is to ensure the nursing supervisor has the ultimate authority in determining final number of staff by skill mix needed for each shift. The Unit Summary Review section of the Screenings Review-Supervisor Responsibility showed this screen summarizes the staffing requirements for the next shift; a description of some of the major items on this screen includes the staffing needs based on KHAT screening results AND title 22 staffing ratio requirements. Review of the California Code of Regulations Title 22 - Social Security Division 5 - Licensing and Certification of Health Facilities, Chapter 1 General Acute Care Hospital Article 3 - Basic Services 70217 - Nursing Service Staff (a) (11) showed the licensed nurse-to-patient ratios in the medical/surgical care units shall be 1:5 or fewer at all times. On 10/29/24 at 1311 hours, an interview with concurrent review of the Kronos time reports dated 10/21/24 for 2 West-Med/Surg unit night shift (1900 hours - 0700 hours) was conducted with the Nursing Supervisor. The Kronos time report showed the staff meal break schedules were as follows: RN 1’s meal break: 02:11 - 02:42 hours RN 2’s meal break: 01:07 - 01:37 hours RN 3’s meal break: 01:40 - 02:10 hours LVN 1’s meal break: 01:08 - 01:38 hours LVN 2’s meal break: 01:39 - 02:13 hours On 10/24/24 at 1131 hours, an interview and concurrent review of the Daily Staffing Sheets was conducted with the Director of Quality Management. The Director of Quality Management reviewed the above time slots and confirmed the staffing was overlapping their meal breaks for RN 2 with LVN 1, and RN 3 with LVN 2. During these staffing meal breaks, the Nursing Supervisor was responsible for more than five patients and the staffing ratio of 1 licensed nurse to 5 patients was not maintained. On 10/29/24 at 1509 hours, during an interview with the Nursing Supervisor, the Nursing Supervisor confirmed the above meal breaks were provided to the staffing; and during staffing meal breaks, the Nursing Supervisor covered for the nurse’s patient assignments. On 10/29/24 at 1325 hours, the Chief Clinical Officer was interviewed regarding the out-of-ratio event on 10/21/24. The Chief Clinical Officer stated they were unaware of the event until they received from third party later. The Chief Clinical Officer acknowledged they were ultimately responsible for all the nursing services, including maintaining the nurse-to-patient ratio.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39796 Based on interview and record review, the hospital failed to ensure the nursing staff weighed one of four sampled patients (Patient 1) as per the physician’s order. This failure posed the potential for an increased risk of poor health outcomes to this patient. Findings: Review of the hospital’s P&P titled Core: Weight Measurement dated June 2021 showed the purpose of the policy is to establish guidelines for measuring weight. Weight is an anthropometric measurement used in conjunction with other information to calculate estimated energy, protein, and fluid needs, body mass index and the patients’ ideal/desired weight range. Weight change overtime is an indicator of nutritional status and fluid status. The policy includes to ensure proper measurement of patient weights scheduled within 24 hours of admission and weekly thereafter. Timing of weight assessment maybe individualized based on physician’s order, nutrition assessment, or interdisciplinary team recommendations. Review of Patient 1’s medical record was initiated on 10/10/24 at 0730 hours. Patient 1’s medical record showed the patient was admitted to the hospital on 2/12/24. Review of the RN Admission Assessment dated 2/12/24, showed the RN had assessed the patient’s weight. * Review of the physician’s order dated 5/27/24 at 0600 hours, showed an order to weigh the patient once a week (Mondays at 0600 hours) and stop after 90 days. Review of the RN notes showed Patient 1’s weights were taken on 6/3, 6/17, and 6/24/24. However, review of Patient 1’s weight flowsheets showed on 6/10/24, the patient’s weight was not taken due to the bed not being calibrated. Further review Patient 1’s weight flowsheets dated 7/1, 7/8, 7/15, and 7/29/24, showed the order was scheduled and not carried out. Review of Patient 1’s medical record failed to show documented evidence the patient’s weights were taken once a week as ordered by the physician. * Review of the physician’s order dated 7/16/24 at 0937 hours, showed an order to weigh once; the patient needed a new weight as there were no new weights for three weeks. However, review of Patient 1’s medical record failed to show documented evidence Patient 1’s weight was taken on 7/16/24, as ordered by the physician. * Review of the physician’s order dated 8/27/24 at 1459 hours, showed an order to weigh the patient once. Review of Patient 1’s weight flowsheet dated 8/27/24, showed the order was scheduled and not carrried out. On 10/11/24 at 1326 hours, an interview and concurrent medical record review was conducted with the Director of Quality Management. The Director of Quality Management was asked if there was a weight taken on 7/16/24, as ordered. The Director of Quality Management stated no, the weight was taken on 7/22/24 instead of 7/16/24. The Director of Quality Management was also asked if the weight was taken on the week of 8/27/24, as ordered. The Director of Quality Management stated no, the order was not followed. The Director of Quality Management was asked if the weekly weight was taken for the patient. The Director of Quality Management stated no. The Director of Quality Management was informed and acknowledged the findings. On 10/11/24 at 1540 hours, the findings were shared with the CEO, CCO, and Director of Quality Management.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff repositioned one of 13 sampled patients (Patient 13) every two hours as per the physician’s order. This failure created the risk of substandard health outcomes to the patient. Findings: Review of the hospital’s P&P titled Core: Clinical Guidelines for Pressure Injury dated June 2022 showed the following: * The standard interventions for all patients can include a positioning order (minimum Q2 hour turns). * The Documentation section showed to document the execution of order within the electronic medical record. On 9/6/24 at 1536 hours, an interview and concurrent review of Patient 13’s medical record was conducted with the Director of Quality Management and Director of Wound Care. Patient 13’s medical record showed Patient 13 admitted to the hospital on 6/24/24. Review of the physician’s order dated 6/24/24 at 2039 hours, showed to reposition the patient q2h. Review of the reposition document showed the following: * On 7/30/24 at 1844 hours, the patient’s position was supine. * On 7/30/24 at 2000 hours, the reposition was not done. * On 7/31/24 at 1817 hours, the patient was repositioned to supine. * On 7/31/24 at 2000 hours, the patient was repositioned to supine. * On 8/7/24 at 0654 hours, the patient was repositioned to left side. * On 8/7/24 at 0826 hours, the patient was repositioned to left side. * On 8/7/24 at 1800 hours, the patient was repositioned to supine. * On 8/7/24 at 2000 hours, the patient was repositioned to supine. * On 8/8/24 at 0810 hours, the patient was repositioned to left side * On 8/8/24 at 1000 hours to 1800 hours, the reposition was not done and the “execution remains on worklist, performed by other discipline.” * On 8/9/24 at 0010 hours, the patient was repositioned to left side. * On 8/9/24 at 0212 hours, the patient was repositioned to left side. * On 8/9/24 at 0626 hours, the patient was repositioned to left side. * On 8/09/24 at 0823 hours, the patient was repositioned to left side. During the concurrent interview, the Director of Quality Management stated there was no documented evidence for the patient’s repositioning to be performed by other discipline in the medical record. The Director of Quality Management confirmed the above findings.”