Kindred Hospital Brea

“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 observation, interview, and record reviews, the hospital failed to ensure patient received care in safe setting as evidenced by: 1. The hospital failed to ensure Physician 1 had sufficient required documented evidence for practice clinical privilege. In addition, the hospital did not have OPPE for the medical staff. 2. The hospital failed to implement the hospital’s P&Ps related to infection control prevention. a. Physician 1 did not have documented evidence of an annual influenza vaccine 2025. b. One staff (RT) did not appropriately wear a gown when providing care to a patient. 3. The hospital failed to show documented evidence of the incidents that were reported, investigated, reviewed for one of four sampled patients (Patient 1) 4. The hospital failed to ensure the H&P and the Controlled Substance/Sedative Infusion Flowsheets were accurate and completed as per the hospital’s P&P for one of four sampled patients (Patient 4). The failures create an unsafe environment for the inpatients. Findings : 1. Review of the hospital’s Rules and Regulations of the Medical Staff revised 8/2025 showed invasive procedures shall be performed only by members of the Medical Staff having clinical privileges in those areas. On 7/16/26 at 1007 hours, Patient 1’s closed medical record review was conducted with DON. Review of the Change of Condition dated 4/10/26, showed RN 2 documented the patient’s midline was pulled out on 4/10/26 at 0830 hours. Physician 1 was notified of that event. Review of the Progress Note dated 04/11/26, showed Physician 1 documented the patient’s midline was removed. The peripheral IV line in arms was infiltrating. The peripheral IV line in legs was present but inadequate for current medication regimen. Obtained patient consent for a central line placement, arranged for ultrasound- guided central line placement to restore vascular access. The patient was discussed with critical need for vascular access to administer life-threatening medications including antibiotics, antifungals, blood pressure medications, and nutritional support. Review of the Informed Consent for Surgical and Special Procedures showed Patient 1 signed an informed consent for central line placement by Physician 1 on 4/11/26 at 1102 hours. Review of the Physician Orders showed Physician 1’s telephone order on 4/11/26 at 1130 hours, to do a chest x-ray to verify Patient 1’s CVP line placement. Review of the Diagnostic Radiology dated 4/11/26, showed the chest x-ray was completed for the patient on 4/11/26 at 1130 hours. The chest x-ray results electronically signed by a radiologist showed “right central line pointing towards right internal jugular vein and adjustment suggested.” Review of the Physician 1’s Progress Note dated 4/12/26, showed a central line placement but mispositioned. The plan was for midline placement tomorrow (4/13/26) per the family’s preference to avoid more invasive procedure. Review of the Nurses Notes dated 4/12/26 at 1533 hours, showed the right subclavian, triple lumen central line was removed. On 7/16/26 1416 hours, Physician 1’s credential file was reviewed with AA/MSC and DQM. Physician 1’s credential file showed Physician 1’s clinical privileges were approved on 10/31/24, with a specific indication for “Insertion and management of central venous catheters-1 proctored case until requirement met.” On 7/16/26 at 1507 hours, AA/MSC and DQM were not able to provide documented evidence of Physician 1 had a proctored central venous catheter proctoring before performed central venous catheter insertion on Patient 1 as the medical staff clinical privilege required. The DQM confirmed they did not have one in the building per Medical Staff Rules. The DQM further stated the hospital required OPPE for all medical staff members and they just started recently. 2. a. Review of the Resource Titled: Procedure- Healthcare Workers Immunizations dated 3/2026 showed all employees, physicians, licensed independent practitioners (LIPs), and contractors are required to provide annual immunizations documentation. All healthcare workers need to provide documentation they received or declined the influenza vaccine if they worked in the facility at least one day during flu session. On 7/15/26 at 1055 hours, review of Patient 1’s closed medical record was conducted with the DON. The patient’s medical record showed Physician 1 delivered medical services to Patient 1 on 2/11/26 and 4/11/26. On 7/16/26 at 1416 hours, Physician 1’s credential file was reviewed with the AA/MSC and the DQM. During the concurrent review, the DQM was unable to locate documentation within the hospital pertaining to Physician 1’s 2025 annual influenza vaccine. Consequently, the DQM contacted Physician 1’s office to request the relevant records. It was reported that the hospital did not have evidence indicating whether Physician 1 received or declined the influenza vaccine in 2025 as required by hospital’s P&P. b. Review of the Resource Titled: Procedure -Donning and Doffing Personal Protective Equipment, dated 6/2022, showed gowns to be donned and wrap around the back. On 7/15/26 at 0837 hours, Patient 3’s room was toured and observed for patient care with the DQM and DON. It was observed one staff who wore scrub was standing next to the patient and providing the breathing treatment to the patient. The patient was identified as being on contact precaution. The staff donned a protective gown but not wrap around the back as per the hospital’s P&P. The DON confirmed the findings and stated that the staff was a respiratory therapist. 3. Review of the hospital’s P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated 6/2023, showed that the patient information will be documented on the hospital’s Handoff Communication Tool or within the designated pathway in the EMR ( Electronic Medical Record). The patient information may include patient’s condition, care, treatment, services, and any recent or anticipated changes to any of these. The RN is accountable for the care outcomes of his/her patients. As clinical decision- maker and care coordinator, the RN oversees the direct care activities of other nursing staff and health professionals. To help manage this responsibility, the RN must effectively communicate the plan to meet the needs of the patient. This may be done via huddle that promotes situational awareness, touch points with clinical team members to identify changes that need to be addressed. Review of the Resource Titled: Procedure -Event Reporting dated 4/2025 showed that hospital personnel are responsible for reporting in a timely and efficient manner, patient, visitor, unsafe conditions through the Event Reporting System. The procedures are * Take any necessary steps to ensure the patient’s safety, * Staff members that witness or identify an event must notify their supervisor as soon as possible, but no later than the end of the shift worked. * Events should be entered into the ERS system at the time of event, but no later than 24 hours after it occurs or is discovered. * The aggregated results of events, including trends, patterns, and corrective actions taken is response to events will be reported at Patient Safety and Reliability Committee and forwarded to Quality Council, MEC (Medical Executive Committee), and Governing Board Committees. Review of Patient 1’s closed medical record with DON was conducted on 7/15/26 at 1055 hours. Review of the History and Physical dated 2/11/26, showed Patient 1 had acute and chronic respiratory failure. The patient required ongoing mechanical ventilation support via tracheostomy and was diagnosed with bronchiectasis. Additional diagnoses included severe protein-calorie malnutrition with failure to thrive, and pneumonia. a. The hospital failed to ensure a registry RN (RN 4) documented or reported an incident of accidentally pulling out a midline for Patient 1 on 3/21/26. Cross reference to A 398. b. Review of Change of Condition dated 4/10/26, showed during RN 2’s rounding the patient at 0730 hours, the patient’s midline was assessed to be intact with IV fluid infusion. RN 6 (the wound Care RN) completed their treatment and informed RN 2 at 0830 hours that the patient’s midline was out. The wound care orientee RNs stated they did not notice that until after wound care was completed and stated they did not pull it out. RN 2 documented the patient was alerted and wrote on her cell phone that it was the wound care team assistant pulled out the line. The House Supervisor was notified regarding the event, and RN 6 notified about further investigation findings with supervisor and RN 2. Physician 1 also notified regarding the event. On 7/16/26 1007 hours, an interview was conducted with RN 2, RN 2 confirmed her notes and reported the event to the House Supervisor. The House Supervisor conducted an interview for both RN 2 and RN 6, but RN 2 did not get any feedback from the House Supervisor. A follow-up interview was conducted with the DON on 7/16/26 at 1507 hours, the DON could not be able to locate an incident report in the system by the House Supervisor for 4/10/26 incident. The DON further confirmed no documented evidence of the interview, incident review, investigation for this second time that the midline was pulled out. c. Review of the Other Change of Condition showed RN 3 documented an accidental removal of the G tube on 4/26/26 at 0145 hours. The physician was notified of the incident, ordered intravenous fluids, and inserted a Foley catheter into the G tube site to prevent closure of abdominal opening, and “MD to be notified later” during working hours. Review of the Change of Condition dated 4/26/26 at 1701 hours, showed day shift RN documented the physician’s insertion of a new 18 French G tube with a 20 mL balloon. A KUB X-ray using gastrografin (an iodine-based contrast agent that enhances X-ray clarity for diagnostic purposes) was performed to verify the placement of the new G tube. On 7/16/26 at 1149 hours, CNA 1 was interviewed regarding the G tube removal incident that occurred on 4/26/26. CNA 1 recalled that the event took place while repositioning the patient. She stated that the G tube slipped out, with the balloon still inflated at the time of removal. CNA 1 promptly reported the incident to the attending RN and House Supervisor. She could not recall being interviewed by the supervisor about the incident. CNA 1 affirmed her understanding of the importance of maintaining lines and the need to be vigilant with them. On 7/16/26 at 1507 hours, the DON confirmed there was no documented evidence of an incident report in the system for 4/26/26 Patient 1’s G tube accident removal nor a supervisor investigation of this incident. CNA 1’s competency review showed competency for repositioning patients of artificial airway but nothing for patients with G tube. On 7/16/26 at 1507 hours, during interview with the DON, the DON stated there was no documented evidence for reporting Patient 1’s care incidents in their reports. Those would be discussed in their huddle meeting and were not documented. The DON stated if there was no report, then would not be investigated, analysis for improvement and prevent future events from recurrence. 4. a. Review of the Resource Titled: Procedure - Corrections to the Medical Record dated 4/2025 showed to making corrections to a Paper Medical Record: * In black ink, draw a single line through the incorrect data * Write “error” above the incorrect data * Write the correct data below the lined-out material * Sign, date and time the correction On 7/15/26 at 1526 hours, Patient 4’s medical record review was conducted with Director of Pharmacy and RN 1. They confirmed the following corrections were not follow the hospital P&P. * Three pages of the Controlled Substance/Sedative Infusion Flowsheet used for documenting the medication “Dexmedetomidine,” (a sedative medication) pertaining to the dates 7/14/26 had their original date entries changed from “15” to “14”; specifically, the number “5” was overwritten with a “4.” - The Controlled Substance/Sedative Infusion Flowsheet for 7/14/26 at 0220 hours, showed the RASS value “0” was recorded over the previously documented “-1.” - The Controlled Substance/Sedative Infusion Flowsheet beginning at 0420 hours on 7/14/26, showed it was noted that at 0620 hours, the infused amount was amended from “8” to “9.” * Review of the Controlled Substance/Sedative Infusion Flowsheet for documenting the medication “Propofol” (a sedative medication) administration titration from 7/14/26 at 0830 to 7/15/26 at 0800 hours, showed the following: - The Controlled Substance/Sedative Infusion Flowsheet showed an entry at 0245 hours on 7/15/26. The infusion rate and the infusion amount showed a corrective data were entered, a line crossed the old data with an initial, but no word of “error” noted. - The Controlled Substance/Sedative Infusion Flowsheet showed an entry on 7/15/26 at 0445 hours. The time “0445” was amended to obscure an illegible numeral. b. Review of the hospital’s P&P titled Core: Propofol (Diprivan) Continuous Infusion (Outside of Procedure/Surgery Area) dated 6/2022, showed in the physician progress notes, the prescribing physician must include indication for use, expected outcome, and estimated duration of therapy. On 7/15/26 at 0917 hours, the ICU was toured by the DQM and DON. Patient 4 observed receiving a propofol infusion and under the care of RN 1, who reported that the patient had been admitted two days prior. Initially, the patient was administered dexmedetomidine via IV drip; however, this medication was discontinued due to lack of efficacy. On 7/14/26, the sedation order was updated to administer propofol to the patient. Review of Patient 4’s medical record was conducted with the DQM on 7/16/26 at 1336 hours. Patient 4’s medical record showed the patient was admitted to the hospital on 7/13/26. Review of the History and Physical electrically signed by Physician 2 on 7/14/26 at 2323 hours, showed the “DATE OF ADMISSION: 5/13/2026... DATE OF SERVICES: 5/14/2026....He on Precedex ... He not tracking ... equipment for in his head.” Review of the Progress Note dated 7/15/26, showed Physician 2 had examined Patient 4 at the bedside and the patient was on Precedex (or dexmedetomidine). However, review of the physician’s orders showed Precedex was discontinued on 7/14/26 at 1026 hours, and the propofol was ordered to administer to the patient on 7/14/26 at 0730 hours. The Progress Notes did not include the required document related to the use of propofol as per the hospital’s P&P. The DQM confirmed that these entries contained typographical errors and did not accurately represent the patient’s clinical condition.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the nursing supervisor’s specific leadership responsibilities for patient care plan. The failure creates an unsafe patient care environment. Findings: On 7/15/26 at 1055 hours, during an interview with the DON, the DON verified that that Patient 1 experienced several incidents requiring reporting, including: removal of a midline on 3/21/26 by a registry RN, removal of a second midline on 4/10/26, and dislodgement of the G tube by a CNA while repositioning on 4/26/26. These events should have been reported as incidents for investigation and review. However, the DON noted there was no documented evidence in the hospital’s incident reports. The DON stated that the assigned House Supervisor was responsible for incident reporting and investigation. Events occurring during a shift were discussed in staff huddles but were not formally documented. On 7/15/26 at 1315 hours, an interview was conducted with the resource nurse, RN 5 regarding the incident on 3/21/26. It was confirmed that such incidents should be reported to the shift House Supervisor. On 7/16/26 at 1007 hours, RN 2 was interviewed for 4/10/26 incident of pulling out the midline pull out. RN 2 stated she reported to the shift House Supervisor, was waiting for the investigation result. On 7/16/26 at 1149 hours, CNA 1 was interviewed regarding the G tube dislodgement incident that occurred on 4/26/26. CNA 1 stated that the House Supervisor on duty was informed of the event. She did not recall any subsequent follow-up communication concerning the matter. On 7/16/26 at 1507 hours, review of shift assignments was conducted with the DON regarding Patient 1’s incident dates, including 3/21/26 day shift, 4/10/26 day shift, and 4/25/26 night shift. The shift assignments showed that different House Supervisors were assigned on each occasion. The DON was requested to provide documentation regarding the House Supervisor responsibilities related to incident reporting. The DON provided the printed job description from the corporate site and clarified that the Nursing Supervisor’s role did not include specific responsibilities related to incident reporting management. Review of the Charge Nurse job description showed responsibilities such as supervising nursing staff, assessing patient needs, and providing nursing care. The DON stated that, in the current clinical environment, the House Supervisor assumed broader duties beyond nursing responsibilities. Furthermore, the DON confirmed that the hospital did not have documentation outlining responsibilities relevant to the House Supervisor role.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff reviewed, revised, or updated individualized care plan for one of four sampled patients (Patient 1). This failure could lead to lack of knowledge in providing care and delivery improper care to the patient. Findings: Review of the hospital’s P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated 6/2023, showed patients are re-evaluated by a licensed nurses (RN, LPN/LVN- according to state specific practice acts) at a minimum every 12 hours shift-based on level of care and patient care needs. An RN directs the nursing care of every patient thought delegation and supervision to other nursing and non-nursing personnel. The goal of the assessment reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implementing patient specific interventions. The assessments and data collection performed by the licensed healthcare professionals will include and address: data analysis to develop a plan of care to meet the patient’s care or treatment needs. On 7/15/26 at 1055 hours, Patient 1’s closed medical record was reviewed with the DON. Review of the Nurses Notes showed on 3/21/26 at 1929 hours, RN 5 reported that the patient’s midline catheter was inadvertently removed by the primary nurse (RN 4). Review of Change of Condition dated 4/10/26, showed RN 2 noted for a midline was pulled out on 4/10/26 at 0830 hours. The wound care assistant pulled out the line. Review of the Other Change of Condition showed RN 3 documented an accidental removal of the G tube on 4/26/26 at 0145 hours. Review of the Plan of Care showed a care plan dated 04/01/26, addressing the risk of injury. The intended outcome was for the patient to remain free of injuries as measured by not pulling out lines or tubes. On 7/16/26 at 1507 hours, the DQM was requested to provide Patient 1’s care plans as documented in the electronic medical record. Upon accessing the EMR, the DQM indicated that Patient 1 had been discharged; therefore, the closed medical record was not available for review of the care plan. During a subsequent interview with the DON, the DON stated having reviewed the complete medical record for Patient 1. The DON confirmed that there was no documented evidence of an individualized, updated, or revised plan of care addressing Patient 1’s needs following the incidents.”

“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: 22553 Based on interview and record review, the hospital failed to ensure competency evaluation including repositioning patients with G tube for one CNA (CNA 1). This created the risk of an unsafe patient care environment. Findings: On 7/15/26 at 1017 hours, a closed medical record review for Patient 1 was conducted with the DON. Review of the Other Change of Condition showed RN 3 documented an accidental removal of the G tube on 4/26/26 at 0145 hours. Review of the Nurses Notes showed that CNA 1 had repositioned Patient 1 from side to side every two hours on 4/26/26 at 0044, 0202, and 0402 hours. During an interview with CNA 1 on 7/16/26 at 1149 hours, CNA 1 stated that Patient 1’s G tube was initially covered with a dressing but became dislodged when CNA 1 turned the patient to one side, resulting in the entire tube slipping out, including the inflated balloon at the end of the tube. CNA 1 acknowledged being instructed on the importance of maintaining awareness regarding lines. On 7/16/26 at 1507 hours, the DON reviewed CNA 1’s competency evaluation for patient repositioning for the year 2025. The evaluation included competencies for general patient repositioning and for patients with artificial airways, but there was no competency assessment specific to patients with G tubes. The DON noted that such competency should be included.”

“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 a registry RN (RN 4) documented or reported an incident of accidently pulling out a midline for one of four sampled patients (Patient 1). There was no documented evidence that the director of nursing service provided for the adequate supervision and evaluation of this registry service to ensure the nursing service provided in a safe manner to the patient. These failures created the increased risk of poor health outcomes to the patients. Findings: Review of the hospital’s P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated 6/2023 showed that the patient information will be documented on the hospital’s Handoff Communication Tool or within the designated pathway in the EMR (Handoff Communication Tool or Discharge Pathway). The patient information may include patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. The RN is accountable for the care outcomes of his/her patients. As clinical decision-maker and care coordinator, the RN oversees the direct care activities of other nursing staff and health professionals. To help manage this responsibility, the RN must effectively communicate the plan to meet the needs of the patient. This may be done via huddle that promotes situational awareness, touch points with clinical team members to identify changes that need to be addressed. Review of the Resource Titled: Procedure -Event Reporting dated 4/2025 showed that hospital personnel are responsible for reporting in a timely and efficient manner, patient, visitor, unsafe conditions through the Event Reporting System. The procedures are * Take any necessary steps to ensure the patient’s safety, * Staff members that witness or identify an event must notify their supervisor as soon as possible, but no later than the end of the shift worked. * Events should be entered into the ERS system at the time of event, but no later than 24 hours after it occurs or is discovered. * The aggregated results of events, including trends, patterns, and corrective actions taken is response to events will be reported at Patient Safety and Reliability Committee and forwarded to Quality Council, MEC (Medical Executive Committee), and Governing Board Committees. Review of Patient 1’s closed medical record with DON was conducted on 7/15/26 at 1055 hours. Review of the History and Physical dated 2/11/26, showed Patient 1 had acute and chronic respiratory failure. The patient required ongoing mechanical ventilation support via tracheostomy and was diagnosed with bronchiectasis. Additional diagnoses included severe protein-calorie malnutrition with failure to thrive, and pneumonia. Review of the Bedside Procedure (specify) showed on 3/10/26 at 1619 hours, a RUA midline placement was inserted for Patient 1. Review of the Nurses Notes showed on 3/21/26 at 1929 hours, RN 5 (the resource nurse) entered a comment showing the right upper arm 5 FR midline that was “accidently pulled out per Primary nurse.” The midline was a 15 cm, double lumen IV. The DON could not locate documented evidence showing the primary RN (RN 4) documented in the patient’s medical record regarding pulling off the midline catheter. On 7/15/26 at 1315 hours, RN 5 was interviewed regarding the incident that occurred on 3/21/26. RN 5 reviewed her documentation from the data in question and stated that RN 4 had requested assistance with starting a peripheral IV for the patient due to the need for multiple medications and difficulty obtaining IV access. RN 5 stated that RN 4 accidentally pulled out the midline catheter but did not specify the exact time or circumstances of the event. RN 5 stated she asked RN 4 about reporting the incident, and RN 4 replied affirmatively. RN 5 did not follow up further on the incident report, as she believed it was the responsibility of the primary RN to submit it. On that day, RN 5 was assigned as a resource nurse, providing support as needed and covering staff during their breaks. RN 5 indicated that it would be the House Supervisor’s responsibility to ensure the incident was properly documented and investigated if appropriate. On 7/15/26 at 1055 hours, during an interview with the DON, the DON stated that patient line removal was classified as incidents and should be reported within the hospital system. However, the DON was unable to locate an incident report related to this event occurred on 3/21/26. On 7/16/26 at 0936 hours, the DON confirmed that there was no documented evidence of an incident report, investigation, review, or analysis regarding Patient 1’s midline removal on 3/21/26, and the registry company for RN 4 was not informed about the incident.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on interview and record, the hospital failed to ensure the Controlled Substance /Sedative Infusion Flowsheet for propofol were not documented as per the hospital’s P&P for one of four sampled patients (Patient 4). The failure creates an unsafe patient care environment. Findings: Review of the hospital’s P&P titled Core: Propofol (Diprivan) Continuous Infusion (Outside the Procedure/Surgery Area) dated 06/2022, showed vital signs should be monitored and documented every 15 minutes during active dose titration. Once sedation goals are met, continue to monitor vital signs and sedation level every 15 minutes for one hour and at least two hours when propofol is infusing but not being titrated. On 7/15/26 at 0917 hours, the ICU was toured with DQM and DON. Patient 4 was observed with propofol infusing. RN 1 was the attending RN for Patient 4. RN 1 provided and reviewed Patient 4’s Controlled Substance/Sedative Infusion Flowsheet that showed the following: * Two signatures required for container change and at shift change. * Assess and document vital signs of at least every 15 minutes during active titration and for an hour after, then every two hours. Further review of Patient 4’s Controlled Substance/Sedative Infusion Flowsheet showed * On 7/14/26 at 0820 hours and 7/15/26 at 0715 hours, there was no documented evidence of the second registered nurse’s signature at the shift change as required by the protocol. * On 7/14/26 at 0845 hours, the propofol was infused to the patient with rate of 20 mcg/kg/min. At 0900 hours, the propofol dose was increased to 25 mcg/kg/min. The vital signs were monitored and documented every 15 minutes from 0915 to 1000 hours, or at 0915 , 0930, 0945, 1000 hours. The next vital signs were assessed and documented at 1200 hours. There was no documented evidence the vital signs were assessed and documented the “one hour” vital signs per the hospital’s P&P. On 7/15/26 at 1526 hours, an interview was conducted with RN 1 regarding the documentation practices for the Controlled Substance/Sedative Infusion Flowsheets. RN 1confirmed the previously identified issues related to documentation accuracy and adherence to hospital’s P&P. RN 1 acknowledged that the flowsheets lacked required signatures for the shift changes and vital signs were not consistently documented as per the hospital’s P&P.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff supervised and evaluated the nursing care for one of four sampled patients (Patient 1) as evidenced by: * The nursing staff did not obtain and document Patient 1’s vital signs from 10/16/26 at 2000 hours to 10/17/26 at 0304 hours. * The nursing staff did not monitor and document Patient 1’s ECG from 10/16/25 at 1601 hours to 10/17/26 at 0304 hours. Patient 1 coded on 10/17/25 at 0304 hours, was transferred to ICU, and no ECG trips were obtained and kept in medical record. These failures had the potential to negatively impact Patient 1’s well-being. Findings: Review of the hospital’s P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated June 2023 showed: * Nursing Department: - Patients are re-evaluated by a licensed nurse (RN, LPN/LVN - according to state specific practice acts) at a minimum every 12 hours shift-based on level of care and patient care needs. - Patient reassessment is based on but not limited to the following: to evaluate patient response to care, treatment, and services; to respond to a significant change in status and/or diagnosis or condition. - All nursing assessments/reassessments are recorded in the patient medical record by a licensed nurse. - Physician orders for routine vital signs will be interpreted by nursing personnel as follows: Telemetry patient: every four hours; routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment. * Respiratory Therapy - The respiratory therapist will notify and discuss with the attending physician, those patients identified with high-risk clinical indicators for difficult intubation/airway and a plan of care will be developed to include interventions to maintain airway patency. Review of the hospital’s P&P titled Continuous Cardiac Monitoring dated 9/2/24, showed patient that do not meet the following criteria will be discontinued from cardiac monitoring: - Patient with dysrhythmias receiving frequent adjustments in anti-arrhythmia medications. - Active ischemic heart disease/ unstable cardiac disease/acute coronary syndromes. - Patient with hypotension, respiratory failure, or impeding respiratory failure. On 6/17/26 at 1341 hours, a concurrent interview and closed record review for Patient 1 was initiated with the COO and the Director of Quality Management. Medical record review for Patient 1 showed the patient was admitted to the hospital on 9/23/25 and was discharged on 10/17/25. Review of the physician’s History and Physical dated 9/24/25 at 1611 hours, showed Patient 1 was previously admitted to an acute care hospital for respiratory failure with acute systolic heart failure. Patient 1 had a cholecystostomy tube placed for acute cholecystitis. Then, Patient 1 was transferred to acute long-term care for further rehabilitation. Review of the physician’s order dated 9/23/26, showed to admit to the hospital as inpatient, telemetry unit. Review of the physician’s order dated 9/23/25, showed the order for telemetry cardiac monitoring, starting on 9/23/25 and “stop after 72 hours, renewable.” The stop date/time was 9/26/25 at 1558 hours. Review of the physician’s order dated 10/8/25 at 1759 hours, showed the order for BIPAP with an IPAP level of 14, EPAP level of 5, respiratory rate of 14, and a FiO2 of 50%, starting on 10/8/25 at 1900 hours at night and as needed. Review of the physician’s Progress Note date 10/10/25 at 2119 hours, showed Patient 1 had an altered level of consciousness encephalopathy, severe cardiomyopathy, left ventricular ejection fraction at 25%, atrial fibrillation, acute hypoxic respiratory failure, status post recent intubation, extubated on 9/7/25 secondary to heart failure and pneumonia, and severe anemia. The plan included telemetry monitoring during hospitalization. Review of the VS Flowsheet from 10/11 to 10/17/25 showed the following: - On 10/11/25 at 0400 hours, Patient 1’s VS were left blank; at 2000 hours, Patient 1 had a pulse of 80 bpm, a respiratory rate of 20 breaths per minute, the temperature and BP (blood pressure) were left blank. - On 10/15/25 at 0000 and 0800 hours and on 10/16/25 at 0000 hours, Patient 1’s VS were left blank. - On 10/16/25 at 2000 hours, Patient 1 had an oral temperature of 97.2°F, a pulse of 88 bpm, a respiratory rate of 20 breaths per minute, and a BP of 121/66 mmHg. - On 10/17/25 at 0000 hours, Patient 1’s VS was left blank. Review of Patient 1’s rhythm strips dated 10/16/25 at 1601 hours, showed Patient 1 had atrial fibrillation with heart rate of 104 bpm. Review of the Reposition dated 10/16/25 at 2333 hours, showed Patient 1 was repositioned to the left side at 10/16/25 at 2200 hours. Review of the Nurse Notes dated 10/17/25 at 0341 hours, showed at 0312 hours, Patient 1 was repositioned in bed, when the patient turned blue, a rapid response was called. When Patient 1 lost their pulse, code blue was initiated until 0328 hours. Review of the Change of Condition dated 10/17/25 at 0459 hours, showed Patient 1 had a cardiac arrest, code blue was initiated, Patient 1 was intubated and transferred to ICU. There was no documentation showing Patient 1’s rhythm strip was continued to monitor and document after 10/16/25 at 1601 hours. There was no documentation showing the vital signs documented after 10/16/25 at 2000 hours until Patient 1 coded on 10/17/25 at 0304 hours. Review of the RT notes dated 10/17/25 at 0512 hours, showed the code blue was on 10/17/25 at 0304 hours. Patient 1 was intubated at 0328 hours. Patient 1 had been non-compliant and was refusing BIPAP during the shift. Further review of the medical record showed there was no documentation showing the RT informed the physician Patient 1 refused BIPAP during the night shift. Review of the Discharge Summary dated 10/17/25 at 2056 hours, showed Patient 1 had bradycardia and hypoxia last evening. The patient was intubated for airway protection, and was transferred to an acute care hospital for further treatment. On 6/18/26 at 0935 hours, an observation of the Cardiac Monitoring station and interview was conducted with the Director of Clinical Services and the Monitor Technician. The Monitor Technician stated she monitored ICU and Med Telemetry patients. The EKG strips were printed out once per shift for Med Tele unit. The ICU nurses monitored their patients and printed their own strips. On 6/18/26 at 1405 hours, an interview and medical record review was conducted with the Director of Clinical Services. The Director of Clinical Services confirmed that vital signs were not documented starting on 10/16/26 at 2000 hours, and the rhythm strips were not documented from 1601 hours on 10/16/25 until Patient 1 coded on 10/17/26 at 0304 hours . The CNA last checked on the patient at 10/16/25 at 2200 hours. The medical record did not include documentation of the rhythm trips during code blue or while Patient 1 was in the ICU. On 6/18/26 at 1451 hours, an interview was conducted with the Director of Quality Management. The Director of Quality Management confirmed the physician’s order for telemetry monitoring was not renewed after the stop date/time was on 9/26/25 at 1558 hours. The Director of Quality Management acknowledged that the order for telemetry monitoring should be reviewed or renewed for Patient 1. On 6/22/26 at 0900 hours, an interview was conducted with RN 1. RN 1 stated he did not recall Patient 1. RN 1 stated the CNA checked and documented vital signs in the patient’s medical record and provided a paper copy for nurses to review. If vital signs were abnormal, the RN rechecked the vital signs, notified the physician, informed the family, and documented the change. RN 1 stated the CNA might give him the VS paper, but did not document it in patient’s medical record. RN 1 also stated the Monitor Technician usually gave ECG rhythms to RN for review, but RN 1could not recall if the patient’s ECG was missing. On 6/30/26 at 1515 hours, the COO acknowledged the RT did not notify the physician about Patient 1’s refusal of BIPAP on the night shift of 10/17/25. The COO acknowledged there was no ECG documented during the code for Patient 1.”

“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: 38660 Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 1) plan of care was developed and updated to reflect the patient care and condition during their hospitalization as evidenced by: * A care plan related to blood transfusion was not developed for Patient 1 who received a blood transfusion. * Patient 1 fell three times, and the nursing staff did not update the fall care plan. * The care plan was not developed to address and prevent Patient from removing the midline and cholecystostomy tube. These failures created a risk of not providing the necessary care and services to meet the patient’s needs. Findings: Review of the hospital’s P&P titled Interdisciplinary Assessment and Re-Assessment dated June 2023 showed patients are re-evaluated by a licensed nurse (RN, LPN/LVN - according to state specific practice acts) at a minimum every 12 hours shift-based on level of care and patient care needs. An LPN/LVN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurses, RN and/or LVN may update the patient’s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse. On 6/17/26 at 1341 hours, a concurrent interview and closed record review for Patient 1 was initiated with the COO and the Director of Quality Management. Medical record review for Patient 1 showed the patient was admitted to the hospital on 9/23/25 and was discharged on 10/17/25. * Review of the physician’s order dated 10/13/25 at 0906 hours, showed the physician’s order for one unit of packed red blood cells for the hemoglobin of 6.0 g/dL. Review of the Blood/ Blood Component Transfusion Record dated 10/13/25, showed the blood transfusion was started at 1625 hours and ended at 2025 hours. Review of the physician’s order dated 10/14/25 at 1447 hours, showed the physician’s order for one unit of packed red blood cells for Patient 1. Review of the Blood/ Blood Component Transfusion Record dated 10/14/25, showed the blood transfusion was started at 1630 hours and ended at 2008 hours. Patient 1’s medical record failed to show a nursing care plan had been developed to address the blood transfusion. * Review of the Change of Condition (CoC) dated 10/1/25 at 0651 hours, showed Patient 1’s cholecystostomy tube was found out on 09/30/25 at 1935 hours. * Review of the CoC dated 10/2/25 at 0434 hours, showed Patient 1 pulled out his midline on 10/2/25 at 0405 hours. Review of the CoC dated 10/15/25 at 0752 hours, showed Patient 1 pulled out his midline on 10/15/25 at 0600 hours. * Review of the Fall risk screening dated 10/8/25 at 1631 hours, showed Patient 1 had a fall during this stay and was at high risk for falls. Review of the CoC dated 10/8/25 at 1633 hours, showed Patient 1 was found on the floor, alert, oriented with period of confusion. Patient 1 advised to remain in bed and use call light for assistance. Patient was put back to bed, activating the bed alarm, placing floor mats, conducting frequent visual checks, and provided needs as required. Review of the CoC dated 10/13/25 at 0158 hours, showed Patient 1 was found lying on the floor next to the left side of bed. Review of the CoC dated 10/16/25 at 1902 hours, showed Patient 1 was found on the floor with knees down and arms over the bed. On 6/18/26 at 1451 hours, an interview and concurrent medical record with the Director of Quality Management. Director of Quality Management verified the patient care plan was not updated after Patient 1 fell on 10/8, 10/13, and 10/16/2025. The patient care plans had not been developed to address and prevent the patient from removing the midline and cholecystostomy tube.”

“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: 38660 Based on observation, interview, and record review, the hospital failed to ensure the hospital’s P&Ps were implemented as evidenced by: 1. The nursing staff failed to notify family member for one of four sampled patients (Patient 2) when Patient 2 was moved to Room 503B on 6/11/26. 2. The Monitor Technician set the heart rate alarm at 50-125 bpm without obtaining a physician’s order or following the hospital’s P&P. 3. The hospital failed to respond to family grievance for one of four sampled patients (Patient 1) as per the hospital’s P&P. These failures created the risk of poor health outcomes and unsafe conditions for patients receiving services in the hospital. Findings: 1. Review of the hospital’s P&P titled Assessment and Re-Assessment dated June 2023 showed patient and family specific education to assist with informed decision-making regarding care. Coordination of care by sharing patient information internally and externally with other caregivers. On 6/17/26, medical record review for Patient 2 showed the patient was admitted to the hospital on 3/4/26. Review of the physician’s Progress Note date 3/15/26, showed Patient 2’s was alert and tracking, but not following commands. On 6/17/26 at 0900 hours, a concurrent interview and record review for Patient 2 was conducted with the Director of Quality Management. Review of the Encounter data for Patient 2 showed Patient 2 was moved from room 501 A to Room 503 B on 6/11/26. There was no document evidence showing Patient 2’s family member was not notified. The Director of Quality Management confirmed the above findings. 2. Review of the hospital’s P&P titled Procedure - Continuous Cardiac Monitoring dated January 2026 showed: * Alarm on the telemetry monitor will always be maintained in the “ON” position. Exceptions to this include: - Physician orders for terminal weaning - Physician orders for withdrawal of life support. * Alarm parameters can only be changed or disabled per the physician’s order. - Registered Nurse/designee can implement the change in alarm parameters and/or disable the alarms. * Cardiac monitoring: - Is ordered by a physician. - Once initiated, will have qualified staff to maintain visual surveillance of monitors 24 hours a day. As a result, clinical changes related to cardiac monitoring, including rhythm changes and alarms, are identified and communicated consistently and promptly. On 6/18/26 at 0935 hours, an observation of the Cardiac Monitoring station and interview was conducted with the Director of Clinical Services and the Monitor Technician. Two patients’ ECGs showed the heart rates above 110 bpm with alarms disabled. The Monitor Technician stated she monitored ICU and Med Tele patients, setting the heart rate alarms at 50-125 bpm for all patients unless a specific setting rate was ordered by physician. The Director of Clinical Services confirmed the alarm parameter were set at 50-125 bpm. On 6/18/26 at 1522 hours, an interview was conducted with the COO. The COO verified the hospital’s P&P do not include any alarm settings for heart rates ranging from 50 to 125 bpm. 3. Review of the hospital’s P&P titled Patient Complaints and Grievances dated 4/23/26, showed facility will make all reasonable attempts to resolve Grievances and provide a written response to the patient or authorized representative within seven (7) days or receiving the Grievance, using the Grievance letter template. Once the Grievance letter has been provided to the patient, then the facility may consider the Grievance close. If the patient or authorized representative remains dissatisfied with the response, the complaint is repeated, requests to file a formal grievance, or the issue requires further investigation, it will be handled as a grievance. Facility will thereafter communicate directly with the patient or authorized representative regarding the Grievance. On 6/17/26, medical record review for Patient 1 showed the patient was admitted to the hospital on 9/23/25 and was discharged on 10/17/25. On 6/17/26 at 1443 hours, a concurrent interview and record review for Patient 1 was initiated with the COO, the Director of Quality Management and the Director of Case Management. The Director of Case Management stated Family Member 1 emailed a grievance on 10/23/25, she replied to the family member, and forwarded the grievance to the former Director of Quality Management for review. On 6/18/26 at 1027 hours, a concurrent interview and review of the grievance was conducted with the COO. The COO stated the former Director of Quality Management had mailed a letter to the family member after completing the investigation on 11/24/25. When the COO received a similar grievance on 3/11/26, she forwarded it to both the Corporate Risk Management staff and the former Director of Quality Management. The Corporate Risk Management staff believed the letter had already been sent on 11/24/26 and so they did not respond to the family.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 40597 Based on observation, record review, and interview, the facility failed to maintain the building services. This was evidenced by the failure to provide approval for the temporary installation of the chiller unit. This could result in a malfunction of the building’s cooling system during an emergency. This affected 43 of 43 patients in seven of seven smoke compartments. NFPA 101 - Life Safety Code, 2012 Edition 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 National Electrical Code, 2011 Edition 110.2 Approval. The conductors and equipment required or permitted by this Code shall be accepted only if approved. Findings: During a tour of the facility, record review, and interview with the Building Engineer, Director of Quality, and Facility Manager on 6/4/26, the emergency chiller was observed, and records were reviewed. At 9:41 a.m., the facility failed to provide a building permit for the temporary chiller that was installed on a wheeled platform outside next an emergency generator. The Trane chiller model RTAA-80 was a packaged unit with two compressors. The chiller was tied into by the main electrical switch gear that was identified as CH1- 225 amperes. During a concurrent interview, the Building Engineer stated that the temporary chiller was rented when the existing unit failed. The failure date was unknown. At 11:29 a.m., the Facility Manager stated that the California Department of Health Care and Access Information (HCAI) representative would return in two weeks to check the status of the existing chiller. There was no field visit report from HCAI available for review. During a concurrent interview, the Facility Manager stated that he did not obtain an emergency authorization from the HCAI representative.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 40597 Based on observation, record review, and interview, the facility failed to maintain the heating, ventilation, and air conditioning (HVAC) system. This was evidenced by the failure to provide acceptance testing for the installation of a temporary chiller unit, by missing a repair report of the compressor assembly, and by incomplete periodic maintenance records. This could increase the risk of fire in the HVAC system during an emergency. This affected 43 of 43 patients in seven of seven smoke compartments. NFPA 101, Life Safety Code, 2012 Edition 19.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ’ s specifications, unless otherwise modified by 19.5.2.2. 9.2 Heating, Ventilating, and Air-Conditioning. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems, Edition 2012 7.1 General 7.1.1* An acceptance test shall be performed to determine that the protective measures required in this standard function when needed in order to restrict the spread of fire and smoke. 7.1.2 Records shall be maintained on acceptance test results. 7.1.2.1 Record shall be available for inspection. 7.3 Controls and Operations Systems. 7.3.4 The test shall be performed to determine that the system operates under the standby power or emergency operations mode conditions as well as under conditions. Findings: During a tour of the facility, record review, and interview with the Building Engineer, Director of Quality, and Facility Manager on 6/4/26, the HVAC system was observed, and records were reviewed. 1. At 9:41 a.m., the facility failed to provide acceptance testing of the temporary chiller. The chiller packaged unit was sitting on a wheeled platform and located outside next to an emergency generator. The chiller, Trane model RTAA, was an 80 ton unit that was intended to provide cool temperatures in the building’s HVAC system. During a concurrent interview, the Building Engineer stated that the vendor installed the chiller and they would have the installation records. At 12:55 p.m., there was no acceptance testing for the temporary chiller available for review. During a concurrent interview, the Facility Manager stated that they plan to reconnect the existing chiller to the building next week. The temporary unit will be returned. 2. At 11:35 a.m., the facility failed to provide a repair report of the compressor assembly. A document titled, “Service Report” indicated that the technician removed the failed compressor and replaced it on 5/27/26. However, the compressor had not been tested. The technician notes indicated that temporary chiller unit had to be disconnected by TEM in order to verify the operation of the new compressor. During a concurrent interview, the Facility Manager confirmed the finding. 3. At 12:57 p.m., the facility failed to perform maintenance as required by the manufacturer’s published instructions. The user manual titled, “Installation Operations Maintenance Model RTAA-80” indicated that periodic maintenance was required weekly, monthly, and annually. The monthly records provided were incomplete. The inspection check box was not marked for completion in the month of March and May 2026. During a concurrent interview, the Facility Manager stated that even though the box was not check-marked, it did not mean that the inspection was not done.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure that nursing staff evaluated the care of two of four sampled patients (Patients 3 and 4) as evidenced by: 1. The nursing staff did not assess or address Patient 4’s long fingernails and toenails. 2. The nursing staff did not obtain and document Patient 3’s vital signs immediately prior to initiating the blood transfusion as required by the hospital’s P&P. These failures had the potential to result in unsafe care for the patient. Findings: 1. On 5/26/26, Patient 4’s open medical record was reviewed. Patient 4’s medical record showed Patient 3 was admitted to the hospital on 4/13/26. On 5/26/26 at 1330 hours, during an observation conducted with RN 1 in the presence of the RN Educator, Patient 4’s nails were noted to be overgrown. RN 1 was asked to measure the patient’s fingernails and toenails. The patient’s left 4th fingernail measured 0.6 cm from the fingertip to the edge of the nail. The patient’s left 4th toenail measured 0.45 cm from the toe to the edge of the nail. When asked, RN 1 stated that a “specialist” would provide nail care. Further review of the medical record failed to show any documentation of a referral, assessment, or follow-up related to nail care. On 5/27/26 at 0811 hours, during interview with the DON, the DON stated that nursing staff were not allowed to cut a patient’s nails. A physician’s order and family consent would be required for nail cutting, and in some cases, family would cut a patient’s nails. 2. Review of the hospital’s P&P titled Transfusion Therapy dated 06/23, showed: VS will be observed and documented at minimum at the following intervals/times: a. Pre-transfusion baseline VS immediately prior to initiation of transfusion b. Check VS 15 minutes after start of transfusion c. Thereafter, check VS hourly until the transfusion is complete d. Check VS 30 minutes after transfusion is complete e. Immediately when a transfusion reaction is suspected or change in clinical condition occurs. On 5/26/26, Patient 3’s medical record was reviewed and showed the patient was admitted to the hospital on 5/14/26. Review of the Physician’s Order dated 5/24/26 at 1235 hour and 1713 hours, showed to transfuse one unit of PRBC, total two units. Review of the Blood/Blood Component Transfusion Record dated 5/24/26, showed the blood transfusion was initiated at 1630 hours and ended at 1900 hours. However, the pre-transfusion baseline VS were documented at 1600 hours, which was not immediately prior to initiation of the transfusion as required by the hospital’s P&P. Review of the Blood/Blood Component Transfusion Record dated 5/24/26, showed the blood transfusion was initiated at 2315 hours on 5/24/26 and ended at 0215 hours on 5/25/26. The pre-transfusion baseline VS for this transfusion were documented at 2245 hours, which was not immediately prior to initiation of the transfusion as required. On 5/27/26 at 0900 hours, the COO, DON, and Director of Quality Management 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: 35310 Based on interview and record review, the hospital failed to ensure that nursing staff developed a care plan addressing the blood transfusion for one of four sampled patients (Patient 3). This failure posed a risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and compromised patient safety during the blood transfusion process. Findings: Review of the hospital’s P&P titled Interdisciplinary Assessment and Re-Assessment dated June 2023 showed the clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurses, RN and/or LVN may update the patient’s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse. Review of Patient 3’s medical record on 5/26/26 showed the patient was admitted to the hospital on 5/14/26. Review of the Physician Orders dated 5/24/26 at 1235 and 1713 hours, showed to transfuse one unit of packed red blood cells. Review of the Blood/Blood Component Transfusion Record dated 5/24/26, showed the blood transfusion was initiated at 1630 hours and ended at 1900 hours due to a Hgb level of 5.4 g/dL (the standard reference range for adult men is 13.5 to 17.5 g/dL). Review of the Blood/Blood Component Transfusion Record dated 5/24/26, showed the blood transfusion was initiated at 2315 hours on 5/24/26 and ended at 0215 hours on 5/25/26. However, further review of the medical record failed to show that a plan of care addressing the blood transfusion was initiated for Patient 3. On 5/27/26 at 0900 hours, the COO, DON, and Director of Quality Management acknowledged the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the medication was administered as per the physician’s order for one of four sampled patients (Patient 3). This failure created the risk of medication errors and poor health outcomes to the patient. Findings: Review of Patient 3’s medical record on 5/26/26, showed the patient was admitted to the hospital on 5/14/26. On 5/26/26 at 1325 hours, Patient 3 was observed receiving Levophed (a medication used to increase blood pressure) IV at 14 mcg/min. Review of the Physician’s Order dated 5/25/26 at 0843 hours, showed to titrate Levophed to keep SBP greater than 100 mmHg by 1 mcg/min every one minute, May stop when MAP >65 mmHg or per MD order. Review of the Vasoactive Infusion Flowsheet dated 5/26/26, showed once hemodynamic goal(s) were met, vital signs will be documented every 15 minutes for one hour. The Flowsheet also showed following: * At 0700 hours, BP was 119/63 mmHg and MAP was 81 mmHg. Levophed was infusing at 14 mcg/min. * At 0800 hours, BP was 146/83 mmHg and MAP was 104 mmHg. Levophed was infusing at 14 mcg/min. * At 0900 hours, BP was 131/50 mmHg and MAP was 77 mmHg. Levophed was infusing at 14 mcg/min. * At 1000 hours, BP was 138/39 mmHg and MAP was 72 mmHg. Levophed was infusing at 14 mcg/min. * At 1100 hours, BP was 109/57 mmHg and MAP was 74 mmHg. Levophed was infusing at 14 mcg/min. * At 1200 hours, BP was 132/60 mmHg and MAP was 84 mmHg. Levophed was infusing at 14 mcg/min. * At 1300 hours, BP was 147/78 mmHg and MAP was 101 mmHg. Levophed was infusing at 14 mcg/min. * At 1400 hours, BP was 125/52 mmHg and MAP was 76 mmHg. Levophed was infusing at 14 mcg/min. However, further review of the medical record failed to show justification for not titrating down the Levophed infusion when the patient’s blood pressure and MAP exceeded the ordered goal (SBP >100 mm Hg). On 5/27/26 at 0900 hours, the COO, DON, and Director of Quality Management acknowledged the above findings.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the transfer options to a higher level of care were discussed and documented for one of four sampled patients (Patient 1). This failure created a risk that the discharge plan and the results of the evaluation were not fully communicated or understood. Findings: On 5/26/26, Patient 1’s medical record was reviewed and showed the patient was admitted to the hospital on 4/5/26 and was discharged on 4/30/26. Review of the Progress Note dated 4/29/26, showed on 4/28/26, Patient 1’s family member stated Patient 1’s family would like Patient 1 transferred to a higher level of care. The family was informed that the Case Manager would need to coordinate and arrange the transfer to the receiving hospital. Review of the Treatment Team Communication, Communication: DC planning dated 4/29/26 at 1012 hours, showed Patient 1’s family member preferred to have the patient transferred to another hospital, possibly for tertiary care. NP 1 was aware of the family’s preferences. Review of the Treatment Team Communication, Communication: DC planning dated 4/30/26 at 1417 hours, showed Patient 1’s family was willing to take Patient 1 home that day AMA. On 5/26/26 at 1012 hours, a concurrent interview and record review was conducted with the Case Manager. When asked, the Case Manager stated that they remembered discussing the transfer options, the goals of transferring to a higher level of care, and the transfer process. When asked, the Case Manager stated they did not document the encounter with Patient 1’s family member. On 5/27/26 at 0900 hours, the COO, DON, and Director of Quality Management acknowledged the above findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure two of five sampled patients (Patients 1 and 2), or their representatives, were provided with the information necessary to make informed decisions regarding their care. These failures had the potential to limit the patients’ ability to make informed decisions about their treatment. Findings: Review of the hospital’s P&P titled “Patient Rights and Responsibilities” dated 6/2022 showed, the list of Patient Rights and Responsibilities is provided to each patient at admission as part of the admission packet. The Patient Rights and Responsibilities showed the patient has the right to participate in the development and implementation of their plan of care and to make informed decisions involving their health care, including managing pain effectively. This right includes the following: -Receiving information about the illness, the course of treatment, and prospects for recovery in terms that the patient can understand. -Receiving as much information about any proposed treatment or procedure as the patient may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate courses of treatment or nontreatment and the risks involved in each and to know the name of the person who will carry out the procedure or treatment. -Actively participate in decisions regarding medical care. To the extent permitted by law, this includes the right to refuse treatment. Review of the hospital’s P&P titled “Assessment and Re-Assessment” dated 6/2023 showed an acute change of condition is defined as a clinically important change from a patient’s established and documented baseline in physical, cognitive, behavioral, or functional domains. Under the section titled “Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition,” the policy states the nurse assigned to the patient, or supervising the patient’s care, is responsible for notifying and communicating with the patient’s primary physician or designees through appropriate channels and the established chain of command to ensure physician response. The policy further requires staff to notify the Nursing Supervisor of any change in the patient’s condition. It also specifies that additional personnel, including the Nurse Manager, Chief Clinical Officer, or Director of Respiratory, are notified as appropriate and in accordance with facility designation, which includes notifying the patient’s family or significant other. 1a. On 5/14/26 at 1256 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated they had not been notified of significant changes in Patient 1’s condition, including the positive Candida auris result, and learned of these updates only after Patient 1 was transferred, when the receiving facility provided the information. On 5/15/26 at 1049 hours, a concurrent interview and record review for Patient 1 was initiated with the Director of Nursing and Clinical Services. Medical record review for Patient 1 showed the patient was admitted to the hospital on 2/18/26. Review of Patient 1’s laboratory results showed a specimen collected on 2/26/26, tested positive for Candida auris, with the result reported on 2/27/26 at 1306 hours. Review of Patient 1’s medical record failed to show documented evidence that the physician and Patient 1’s responsible party were notified that the patient tested positive for Candida auris. Review of the infectious disease provider’s progress note dated 2/28/26, showed laboratory results were reviewed, including a reference to a prior Candida auris test dated 2/18/26, that was negative; however, there was no mention of the positive Candida auris test result reported on 2/27/26. On 5/15/26, during the concurrent interview and record review for Patient 1, the Director of Nursing and Clinical Services verified the findings and stated the nurses should have notified both the physician and the patient’s responsible party of changes in condition, including the positive Candida auris test result. b. Review of the infectious disease provider’s progress note dated 2/28/26, showed Patient 1 had fevers for the past two days secondary to aspiration versus urinary tract infection versus dysregulation after brain bleed. Patient 1 was empirically started on antibiotics for the fevers. Review of Patient 1’s Change of Condition progress note dated 2/26/26 at 1919 hours, showed the patient had a fever. However, review of Patient 1’s medical record failed to show documentation that the patient’s responsible party was notified of the patient’s change in condition. On 5/15/26, during the concurrent interview and record review for Patient 1, the Director of Nursing and Clinical Services verified the findings. 2. Review of the hospital’s P&P titled “Physical Restraints (Violent and Non-Violent Behavior) and Seclusion” dated 6/2023 showed hand mittens or mitts, whether tied down or not, are considered restraints. Staff will notify the patient’s legal representative as soon as possible after the restraint is applied and document the discussion in the patient’s medical record. On 5/15/26 at 0948 hours, Patient 2 was observed lying in bed with bilateral hand mittens in place. On 5/15/26 at 1358 hours, a concurrent interview and record review for Patient 2 was initiated with the Director of Nursing and Clinical Services. Medical record review for Patient 2 showed the patient was admitted to the hospital on 5/12/26. Review of Patient 2’s Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed bilateral hand mittens were applied on 5/12/26 at 2030 hours. However, review of Patient 2’s medical record failed to show documentation that Patient 2’s responsible party was notified of the use of restraints. On 5/15/26, during the concurrent interview and record review for Patient 2, the Director of Nursing and Clinical Services verified the findings.”

“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: 26756 Based on interview and record review, the hospital failed to ensure the soft-touch call light was initiated upon admission for one of six sampled patients (Patient 2). This failure created the risk the patient’s requests may not be responded to in a timely manner. Findings: During Patient 2’s medical record review on 4/9/26, the medical record showed Patient 2 was admitted to the hospital on 10/4/25 and discharged on 1/4/26. During a review of the History and Physical Examinations dated 10/5/25, the History and Physical Examination showed Patient 2 had functional quadriplegia. During a review of the Physical Therapy Initial Evaluation dated 10/6/25 at 0812 hours, the Physical Therapy Initial Evaluation showed Patient 2 had a history of quadriplegia due to traumatic fall. Patient 2 was awake, alert, and used mouthing to communicate. Patient 2 had 1/5 muscle strength in bilateral upper extremities. During a review of the Safety Assessment dated 12/14/25 at 1929 hours, the Assessment showed the soft touch call light was within reach. During a review of Patient 2’s medical records, the medical records failed to show the soft-touch call light was available or in use prior to 12/14/25 following the admission on 10/4/25. During an interview and concurrent medical record with the Director of Clinical Nursing Services on 4/10/26 at 1030 hours, the Director of Clinical Nursing Services verified 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: 26756 Based on interview and record review, the hospital failed to ensure the nursing staff developed a care plan addressing the blood transfusion for one of six sampled patients (Patient 4). This failure posed a risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and compromised patient safety during the blood transfusion process. Findings: During a review of the hospital’s P&P titled Interdisciplinary Assessment and Re-Assessment dated 6/23, the P&P showed the clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurses, RN and/or LVN may update the patient’s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse. During a review of Patient 4’s medical record on 4/9/26, the medical record showed Patient 4 was admitted to the hospital on 3/30/26. During a review of the Physician Orders dated 4/7/26 at 1223 hours, the Physician’s Orders showed an order to transfuse one unit of packed red blood cell. During a review of the Blood/Blood Component Transfusion Record dated 4/7/26, the Blood/Blood Component Transfusion Record showed the blood transfusion initiated at 1220 hours and ended at 1425 hours. Review of the medical record did not show that a plan of care addressing the blood transfusion was initiated for Patient 4. During an interview and concurrent medical record with the Director of Clinical Nursing Services on 4/10/26 at 1030 hours, the Director of Clinical Nursing Services 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: 26756 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary nursing services for two of six sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 1: a. The Vital Signs were not consistently documented as required by the hospital’s P&P for Patient 1. b. The MAP was not consistently assessed to determine the need of Levophed (vasopressor medication used to raise dangerously low blood pressure), as per the physician’s order for one of six sampled patients (Patient 1). c. The RASS assessment was not consistently assessed as per the hospital’s protocol and physician’s order for Patient 1. d. Cardiac monitoring strips were not obtained when a code blue was initiated as per the hospital’s P&P for Patient 1. 2. For Patient 2: a. The urine output was not consistently documented as per the physician ’ s order for Patient 2. b. The nursing staff failed to obtain physician’s orders for three-way Foley irrigation and Foley catheter change for Patient 2. These failures placed the patients at risk for adverse health outcomes. Findings: 1. During Patient 1’s medical record review on 4/9/26, the medical record showed Patient 1 was admitted to the hospital on 1/29/26 and expired at the hospital on 2/5/26. a. During a review of the hospital’s P&P titled Interdisciplinary Assessment and Re-Assessment dated 6/23, the hospital’s P&P showed: ... k. Physician’s Orders for routine vital signs will be interpreted by nursing personnel as follows: ii. Telemetry patient = every four hours iii. Intensive Care Unit = every two hours. During a review of the Nursing Admission, the Nursing Admission showed Patient 1 arrived at the unit on 1/29/26 at 1530 hours. During a review of the Vital Signs dated 1/29/26 at 1530 hours, the Vital Signs showed the admission vital signs were completed. During a review of the Physician’s Order dated 1/29/26 at 1712 hours, the Physician’s Order showed to admit Patient 1 to telemetry unit. During a review of the Physician’s Orders dated 1/29/26 at 2016 hours, the Physician’s Order showed to admit Patient 1 to ICU. During a review of the Vital Signs dated 1/30/26 at 0800 hours, the Vital Signs showed the Vital Signs were measured. However, further review of Patient 1’s medical record failed to show documentation of Patient 1’s vital signs between 1/29/26 at 1530 hours and 1/30/26 at 0800 hours. Further medical record also showed Patient 1’s vital signs were measured on 1/30/26 at 2300 hours and 1/31/23 at 0401 hours. However, there were no documented vital signs for five hours and one minutes. b. During a review of Physician’s Orders dated 1/30/26 at 1212 hours, the Physician’s Order showed to administer norepinephrine (same as Levophed) IV drip start at 1 mcg/min and titrate by 1 mcg/min every 1 to 15 minutes to keep MAP greater than 65 mmHg. Review of the Vital Signs showed Patient 1’s MAP was greater than 65 mmHg from 1100 hours to 1900 hours on 1/30/26. Review of the Vasoactive Infusion Flowsheet dated 1/31/26 at 1130 hours, showed the MAP was 63 mmHg and the norepinephrine was initiated. Further review of Patient 1’s Vital Signs from 2000 hours on 1/30/26 to 1130 hours on 1/31/26 failed to show Patient 1’s MAP was assessed. c. During a review of the Controlled Substance/Sedative Infusion Flowsheet dated 8/24, the Controlled Substance/Sedative Infusion Flowsheet showed to assess and document vital signs at least every 15 minutes during active titration and for one hour after, then every two hours. During a review of the Physician’s Orders dated 2/2/26 at 0949 hours, the Physician’s Orders showed to administer dexmedetomidine hydrochloride (sedative medication) IV drip starting at 0.2 mcg/kg/hr and to titrate by 0.2 mcg/kg/hr every 15 minutes to maintain RASS score between 0 and -2. Review of the RASS CAM ICU showed the following: * On 2/2/26 at 1200 hours, RASS was -2. * On 2/2/26 at 1610 hours, RASS was -2. * On 2/2/26 at 1930 hours, RASS was -2. * On 2/3/26 at 0810 hours, RASS was 1. Review of the Medication Administration record showed the following: * On 2/2/26 at 1200 hours, the infusion started at 0.2 mcg/kg/hr. * On 2/2/26 at 1610 hours, the infusion was at 0.6 mcg/kg/hr. However, Patient 1’s RASS remained at -2, and there was no documentation explaining the reason for upward titration. * On 2/3/26 at 0945 hours, the infusion was at 0.8 mc/kg/hr. However, Patient 1’s RASS was 1 at 0810 hours (the titration was changed one hour 35 minutes later). d. During a review of the hospital’s P&P titled Continuous Cardiac Monitoring dated 1/26, the P&P showed the strips would become part of the patient’s permanent medical record. Review of the Physician Orders dated 2/3/26 at 1611 hours, showed an order to administer norepinephrine IV drip starting at 5 mcg/min and titrate by 5 mcg/min every 1 to 15 minutes to keep MAP greater than 65 mmHg. If the drip was off for 24 hours, the order was to be discontinued. Review of the Vasoactive Infusion Flowsheet showed norepinephrine was initiated on 2/3/26 at 1530 hours and was off at 2122 hours. Review of the Vasoactive Infusion Flowsheet showed norepinephrine was initiated on 2/4/26 at 1310 hours, with the last documented infusion occurring on 2/5/26 at 0020 hours. Review of the physicians order dated 2/5/26 at 0254 hours, showed to administer phenylephrine (medication used to increase blood pressure) 25 mcg/min every 1 to 15 minutes to keep MAP greater than 65 mmHg. Review of the Vasoactive Infusion Flowsheet dated 2/5/26, showed phenylephrine was initiated at 0240 hours and the last documented infusion was at 0310 hours. Review of the Code Blue Flowsheet dated 2/5/26, showed the code was called at 0330 hours. During a review of the Progress Notes dated 2/5/26 at 0324 hours, the Progress Notes showed Patient 1’s blood pressure continued to drop despite maximum infusion of phenylephrine, dobutamine and norepinephrine. There was no documentation in the medical records to show the norepinephrine was infusing between 0020 hours to 0330 hours on 2/5/26. In addition, there was no documentation that phenylephrine was infusing between 0310 hours and 0330 hours on 2/5/26. Further medical record review failed to show the cardiac strip was obtained prior and during the code blue. During an interview and concurrent medical record with the Director of Clinical Nursing Services on 4/13/26 at 1030 hours, the Director of Clinical Nursing Services and COO/CCO verified the above findings. 2. During a review of Patient’ 2 medical record on 4/9/26, the medical record showed Patient 2 was admitted to the hospital on 10/4/25 and was discharged on 1/4/26. a. During a review of the Physician’s Order dated 10/4/25 at 1800 hours, the Physician’s Order showed to report intake and output every 12 hours and 24 hours at 0600 and 1800 hours. During a review of the Patient 2’s I&O dated 1/3/26 at 1850 hours, the I&O showed Patient 2 had 800 ml of the urine output. During a review of the Change of Condition dated 1/4/26 at 1229 hours, the Change of Condition showed Patient 2’s bladder was noted to be distended, and the indwelling urinary catheter was found to be non-patent. A new indwelling urinary catheter was inserted, and immediate urine output of 1000 ml was noted. However, further review of the medical record failed to show the urine output for 1/4/26 at 0600 hours, for the night shift (1800 hours on 1/3/26 to 0600 hours on 1/4/26) prior to the change of condition on 1/4/26 at 1229 hours. During an interview and concurrent medical record review with the Director of Clinical Nursing Services on 4/10/26 at 1236 hours, the Director of Clinical Nursing Services verified the above findings. b. During a review of the hospital’s P&P titled Guideline-Indwelling Catheter Standards and Practice dated 3/25, the P&P showed to only change indwelling catheters when medically indicated rather than at arbitrarily fixed intervals. During an interview on 4/10/26 at 1236 hours with the Infection Preventionist, in the presence of the Director of Clinical Nursing Services, the Infection Preventionist stated that long-term indwelling urinary catheters were no longer required to be changed at fixed intervals under updated guidelines and that catheter changes should be directed by the urologist. During a review of the Nurses Notes dated 10/4/25, 11/11/25, and 12/14/25, the Nurses Notes showed the indwelling urinary catheter was changed due to neurogenic bladder. However, further review of the medical record failed to show the physician’s order for nurses to change the indwelling urinary catheter. During a review of the Change of Condition dated 1/4/26 at 1229 hours, the Change of Condition showed Patient 2’s bladder was noted to be distended and the indwelling urinary catheter was found to be non-patent. A new indwelling urinary catheter was inserted, and an immediate output of 1000 ml of very dark bloody urine was noted. During a review of the Discharge Summary dated 1/4/26, the Discharge Summary showed Patient 2 would need bladder irrigation to prevent catheter clogging. The nursing staff attempted to place a 3-way urinary catheter for bladder irrigation but were unsuccessful. However, further review of the medical record failed to show that nursing staff obtained a physician’s order for the three-way urinary catheter needed for bladder irrigation. During an interview and concurrent medical record review with the Director of Clinical Nursing Services on 4/10/26 at 1236 hours, the Director of Clinical Nursing Services verified the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to ensure the medication was always secured and administered as per the order for two of six sampled patients (Patients 1 and 5). These failures created the risk of medication errors and poor health outcomes to the patients. Findings: 1. During a review of the hospital’s P&P titled “Administration of Oral Medication,” dated 06/22, the P&P showed all medications must be properly stored/secured at all times prior to administration. Prepared medications must never be left unsecured. During an observation of Patient 5’s medication administration on 4/9/26 at 1400 hours, with the Director of Clinical Nursing Services, LVN 1 was observed preparing the medication. The medication was observed unattended on the overhead table located in the hallway in front of the entrance door. The Director of Clinical Nursing Services verified the findings 2. During Patient 1’s medical record review on 4/9/26, the medical record showed Patient 1 was admitted to the hospital on 1/29/26 and expired at the hospital on 2/5/26. a. During a review of the Physician’s Orders dated 1/29/26 at 2118 hours, the Physician’s Order showed to administer melatonin (medication that helps regulate the sleep-wake cycle) 6 mg and Ativan (medication used to treat anxiety, agitation) 0.5 mg immediately. Review of the medical record failed to show Patient 1 received melatonin and Ativan. b. The IV drip was not titrated as per the physician’s order for one of six sampled patients (Patient 1). Cross reference to A 398, example # 1 (c). c. Review of Patient 1’s Physician’s Order dated 2/3/26 at 1611 hours, showed to administer norepinephrine IV drip starting at 5 mcg/min and titrate by 5 mcg/min every 1 to 15 minutes to keep MAP greater than 65 mmHg. If the drip is off for 24 hours, discontinue the order. Review of the Vasoactive Infusion Flowsheet showed norepinephrine was initiated on 2/3/26 at 1530 hours and was off at 2122 hours. Review of the Vasoactive Infusion Flowsheet showed norepinephrine was initiated on 2/4/26 at 1310 hours. The last documented infusion was on 2/5/26 at 0020 hours. During a review of the Physicians Order dated 2/5/26 at 0254 hours, the Physician’s Order showed to administer phenylephrine IV drip starting at 50 mcg/min and titrate by 25 mcg/min every 1 to 15 minutes to keep MAP greater than 65 mmHg. During a review of the Vasoactive Infusion Flowsheet dated 2/5/26, the Vasoactive Infusion Flowsheet showed phenylephrine was initiated at 0240 hours and the last documented infusion was at 0310 hours. During a review of the Code Blue Flowsheet dated 2/5/26, the Code Blue Flowsheet showed the code blue was called at 0330 hours. Review of the Progress Note dated 2/5/26 at 0324 hours, showed Patient 1’s blood pressure continued to drop on max even after adding phenylephrine to dobutamine and norepinephrine. There was no documentation showing that norepinephrine was infusing between 0020 hours and 0330 hours on 2/5/26. There was also no documentation showing that phenylephrine was infusing between 0310 hours and 0330 hours on 2/5/26. During an interview and concurrent medical record review with the Director of Clinical Nursing Services on 4/13/26 at 1030 hours, the Director of Clinical Nursing Services and COO/CCO verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure that the plan of care for one of six sampled patients (Patient 3) was updated to reflect the use of restraints. This failure posed a risk of substandard outcomes for 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 under Clinical/Nursing Staff and Physician/Licensed Practitioner/Allied heath Practitioner Responsibilities, Patient Plan of Care: The RN will create and modify the patient’s plan of care. During a concurrent interview and record review on 3/18/26 at 0949 hours, with the Nursing House Supervisor, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 2/25/26. Review of Patient 3’s Restraint Care Plan dated 2/28/26, showed bilateral limb/soft restraints were placed on Patient 3 on 2/28/26 at 0800 hours due to: risk of injury to self-due to inability to understand or remain oriented, disturbing monitoring equipment or necessary treatment modality (i.e. pulling at lines/tubes/drains), lack of safety awareness/doesn’t seek assistance, unsuccessful attempts to redirect behavior. Review of Patient 3’s Restraint Care Plan signed 2/28/26 at 0800 hours, failed to show the care plan was initiated at the time Patient 3 was placed in restraints. On 3/18/26 at 1020 hours, the Director of Nursing and Clinical Services was notified and acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure for one of six sampled patients (Patient 3), the patients’ response to the use of restraints and the rationale for continued use of restraints were documented on the patients’ record. This failure had the potential to result in the inappropriate use of restraints, unnecessary and prolonged use of restraints. This failure also had the potential to violate the patients’ rights. Findings: Review of the hospital’s P&P titled CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed under monitoring to fulfill care plan goals: 1) Individual patient needs and health status will be used to establish the frequency, nature, and extent of monitoring required. 2) Is accomplished by the RN staff and/or other designated trained staff who report findings to the RN through observations of a patient, direct face-to-face interaction or related direct examination of the patient. a) Patient’s physical response to restraint use. b) Maintenance of patient’s right, dignity, and safety of restraint application, removal or re-application. c) The RN determines if the current restraint should be continued, if less restrictive methods could be used or if restraints could be discontinued based on monitoring date. During a concurrent interview and record review on 3/18/26 at 0949 hours, with the Nursing House Supervisor, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 2/25/26. Review of Patient 3’s Restraint Care Plan dated 2/28/26, showed bilateral limb/soft restraints were placed on Patient 3 on 2/28/26 at 0800 hours due to: risk of injury to self due to inability to understand or remain oriented, disturbing monitoring equipment or necessary treatment modality (i.e. pulling at lines/tubes/drains), lack of safety awareness/doesn’t seek assistance, unsuccessful attempts to redirect behavior. Review of Patient 3’s Restraint Monitoring form (non-violent, non-self destructive behavior) dated 2/28/26, showed under the section titled, Daily Assessment to Determine Need/Response to Restraint(s): * Attempts to pull at lines/tubes/drains * Lack of safety awareness/doesn’t seek assistance * Unsuccessful attempts to redirect behavior * Disturbing monitoring equipment or medically necessary treatment modality redirect behavior * Is the need for restraint resolved? Each bullet listed above had a column where a Y (yes) or N (no) was to be placed to show if the behavior was present. The document failed to show the RN answered the questions listed above to determine the need to continue restraints for Patient 3. On 3/18/26 at 1020 hours, the Director of Nursing and Clinical Services was notified and acknowledged the above findings.”

“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: 39199 Based on interview and record review, the nursing staff failed to follow the physician’s order for administering enteral feeding for one of six sampled patients (Patient 1). This failure had the potential to result in inadequate nutritional intake and negatively impact the patient’s clinical condition. Findings: On 3/18/26 at 1314 hours, Patient 1’s medical record was reviewed with the Director of Nursing and Clinical Services and the RD. Review of Patient 1’s medical record showed the patient was admitted to the hospital on 9/6/25. a. Review of Patient 1’s physician’s order dated 9/24/25 at 1459 hours, showed an order to administer Two Cal HN (a high-calorie, high-protein, liquid nutrition supplement for tube or oral feeding) at a rate of 25 ml per hour via the G-tube. However, documentation in Patient 1’s medical record showed the G-tube feeding was administered at a rate of 20 ml per hour on 9/25/26. Patient 1’s medical record did not show the patient had residuals or intolerance to the G-tube feeding, and there was no clinical justification documented for not following the physician-ordered feeding rate of 25 ml per hour. b. Review of Patient 1’s physician’s order dated 1/28/26 at 1250 hours, showed an order to administer Nepro (a specialized enteral feeding formula) at a rate of 20 ml per hour via the J-tube. However, review of Patient 1’s medical record did not show Nepro was administered on 1/29/26 and 1/30/26. In addition, Patient 1’s medical record showed a total of 180 mL of Nepro was administered on 1/31/26, which was less than half of the prescribed daily volume (a continuous feeding rate of 20 ml per hour would provide approximately 480 ml over 24 hours). On 3/18/26, during the concurrent interview and record review, the Director of Nursing and Clinical Services and the RD verified the 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: 45560 Based on interview and record review, the hospital’s failed to implement their P&P when the legal representative was not notified of the use of restraints for one of six sampled patients (Patient 3). This failure had the potential to put the patient at risk for negative health outcomes by continuing the use of restraints without the patient’s legal representative being made aware of the restraint use. Findings: Review of the hospital’s P&P titled CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed under procedure, the following guidelines for restraint application are required for each restraint episode for non-violent and violent/self-destructive behavior. Staff will notify the patient’s legal representative as soon as possible after the restraint is applied and document discussion in the patient’s medical record. During a concurrent interview and record review on 3/18/26 at 0949 hours, with the Nursing House Supervisor, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 2/25/26. Review of Patient 3’s Restraint Care Plan dated 2/28/26, showed bilateral limb/soft restraints were placed on Patient 3 on 2/28/26 at 0800 hours due to: risk of injury to self-due to inability to understand or remain oriented, disturbing monitoring equipment or necessary treatment modality (i.e. pulling at lines/tubes/drains), lack of safety awareness/doesn’t seek assistance, unsuccessful attempts to redirect behavior. On 3/18/26 at 0949 hours, the Nursing House Supervisor was unable to locate documentation showing Patient 3’s legal representative was notified when restraints were initiated. On 3/18/26 at 1020 hours, the Director of Nursing and Clinical Services was notified and acknowledged 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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary nursing care for two of six sampled patients (Patients 1 and 2) as evidenced by: 1. The nursing staff failed to stage the pressure injury as per the hospital’s P&P for Patient 1. 2. The nursing staff failed to complete the wound care competency prior to the assessment of the wound for Patient 1. 3. The nursing staff failed to consistently perform the documentation of meal intake as per the hospital’s P&P for Patient 1. 4. The nursing staff failed to perform oral hygiene on 11/4/25, per random date selection for Patient 1. 5. The nursing staff failed to clarify with the physician about removing IV midline prior to the discharge for Patient 1. 6. The nursing staff failed to consistently perform reposition on 9/26/25 for Patient 2. 7. The nursing staff failed to show document of interventions when lorazepam (a medication for anxiety) was ineffective for Patient 2. These failures increased the risk of substandard healthcare outcomes for the patients. Findings: 1. Review of the hospital’s P&P titled Clinical Guidelines for Pressure Injury dated 6/22, showed the following definitions: * Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. * Stage 3 Pressure Injury: full-thickness skin loss: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. * Stage 4 Pressure Injury: full-thickness skin and tissue loss: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. * Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss: 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. On 2/27/26, Patient 1’s medical record was reviewed and showed the patient was admitted to the hospital on 10/21/25. Review of the Nurses Notes dated 10/22/25 at 0941 hours, showed Patient 1 was identified to have unstageable pressure injury to the sacrococcygeal, obscured by necrosis. Review of the Nurses Notes dated 11/24/25 at 1724 hours, showed RN 8 staged Patient 1’s pressure injury to the sacrococcygeal as Stage 3 Pressure Injury. Further review of wound description showed Patient 1 had partial thickness skin loss involving epidermis and/dermis. During an interview and concurrent record review of Patient1’s medical record on 3/2/26 at 1040 hours, RN 1 stated the wound description (partial thickness skin loss) documented on 11/24/25, matched the hospital’s P&P definition of a Stage 2 Pressure Injury. On 3/3/26 at 1050 hours, the Director of Clinical Nursing Services verified the above findings. 2. Review of the hospital’s P&P titled Clinical Guidelines for Pressure Injury dated 6/22, showed the Wound Care Team is accountable for every patient having a thorough skin and wound assessment on admission and appropriate intervals thereafter. On 2/27/26, Patient 1’s medical record was reviewed and showed the patient was admitted to the hospital on 10/21/25. Review of the Nurses Notes dated 11/24/25 at 1724 hours, showed RN 8 staged Patient 1’s pressure injury to the sacrococcygeal as Stage 3 Pressure Injury. Further review of wound description showed Patient 1 had partial thickness skin loss involving epidermis and/dermis. On 3/2/26 at 1107 hours, the Director of Clinical Nursing Services was interviewed and stated that the wound care nurse, not the floor nurse, staged the pressure injury. The Director of Clinical Nursing Services also stated RN 8 was new to the wound care team. Review of the RN Wound Care Member Annual Competencies for RN 8 showed the competency for wound assessment was completed on 2/5/26. On 3/3/26 at 1050 hours, the Director of Clinical Nursing Services verified the above finding, confirming that RN 8 completed the patient’s wound assessment prior to completing the wound care competencies. 3. Review of the hospital’s P&P titled Food and Fluid Intake dated 6/21, showed to accurately document meal, snack, and supplement intake in the medical record. On 2/27/26 Patient 1’s medical record was reviewed. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/21/25. Review of the Orders dated 10/22/25, showed Patient 1’s diet was potassium restricted to 2-3 gram. Random dates (10/22 and 10/23/25) were selected for review of meal and fluid intakes. Review of Nurses Notes showed Patient 1 had 118 ml of fluid intake on 10/22/25 and 918 ml of fluid intake on 10/23/25. The medical record failed to show Patient 1’s oral intakes on 10/22 and 10/23/25. On 2/27/26 at 1239 hours, the Director of Quality Management verified the above findings. 4. On 2/27/26, Patient 1’s closed medical record was reviewed and showed Patient 1 was admitted to the hospital on 10/21/25. During an interview on 2/27/26 at 1305 hours, the Director of Quality Management stated oral care was provided to each patient at least once a day. During an interview on 3/2/26 at 0917 hours, RN 9 stated oral care was provided to each patient twice a day or as needed. A random date (11/4/25) was selected to review the oral care documentation for Patient 1. Review of the medical record failed to show documentation of oral care. On 3/3/26 at 1050 hours, the Director of Clinical Nursing Services verified the above findings. 5. On 2/27/26, Patient 1’s closed medical record was reviewed and showed Patient 1 was admitted to the hospital on 10/21/25. Review of the Physician’s Order dated 11/26/25 at 1027 hours, showed to discharge Patient 1 home. Review of Nurses Notes dated 11/27/25 at 2243 hours, showed that Patient 1 was discharged with midline intact. The physician was informed, and the physician stated to call Patient 1’s family member to see if they could bring Patient 1 back to the hospital to have the line removed. On 3/5/26 at 1000 hours, the COO/CCO was interviewed. The COO/CCO was asked about the discharge procedure and stated that the nursing staff followed the physician’s order. The COO/CCO further stated that the nursing staff that discharging Patient 1 should have clarified with the physician about removing IV midline. 6. On 2/27/26, Patient 2’s medical record was reviewed and showed the patient was admitted to the hospital on 9/24/25. Review of the Physician’s Orders dated 9/24/25 at 0400 hours, showed to reposition Patient 2 every two hours. A random date was selected to review Patient 2’s repositioning documentation. Review of the Flowsheets dated 9/26/25, showed Patient 2 was in supine position from 1600 to 2015 hours (for four hours and 15 minutes). On 3/3/26 at 1050 hours, the Director of Clinical Nursing Services verified the above findings. 7. On 2/27/26, Patient 2’s closed medical record was reviewed and showed the patient was admitted to the hospital on 9/24/25. Review of the Physician’s Orders dated 9/24/25 at 0311 hours, showed an order to administer lorazepam (0.5 mg IV push) as needed for anxiety. Review of the MAR dated 9/26/25 at 0506 hours, showed Patient 2 received lorazepam 0.5 mg IV push. Review of the MAR dated 9/26/25 at 0540 hours, showed documentation that the dose of lorazepam was not effective and that Patient 2 remained anxious and restless. Further review of the medical record failed to show any additional interventions were provided when the medication did not resolve the patient’s anxiety. On 3/3/26 at 1050 hours, the Director of Clinical Nursing Services verified the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure medications were administered appropriately for two of six sampled patients (Patients 2 and 3) as evidenced by: 1. The nursing staff failed to administer medications as per the hospital’s P&P for Patient 3. 2. The nursing staff administered medications as per the physician’s order for Patient 2. These failures created the risk of medication errors and poor health outcomes to the patients. Findings: 1. Review of the hospital’s P&P titled Administration of Medications via Feeding Tube dated 6/23, showed each medication is administered separately through the enteral feeding tube and avoid mixing medications. On 3/2/26, Patient 3’s medical record was reviewed and showed Patient 3 was admitted to the hospital on 1/23/26. Review of the Active medications list showed to administered losartan (a medication used to lower blood pressure) 25 mg daily and amlodipine (a medication used to lower blood pressure) 5 mg daily via feeding tube. On 3/2/26 at 0934 hours, LVN 1 was observed administering medications to Patient 3 with the Nursing Educator present. Patient 3 was receiving enteral tube feeding. LVN 1 was observed placing amlodipine and losartan in a medication cup. LVN 1 crushed the medications and mixed them in sterile water. LVN 1 then administered the mixed medications to Patient 3 through the enteral tube. 2. On 2/27/26, Patient 2’s closed medical record was reviewed and showed Patient 2 was admitted to the hospital on 9/24/25. Review of the Order dated 9/24/25 at 0312 hours, showed to administer amlodipine 5 mg daily per feeding tube. Review of the record showed amlodipine 5 mg was not administered as ordered on 9/24/25, 9/25/25, and 9/26/25. During an interview on 3/4/26 at 1058 hours, the Director of Clinical Nursing Services 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 provide documented evidence that two of two Registered Nurses (RN 1 and RN 2) completed annual competency evaluations in accordance with the hospital’s P&P. This failure to validate clinical skills created an unsafe patient care environment. Findings: Review of the hospital’s P&P titled “Procedure-Evaluation and Verification of Competency” dated 3/2025, showed that staff competency be “...assessed at but not limited to the following periods...upon initial employment and annually thereafter.” Validations must be maintained in the employee’s education file. 1. On 1/23/26 at 1437 hours, a review of RN 1’s (Medical/Surgical/Telemetry) annual education file showed: Multiple clinical categories were left blank, including phlebotomy, handwashing, urinary catheter discontinuation, Decannulation Prevention Program, and restraint policy review. Despite form instructions prohibiting the drawing of lines down columns, a line was drawn from “Glycemic Management” through the remainder of the section. The required verification codes (1-3 for demonstration, observation, or discussion) and preceptor initials were missing for most elements. The Glucometer Waived Testing section was incomplete. 2. On 1/23/26 at 1556 hours, a review of RN 2’s (ICU/House Supervisor) education file showed several incomplete records dated 12/29/25: - Proper Technique to Tie Trash, Biohazardous OR Linen Bags - Hand Hygiene - Administration of Propofol (a medication used to sedate a patient) via Continuous Infusion - Administration of Titratable Vasoactive Drips - Preparation of Sterile IV Admixtures - Turning/Moving Patients with An Artificial Airway - Nursing Supervisor Pharmacy After Hours - Nursing Supervisor Annual Competency During a concurrent interview on 1/23/26 at 1607 hours, the Director of QA confirmed that RN 1 and RN 2 were active in their respective units and acknowledged that the competency files were incomplete and failed to meet the hospital’s documentation standards.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on observation, interview, and record review, the hospital failed to ensure that RN 1 followed established policies and procedures for medication administration via feeding tube for one of three sampled patients (Patient 2). This failure compromised the quality of care and threatened the patient’s safety and the medication’s effectiveness. Findings: Review of the hospital’s P&P titled “Core: Administration of Medications via Feeding Tube” dated 6/2023, showed that qualified personnel administer medications safely and accurately by verifying the practitioner’s order and the specific drug form. 1. On 1/23/26 at 0925 hours, RN 1 was observed administering lansoprazole (a medication used to reduce stomach acid) 30 mg to Patient 2. RN 1 opened the capsule and mixed the granules with 10 ml of sterile irrigation solution. During an interview on 1/23/26 at 1149 hours, the Director of Pharmacy stated that because these granules did not readily dissolve in water, the medication must be mixed with one tablespoon of applesauce or 60 ml of apple juice and administered immediately. The Director of Pharmacy confirmed this specific administration instructions were displayed on the Pyxis screen when the medication was removed. 2. During ongoing observation, RN 1 crushed a 100 mg docusate sodium (a stool softener) tablet and mixed it with 10 ml of sterile irrigation solution for administration via feeding tube. Review of Patient 2’s medical record showed that the doctor ordered 100 mg of docusate sodium in liquid form. During an interview on 1/23/26 at 1146 hours, the Director of Pharmacy confirmed that the tablet form was not on the hospital’s approved therapeutic interchange list. The RN should have consulted a pharmacist before substituting the tablet for the ordered liquid. On 1/23/26 at 1226 hours, RN 1 confirmed the observations and the deviation from the prescribed administration methods.”

“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 interview and record review, the hospital failed to ensure the nursing staff provided necessary care and service for two of six sampled patients (Patients 4 and 6) as evidenced by: 1. The hospital failed to ensure the nursing staff implemented their P&P for the investigation of serious and sentinel events for Patient 4 when a fracture with unknown origin was not reported into the facilities Event Reporting System.. 2. The nursing staff did not follow the physician’s order to reposition Patient 6 every two hours. These failures posed the increased risk of persistent poor practices and unmet patient healthcare needs. Findings: 1. Review of the hospital’s P&P titled CORE: Investigating Serious and Sentinel Events, release date 06/2023 showed under Level 3 Serious Events, serious events are occurrences or situations resulting in actual permanent lessening of bodily functioning (sensory, motor, physiologic or intellectual) not related to the natural course of the patient’s illness or underlying condition. The same document also showed, under Procedure, notice after an event, enter an Event Report. Enter the event in the Event Reporting System as soon as possible but no later than 24 hours after the event; provide as much pertinent, factual information as possible; DO not wait until the investigation is completed. On 1/15/26, review of Patient 4’s medical record was initiated. Patient 4 was admitted to the hospital on 10/21/25. During a review of Patient 4’s left wrist radiology report dated 10/29/25, the report showed Patient 4 was found to have an acute comminuted fracture in the base of the left metacarpal bone. The document also showed that the RN was notified of the findings. During a concurrent interview and record review on 1/15/26 at 0958, with the DNCS, Patient 4’s electronic medical record was reviewed. The DNCS was unable to locate documentation showing the possible origin of Patient 4’s fractured left metacarpal bone. During an interview on 1/15/26 at 1350 hours, with the hospital’s Director of Quality Management, the Director of Quality Management acknowledged when Patient 4’s fracture was discovered, it was of unknown origin and that the event should have been reported on the hospital’s Event Reporting System. On 1/15/26 at 1350 hours, the Director of Quality Improvement was notified and acknowledged the above findings. 37548 2. On 1/14/26 at 1330 hours, review of Patient 6’s medical record was initiated with the DNCS. Patient 6 was admitted to the hospital on 9/26/25. Review of the renewed Physician’s order showed, “Reposition, Renew start 11/7/25 0800, q2h...” Review of repositioning documentation for Patient 6 on random dates showed the patient was not repositioned every two hours as ordered by the physician. On 11/15/25 at 1955 hours, the documentation showed the patient was positioned on the left side. No repositioning was documented for over four hours until 11/16/25 at 0023 hours. The documentation at 0023 hours showed the patient was positioned on the right side. Another four-hour gap occurred between the 0023 entry and the next recorded entry on 11/16/25 at 0445 hours. The documentation at 0445 hours showed the patient was positioned on the left side. On 11/17/25 at 0444 hours, the documentation showed the patient was positioned on the left side. No repositioning was documented for three hours until the next entry on 11/17/25 at 0800 hours. The documentation at 0800 showed the patient was positioned on the right side. The DNCS confirmed these findings on 1/14/26 at 1345 hours.”

“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: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff administered blood products as ordered by the physician for one of six sampled patients (Patient 2). This failure posed the risk for delay in treatment and potential adverse patient outcomes. Findings: On 1/15/26 at 1326 hours, an interview and concurrent record review was conducted with the DNCS. The DNCS stated blood products were delivered from a sister hospital, and the delivery date and time of each unit were recorded on the packing slip and in the Blood Component Transfusion Log Book. The DNCS stated STAT blood transfusion orders should be administered as soon as possible and within one hour, especially if the patient’s hemoglobin level was critically low. Review of Patient 2’s medical record showed the patient was admitted to the hospital on 1/7/26. Review of Patient 2’s laboratory results dated 12/7/25 at 1240 hours, showed the patient’s hemoglobin level was critically low at 4.5 g/dL. Review of Patient 2’s physician orders dated 12/7/25 at 1311 hours, showed to transfuse three units of packed red blood cells STAT. Review of the Packing Slip and the Blood Component Transfusion Log Book showed the three units of packed red blood cells were delivered on 12/7/25 at 2110 hours. However, review of Patient 2’s Blood/Blood Component Transfusion Record dated 12/8/25, showed the first unit of packed red blood cells was not initiated until 0030 hours, three hours and twenty minutes after the packed red blood cells were delivered to the hospital. On 1/15/26, during the interview and concurrent record review, the DNCS verified the findings. On 1/15/26 at 1403 hours, an interview and concurrent record review was conducted with the RN Educator, who stated for STAT blood transfusion orders, the nursing staff were expected to initiate the transfusion within one hour. The RN Educator further stated once the blood was delivered, the nurse should have immediately obtained the blood and began the transfusion, due to the patient’s critically low hemoglobin level.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure its P&P for discharge planning was implemented for one of six sampled patients (Patient 1). This failure had the potential to result in an unsafe discharge for Patient 1. Findings: Review of the hospital’s P&P titled Care Coordination and Discharge Planning dated June 2023 showed discharge planning begins upon the patient’s admission to the hospital. The Case Management/Social Services Department assesses all patients admitted to the hospital. The initial assessment is completed within two business days of admission and includes: the patient’s educational level and vocational status; the patient’s social support network, including family and other relationships; physical abilities, including pertinent medical information; interviews with family members and significant others, as appropriate; financial/income data from those who need financial resource help; who is the caregiver; potential needs; equipment at home prior to admission, health aids needed; discharge plans; and advance directive. On 1/14/26 at 1116 hours, an interview and concurrent record review was conducted with Case Manager 1. Review of Patient 1’s medical record showed the patient was admitted to the hospital on 11/27/25, and discharged home on 12/11/25. Review of Patient 1’s medical record showed the Case Manager’s initial assessment, including discharge planning, was not completed until 12/5/25 at 1756 hours. The assessment was incomplete and lacked required documentation of the patient’s educational level, as required by the hospital’s P&P. On 1/14/26, during the interview and concurrent record review, Case Manager 1 verified the findings. On 1/15/26 at 1450 hours, an interview was conducted with the Director of Case Management, who stated discharge planning must begin within 48 hours of patient admission and was the responsibility of the assigned case manager.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the following: 1. The hospital failed to implement required isolation precautions for one of four sampled patients (Patient 1). 2. The hospital failed to provide documented evidence of tuberculosis (TB) screening for one of two sampled medical staff members (MD 2). These failures posed a potential risk of infection for patients receiving care at the facility. Findings: 1. Review of the hospital’s document titled Guideline-Multi-Drug Resistant Organisms (MDRO) dated 3/2024 showed, “This guideline establishes the process for controlling the spread of gram negative and gram-positive antibiotic-resistant organisms, which may include...Carbapenemase-resistant organisms...All facilities have procedures in place to reduce the risk or prevent the transmission of antibiotic-resistant organism transmission to other patients, employees, and the community...Determining which patients are placed in Contact Precautions identified with Multi-Drug Resistant Organisms shall be based upon...The facility’s Annual Infection Prevention and Control Risk Assessment...These decisions should be based on the recommendations of the Infection Control Committee, IC physician chairperson, and approved at the appropriate committee levels...” On 12/10/25 at 1406 hours, an interview and record review was conducted with the DQM. Patient 1 was admitted to the hospital on 10/3/25, with hospital-acquired pneumonia with Pseudomonas, which originated at the transferring hospital, and was placed under contact isolation. The treatment plan included consulting an Infectious Disease Provider. Review of the Infectious Disease Consultant’s (MD 2) documentation dated 10/4/25, showed the patient was found to have resistant Pseudomonas and Achromobacter infection. Review of MD 2’s order dated 10/6/25, showed that the patient’s isolation precaution was discontinued. On 12/11/25 at 1034 hours, the ICP was interviewed and stated that the hospital’s Annual Infection Prevention and Control Risk Assessment showed CRPA as a MDRO. The ICP stated that according to the hospital’s adoption of the CDPH HAI MDRO Cohorting Guidance, patients with a history of MDRO infection should not have “clearance” recommendations for colonization to discontinue isolation precautions. Patient 1 should have remained under contact isolation for the entire hospital stay. 2. Review of the hospital’s document titled Procedure-Tuberculosis Screening for Healthcare Workers dated 3/2024 showed, “Ensure all healthcare workers receive a baseline screening upon hire using the two-step process and record the results of Tuberculin Skin Testing (TST)...Healthcare workers are required serial screening based on specific state regulatory guidelines or an annual risk assessment conducted by the Infection Preventionist (IP), recommendations and approval of the Infection Control Committee (ICC), Quality Council (QC), Medical Executive Committee (MEC), and Governing Board (GB)...Employees with a documented history of TB or a previous positive TST are evaluated with a chest x-ray initially. If the employee has a current negative chest x-ray and can provide the employee health nurse with a copy, completes a symptom screen and has no symptoms that are suggestive of active tuberculosis through the questionnaire screening process...it is not necessary to obtain another chest x-ray...” On 12/11/25 at 1311 hours, MD 2’s credentialing file was reviewed with the DQM and the ICP. Review of the file showed documentation of a negative chest x-ray result dated 11/21/19. The ICP stated the Medical Staff members should follow the hospital’s procedure for Tuberculosis Screening for Healthcare Workers. The DQM confirmed that there was no Tuberculosis Screening documentation in the record after 2019.”

“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 interview and record review, the hospital failed to ensure the nursing staff notified the family or the next of kin of the Stage 3 PI size progression for one of four sampled patients (Patient 1) as per the hospital’s P&P. This failure posed an increased risk of substandard health outcome for the patient. Findings: Review of the hospital’s P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated June 2023 showed notification responsibilities when an assessment reveals a change or suspected change in condition. The nurse assigned to the patient or supervising care of the patient is responsible for notification of and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. Notify the nursing supervisor of patient change in condition. Others are notified as appropriate (Nurse Manager, Chief Clinical Officer...) and per facility designation, including notification of patient’s family or significant other. Document change of condition, notification and interventions in the medical record. Medical record review for Patient 1 was initiated on 8/14/25. Patient 1 was admitted to the hospital on 4/29/25 and was transferred to the SNF, subacute unit on 5/30/25. Review of the WCN Notes for Patient 1’s community acquired Stage 3 PI on the sacrococcygeal showed the following: - On 4/30/25 at 1504 hours, the PI wound measured 2 cm (length) by 2 cm (width) by 0.2 cm (depth). Necrotic tissue was not visible. The skin color surrounding the wound was dark red or purple and/or non blanchable. - On 5/21/25 at 1637 hours, the PI wound measured 3.5 cm by 4.2 cm by 0.2 cm. There was 25% necrotic tissue. The skin color surrounding the wound was black or hyperpigmented. - On 5/28/25 at 1002 hours, the PI wound measured 4 cm by 5.5 cm by 0.2 cm. There was 40% necrotic tissue. The skin color surrounding the wound was pink or normal for ethnic group. Review of Patient 1’s sacrococcygeal PI photos showed the image on 4/30/25 at 1822 hours, 5/21/25 at 1943 hours, and 5/28/25 at 1739 hours, with the progression of the PI size. On 8/14/25 at 1428 hours, an interview and concurrent record review of Patient 1’s Education Plan for Wound Management was conducted with RN 3. RN 3 stated on 5/14/25, the WCN was unable to contact the patient’s family or next of kin to educate about Patient 1’s Stage 3 PI; and on 5/21/25, there was no documented evidence the WCN educated the family or next of kin of Patient 1’s Stage 3 PI. RN 3 stated the WCN should notify the family and the physician when there was a change in the condition of the wound. RN 3 verified there was a change in the size of the sacrococcygeal PI. The findings were shared with the COO/CCO and the 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: 45560 Based on interview, medical record review, and facility P&P review, the hospital failed to transfer one of six sampled patients (Patient 1) to a higher level of care in a timely manner as order by their physician to treat an intra-abdominal abscess. This delay in care had the potential to negatively impact Patient 1’s well-being. Findings: Review of the Hospital’s 2025 Organizational Plan for the Delivery of Patient Care, Treatment and Services showed, Patient services at the hospital occur through an organized and systematic process designed to ensure the delivery of safe, effective and timely care, treatment and services. The same document also showed, Patient care, treatment and services will be planned, coordinated, provided, delegated and supervised by professional health care providers who recognize the unique physical, emotional and spiritual needs of patient/family teaching, patient advocacy and research. On 7/8/25 at 1400 hours, a medical record review for Patient 1 was conducted with the Director of Quality Management. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 3/22/25. Review of Patient 1’s History and Physical examination dated 3/22/25 showed Patient 1 was admitted to the hospital for an intra-abdominal infection and had a history of kidney and liver transplantation. Review of Patient 1’s Physician Order dated 4/6/25 at 1718 hours, showed an order to request transfer back to the liver transplant team at Hospital A for persistent intra-abdominal abscess measuring 4.5 cm. The order was to be initiated on 4/7/25 at 0600 hours. Further review of the order showed it was acknowledged by RN 1 on 4/6/25 at 1840 hours. On 7/9/25 at 1300 hours a telephone interview was conducted with RN 1. RN 1 stated since it was after hours and case management was not available, the order to arrange for transfer of Patient 1 to Hospital A was endorsed to the night shift nurse to be followed up the next morning. RN 1 stated RN 1 was unaware if the order was passed on to the Case Management. On 7/9/25 at 1057 hours, an interview was conducted with the Director of Case Management. The Director of Case Management stated the order to transfer Patient 1 to Hospital A “fell through the cracks” and they were not notified of the order until 4/9/25. The Director of Case Management stated Patient 1 could have potentially been transferred to Hospital A on 4/7/25, if they were made aware of the order at that time. Review of the Discharge Note of Current Condition dated 4/9/25 at 2018 hours, showed a call was received from Patient 1’s provider at Hospital A accepting Patient 1 for transfer on 4/9/25 at 1745 hours. On 7/10/25 at 1045 hours, the Director of Quality Management and Chief Operating Officer were notified and acknowledged 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: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for making corrections to the paper medical records for two of six sampled patients (Patients 2 and 3). Illegible medical records posed the risk of adverse health outcomes and compromised patient safety. Findings: Review of the hospital’s P&P titled Procedure-Corrections to the Medical Record dated April 2025 showed to make corrections to a paper medical record: a. In black ink, draw a single line through the incorrect data. b. Write “error” above the incorrect data. c. Write the correct data below the lined-out material. d. Sign, date and time the correction. 1. Medical record review for Patient 2 was initiated on 7/9/25. Review of Patient 2’s Blood/Blood Component Transfusion Record dated 7/6/25 at 1410 hours, showed that instead of drawing a single line through the error, the nurse wrote over several original entries, which included dates, times, and vital signs, which compromised the integrity and legibility of the medical record. 2. Medical record review for Patient 3 was initiated on 7/9/25. Review of Patient 3’s Blood/Blood Component Transfusion Records dated 6/28/25 at 1730 and 2220 hours, showed that instead of drawing a single line through the error, the nurse wrote over several original entries of the documented times, which compromised the integrity and legibility of the medical record. On 7/9/25 at 0920 hours, the above findings for Patients 2 and 3 were shared with the Director of Quality Management who acknowledged the entries were not legible. 45560”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the physician’s order and the hospital’s P&P on administering medications intravenously for one of six sampled patients (Patient 4). This failure posed the risk of adverse health outcomes to the patient. Findings: Review of the hospital’s P&P titled Administration of Medications via Injection dated June 2022 showed to administer IV Push medications no faster than 1 ml per minute or slower if recommended by the drug reference or physician order. Review of the manufacturer’s drug reference for pantoprazole sodium (a medication that is commonly used to treat certain stomach and esophagus problems, such as acid reflux) showed to reconstitute pantoprazole sodium for injection with 10 ml of 0.9% sodium chloride and to administer the medication intravenously over a period of at least two minutes. On 7/9/25 at 0845 hours, an observation was conducted of RN 2 administering medication to Patient 4. RN 2 was observed aspirating 4 ml of 0.9% sodium chloride and injecting it into a vial containing 40 mg of pantoprazole sodium to reconstitute the medication. RN 2 was later observed administering the medication via IV push over 15 seconds. RN 2 verified the findings following the medication administration observation. On 7/9/25 at 0940 hours, an interview and concurrent review of Patient 4’s medical record was conducted with RN 2. Patient 4’s medical record showed the patient was admitted to the hospital on 6/30/25. Review of Patient 4’s physician’s order dated 6/30/25, showed to administer pantoprazole sodium 40 mg every 12 hours. The order specified the vial should be diluted with 10 ml of normal saline and the medication should be administered via IV push over two minutes. RN 2 verified the findings during the interview and record review.”

“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: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the provider’s orders and the hospital’s P&P for the administration of blood and blood products for one of six sampled patients (Patient 2) as evidenced by: a. The provider’s order to transfuse two units of packed red blood cells was not followed timely. b. Complete vital signs were not assessed or documented after the blood transfusion was completed. These failures posed a risk to overall patient safety. Findings: a. Medical record review for Patient 2 was initiated on 7/9/25. Patient 2’s medical record showed the patient was admitted to the hospital on 6/9/25. Review of Patient 2’s Physician Orders dated 7/4/25 at 0816 hours, showed to start transfusing two units of packed red blood cells on 7/4/25, as needed (with no provided parameters), with instructions indicating one unit per execution and to stop after two executions. Review of Patient 2’s Lab Hematology Flowsheet dated 7/4/25, showed the patient’s hemoglobin level was 6.2 g/dL (a protein in red blood cells that carries oxygen from the lungs to the rest of the body; the normal range for men is 13.8 to 17.2 g/dL). Review of Patient 2’s Progress Note dated 7/4/25, showed, “pending two units of packed red blood cells due to hemoglobin 6.1.” However, review of Patient 2’s Blood/Blood Component Transfusion Records showed only one unit of packed red blood cells was transfused on 7/4/25, and the second unit was not transfused until two days later, on 7/6/25 at 1410 hours. On 7/9/25 at 0840 hours, an interview and concurrent record review was conducted with the Director of Quality Management. Review of Patient 2’s medical record did not show a physician’s order or progress note entry to hold the second unit. The Director of Quality Management stated the hospital’s process was to transfuse the first unit, recheck the patient’s hemoglobin levels, and transfuse the second unit only if the hemoglobin level was under 7 g/dL. However, the Director of Quality Management was unable to provide the hospital’s P&P to support this process. The Director of Quality Management acknowledged that the physician’s order should be more specific and include parameters or instructions to recheck the patient’s hemoglobin levels after transfusion of the first unit and to transfuse the second unit only if the hemoglobin level was under 7 g/dL. b. Review of the hospital’s P&P titled Transfusion Therapy dated June 2023 showed to obtain vital signs 15 minutes after transfusion initiation, then hourly until the unit is complete. The last set of vital signs is obtained 30 minutes after transfusion is complete. Review of Patient 2’s Blood/Blood Component Transfusion Record dated 7/6/25, showed the transfusion was started at 1410 hours and ended at 1740 hours. There was no documented evidence the patient’s vital signs were obtained 30 minutes after the transfusion was completed. On 7/9/25, the Director of Quality Management verified the findings during the interview and record review.”

“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: 38660 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff supervised and evaluated the nursing care for seven of 12 sampled patients (Patients 1, 2, 7, 8, 10, 11, and 12) as evidenced by: 1. The nursing staff failed to ensure the physician’s order for the use of non-violent restraint was completed for Patient 1 as per the hospital’s P&P. 2. The nursing staff failed to ensure the GT dressing was changed daily for Patient 2 as per the hospital’s Lippincott nursing standards of practice. 3. The nursing staff failed to ensure the call lights for Patients 8, 10, 11, and 12 and ventilator alarms for Patient 7 were addressed on a timely manner. These failures had the potential for unsafe care to the patients. Findings: 1. Review of the hospital’s P&P titled Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed for non-violent behavior restraints, initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints. The initial face-to-face assessment by MD/LP must be performed within one calendar day after the restraints are applied. The ordering practitioner must complete their part of the assessment attending to any nursing findings and new findings related to the restraint use, type of restraint to be used, and criteria for release. On 4/10/25 at 1438 hours, a medical record review for Patient 1 was conducted with the Director or Quality Management. Patient 1’s medical record showed the patient was admitted to the hospital on 2/3/25. Review of the Restraint Initiation/Order (Non-Violent Non-Self Destructive Behavior) showed the following: * On 2/7/25 at 1200 hours, the right hand and left wrist limb/soft restraints were applied for Patient 1. * The section for Nursing Assessment/Reason for Restraint was left blank. * The section for Telephone Order was checked. However, the sections for Nurse Name/Signature, Physician/LIP/AHP Name, Time, and Date were left bank. * The section for Physician/LIP/AHP Assessment/Restraint Order Confirmation showed a signature. However, the sections for Time and Date were left blank. The Director of Quality Management verified the above findings. 2. Review of the hospital’s Lippincott nursing standards of practice titled Enteral Feeding Tube Exit Site Care, Gastrostomy and Jejunostomy dated 11/18/24, showed to wash the surrounding skin with soap and water daily, rinse the area with water and pat it dry when the tube exit site has healed. On 4/10/25 at 0920 hours, during an observation of the medication administration for Patient 2 via the GT was conducted with LVN 1. The dressing of the patient’s GT was observed dated 4/6/25, the LVN confirmed the date written on the GT dressing showed the last date that the patient’s GT dressing was changed. The LVN stated the night shift nurse usually changed the GT dressing for Patient 2. On 4/10/25 at 1120 hours, an interview and concurrent review of Patient 2’s medical record was conducted with LVN 1. Patient 2’s medical record showed the patient was admitted to the hospital on 3/12/25, with a GT. When asked how often the GT dressing was changed, LVN 1 stated the GT dressing was supposed to be changed every day and when it was soiled. On 4/14/25 at 1128 hours, an interview was conducted with the DON. When asked about the GT dressing change, the DON stated the hospital followed Lippincott nursing standard of practice for GT care, and the hospital did not have the P&P for GT care. The DON acknowledged the GT dressing should be changed every day as per hospital’s nursing standard of practice. 37663 3.a. On 4/10/25 at 1516 hours, an observation at the telemetry room was conducted with the DON and Director of Quality Management. MT 1 was observed watching the cardiac monitors. MT 1 was asked about the ventilator alarms. MT 1 stated the ventilator alarms were connected to the call light system. The unit secretary was assigned to answer the call light and she would take over when the unit secretary was on break. She would call the room and ask if the staff was inside the room, if the staff was not in the room, and she would overhead page the RT. The DON stated at night the call light system was assigned to the MT, there was no unit secretary assigned for the night shift. On 4/11/25 at 1150 hours, interview and concurrent record review was conducted with the Director of Quality Management. Review of the call light log showed the following patient calls: - On 4/10/25, Patient 10 called at 1748 hours and the call was cancelled at 1830 hours. The patient’s call was completed after 42.23 minutes. - On 4/11/25, Patient 11 called at 1902 hours and the call was canceled at 1948 hours. The patient’s call was completed after 45.59 minutes. - On 4/12/25, Patient 12 called at 1740 hours and the call was canceled at 1830 hours. The patient’s call was completed after 49.54 minutes. The Director of Quality Management was asked about answering the patient’s calls. The Director of Quality Management stated the call light could only be canceled inside the patient’s room when the staff went to the room to answer the patient’s call. The Director of Quality Management stated he could not say anything about the above calls, sometimes the staff would not cancel the call light until they were done with the patient care. On 4/15/25 at 1010 hours, an interview was conducted with Patient 8 and the patient’s family member with the presence of the Director of Quality Management. Patient 8 was asked if the staff answered the call light when he called for the staff. Patient 8 stated he called last night, and no one came. Patient 8 stated could hear them laughing, but no one came. Patient 8 stated a male staff answered the call light and clicked to cancel the call light, but no one came. The patient called again. The staff answered the call light and clicked to cancel the call light, but no one came. When Patient 8 was asked for the reason he called the staff, Patient 8 stated he had a headache. Patient 8 was asked if he had gotten what he needed, Patient 8 stated eventually someone gave what he needed. Patient stated he was not happy at all with the hospital. Review of the call light log for Patient 8 was conducted with the Director of Quality Management. The call light log showed on 4/14/25 the patient’s call was placed at 1807 hours and was cancelled at 1822 hours; the call was completed after 14 minutes and 24 seconds. b. Review of the ventilator log for Patient 7 showed the following: * The short, repeated ventilator alarm generated calls and call cancellation were recorded on 4/11/25 from 1633 hours to 1651 hours (for 18 minutes). * The patient’s short, repeated ventilator alarm was on and off for 9 minutes on 4/12/ 25 at 0039 hours to 0053 hours. The RT Manager and Director of Quality Management was asked about these short, repeated ventilator alarms. The RT Manager stated there was no indication of the source of alarm, the alarm could be coming from the loose pulse oximeter, the patient might be coughing or moving. The alarms would reset itself. The Director of Quality Management stated the MT did not have to call unless the ventilator alarm was sustained. The MT might notify the nurse if the ventilator was alarming continuously. The Director of Quality Management was asked for the P&P for alarms. The Director of Quality Management stated there was no policy when the MT would initiate to call the RT. The Director of Quality Management was asked for the staff training for the medical device alarms. Review of the hospital’s reference for staff training titled Medical Device - Alarm Safety - Alarm Fatigue showed the following: - In an effort to improve the safety of clinical alarm system, the hospital leaders are required to set alarm management as a priority, established a formal policy and provide staff training around alarm safety. - The risk associated with sensory overload from beeping alarms has been cited as the number one technology -associated risk to patients for several years. When the nurses are unable to distinguish critical versus non-critical alarms, a condition known as “alarm fatigue”, they risk not responding to a life threatening emergency. - Device alarms are intended to alert clinicians of a hazardous condition and potential problems. However, when a caregiver is subjected to too many alarms, it disrupts his or her usual workflow and may result in errors due to omission, distraction, or inattention. - The lack of response due to excessive numbers of alarms resulting in sensory overload and desensitization is known as alarm fatigue. - Many medical devices have alarm systems; among them are bedside physiologic monitors that include call lights and ventilator. The findings were shared with the Director of Quality Management.”

“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: 38660 Based on observation, interview, and record review, the hospital failed to ensure the hospital’s P&P was implemented for one of 12 sampled patients (Patient 2) when the nursing staff failed to ensure the medications were administered separately through the enteral feeding tube for Patient 2. This failure increased the risk of substandard healthcare outcomes to the patients. Findings: Review of the hospital’s P&P titled Administration of Medications via Feeding Tube dated June 2023 showed in part: * Purpose: This procedure establishes a system by which medications will be administered to patients safely, accurately, and efficiently by qualified personnel. * Procedure - Prepare medications: crush tablets using a pill-crushing device and appropriate container to a fine powder, mix the crushed medication in a medication cup with 5 to 10 ml of fresh tap water. - Draw up medication. If ENFit syringe, use a medication straw. - Identify patient by two forms of identification on the wristband. - Observe feeding tube for a change in external tube length or incremental marking at the exit site to assure tube has not migrated. - After verifying proper tube placement, in the RUNNING mode, hit the Flush Now button, input desired flush volume (15-30 ml), then press ENTER. Place the pump to HOLD. - Remove the medication straw and attach the ENFIT medication syringe into the port of the feeding tube. - Slowly deliver the medication: each medication is administered separately through the enteral feeding tube; avoid mixing medications; do not add medication directly to enteral formula; whenever possible, use liquid medications to minimize risk of tube clogging. - After medication is administer, flush with 15- 30 ml fresh tap water either using syringe or use Flush Now on pump. On 4/10/25 at 0920 hours, an observation of medication administration for Patient 2 via GT was conducted with LVN 1. LVN 1 verified Patient 2’s identification and reconciled the following administered medications: * Magnesium oxide (a supplement) 400 mg tablet * Vitamin C (a supplement) 500 mg tablet * Multivitamin (a supplement) one tablet * Fenofibrate (an anti-cholesterol medication) 145 mg tablet * Desmopressin acetate (an antidiuretic medication) 0.1 mg tablet * Famotidine (an antacid - treat heartburn due to acid indigestion) 20 mg tablet * Lactobacillus (a probiotic) one tablet * Vitamin D (a supplement) 1000 IU two tablets Patient 2 was observed having a GT and was on continuous tube feeding. LVN 1 was observed priming the GT with water and started to prepare the medications. LVN 1 was observed placing all medications into a small bag and crushed all medications together by using the pill-crushing device. LVN 1 then draw 30 ml of tap water to flush the patient’s GT and checked for the residue of the GT for Patient 2. LVN 1 mixed the crushed medications with 50 ml of tap water in a cup, withdrew the mixture of medications and water in a syringe, and administered them to Patient 2’s GT. LVN 1 was observed rinsing the cup with 30 ml of tap water, withdrew the mixture in the syringe, and administered to Patient 2’s GT. LVN 1 was then observed flushing the GT with 30 ml of tap water. On 4/10/25 at 1120 hours, an interview and concurrent review of Patient 2’s medical record was conducted with LVN 1. Patient 2’s medical record showed the patient was admitted to the hospital on 3/12/25, and had a GT. The physician’s order to administer the medications to the patient via GT. LVN 1 confirmed LVN 1 she did not administer the medications via GT separately as per the hospital’s P&P. On 4/10/25 at 1140 hours, an interview was conducted with the DON. The DON 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: 37663 Based on interview and record review, the hospital failed to ensure the hospital’s P&P for the delivery of patient care, treatment, and services was implemented for the patients in Telemetry and Med/Surg units. This failure posed the increased risk of substandard health outcomes to the patients. Findings: Review of the hospital’s Organizational Plan for the Delivery of Patient Care, Treatment, and Services dated 3/23/2024, showed the following: * Nursing Service: the goal is to provide quality patient care in an acute long-term health care environment. This is achieved by facilitating and coordinating the members of the healthcare team to meet patient needs, assist in the rehabilitation process, and support the patient in the dying process, as recognized by the standards for the practice of nursing. * Staffing: - Licensed RN/LVN: for Med/Surg, 1 licensed nurse: 5 patients; for Telemetry, 1 licensed nurse: 4 patients. - CNA: 1 CNA: 10 patients for Med/Surg and Telemetry. On 2/3/25 at 1545 hours, an interview and record review was conducted with the COO/CCO and House Supervisor. The House Supervisor was asked for the nurse-to-patient ratio in the Med/Surg and Telemetry units. The House Supervisor stated the hospital practiced team nursing which included RN and LVN. The nurse to patient ratio was one nurse to 5 patients for Med/Surg unit and one nurse to four patients for Telemetry unit. 1. Review of the Shift Assignments dated 12/26/24 for 7 A to 7 P, showed the following: - There was a total of 41 patients, including eight patients in Telemetry, 29 patients in Med/Surg, and four patients in ICU. - Team A’s RN and LVN were assigned to 13 Med/Surg patients. - Team B’s RN and LVN were assigned to eight Med/Surg patients and four Telemetry patients (a total of 12 patients). - Team C’s RN and LVN were assigned to eight Med/Surg patients and four Telemetry patients (a total of 12 patients). - Team D had a LVN with nine Med/Surg patients. The House Supervisor verified the nurse patient ratio was out of ratio. 2. Review of the Night Shift Assignment dated 2/2/25 for 7 P to 7 A, showed the following: - There were eight Telemetry patients and 34 Med/Surg patients (total of 42 patients). - There were four CNAs for 42 patients. The findings were shared with the COO/CCO and verified the 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: 38660 Based on observation, interview, and record review, the hospital failed to ensure one of five sampled patients’ (Patient 2) plan of care was developed to reflect the use of restraints during their hospitalization. This failure created the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023, showed the RN will create and modify the patient’s plan of care. Elements of the Plan of Care includes the following: - The safety issue resulting in restraint use. - Desired measurable outcome-oriented goals. - Alternative interventions to minimize restraint use. - Ongoing evaluation to assess potential use of less restrictive alternatives. - Patient/family education regarding assessment of the need for restraints, including the condition or symptoms that pose harm to the patient; alternatives attempted; monitoring safe use of a restraint, including the patient’s response to the restraint. On 2/3/25 at 1434 hours, a tour of ICU was conducted with the Director of Quality Management and RN 2. Patient 2 was observed on bilateral wrist restraints. RN 2 stated the bilateral soft restraint were initiated when Patient 2 pulled off his trach. On 2/4/25 at 1305 hours, medical record review for Patient 2 was conducted with the Director of Quality Management. Patient 2’s medical record showed the patient was admitted on 1/30/25. Review of the Restraint Initiation/Order (Non-Violent Non-Self Destructive Behavior) showed the following: * On 2/2/25 at 0500 hours, the right and left wrists restraints were applied for Patient 2. * The nursing assessment or the reason for the use of restraint included the risk of injury to self-due to inability to understand or remain oriented, disturbing monitoring equipment or necessary treatment modality (pulling at lines/tubes/drains), and lack of safety awareness/did not seek assistance. Further review of Patient 2’s medical record did not show Patient 2’s plan of care was developed to reflect the use of restraints. The Director of Quality Management verified the 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: 37663 Based on interview and record review, the hospital failed to ensure their P&Ps were implemented as evidenced by: 1. The physician’s verbal order was not entered to the patient’s EMR for one of five sampled patients (Patient 4) as per the hospital’s P&P. This failure posed the increased risk for substandard health outcomes to the patient. 2. The hospital failed to ensure the performance evaluation was conducted annually for CNA 1 as per the hospital’s P&P. These failures posed the increased risk for substandard health outcomes to the patients. Findings: 1. Review of the hospital’s P&P titled Core: Ordering of Medications dated June 2022 showed the policy of the hospital is to ensure all medication orders must be entered into the patient’s medical record (computerized or manual) and must include: drug name, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner. In addition, indications for the medication should either be included as part of the medication order or documented elsewhere in the medical record. Verbal order and telephone orders will be minimized and must follow differentiation between verbal and written policy. All verbal and telephone orders will be read back to the physician or LIP and verified. Verification should include the spelling of the product and all the pertinent information. The authorized personnel transcribing the Verbal Order or Telephone Order is responsible for entering the order into the patient’s EMR. On 2/4/25 at 1425 hours, an interview and concurrent record review was conducted with RN 1 and the Director of Quality Management. RN 1 was asked about the verbal orders. RN 1 stated Patient 4’s physician was here for the patient this morning. Patient 4’s physician gave a verbal order for Lasix (diuretic) IVP. RN 1 stated he entered the physician’s verbal order of Lasix IVP for Patient 4. RN 1 was asked to show the physician’s verbal order that he entered in Patient 4’s EMR. RN 1 stated he wrote the verbal order as the telephone order because he could not enter the physician’s order as the verbal order. Review of Patient 4’s medical record was conducted with RN 1. Patient 4’s medical record showed the patient was admitted to the hospital on 1/29/25. Review of the Chronological Retrieval for Furosemide (same as Lasix) Data showed a physician’s telephone order dated 2/4/25 at 0749 hours, showing to give Lasix 40 mg IV times one dose. The physician’s order was read back to the provider. RN 1 acknowledged the order on 2/4/25 at 1418 hours. On 2/4/25 at 1510 hours, the Director of Quality Management was asked about entering the verbal orders. The Director of Quality Management stated there was an option in the EMR to place a verbal order. The Director of Quality Management showed how to enter a verbal order on the EMR. When asked, the Director of Quality Management stated RN 1 should have entered the above physician’s order as the verbal order. 38660 2. Review of the hospital’s P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose of this policy includes to provide a method to measure the employee’s performance based on the objective data and to validate competency on an ongoing basis. A summary of the employee’s initial and ongoing competency validation is maintained in the employee’s education file. The annual competency validation section showed the competency is an ongoing process and is achieved at least annually or more frequently if the needs indicate or are required by the regulatory agency. Annual skills are ongoing and should be completed throughout the given year. On 2/4/25 at 1550 hours, an interview and concurrent record review was conducted with the Education Manager. Review of the personnel’s files for CNA 1 showed CNA 1’s DOH was 12/10/10, and the Employee Annual Performance Appraisal Form was completed on 6/21/22. CNA ‘s personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital’s P&P. The Education Manager acknowledged the above finding and stated the Annual Performance Appraisal was supposed to be performed every year. On 2/4/25 at 1600 hours, a follow-up interview was conducted with the COO/CCO and the Director of Quality Management. They acknowledged the finding and stated all employees were required to have performance evaluation every year.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 22553 Based on observation, interview, and record review, the hospital failed to ensure RN 2’s qualification and competency were verified prior to providing direct patient care. This failure created the potential risk of unsafe care to the patient. Findings: Review of the hospital’s P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose of this P&P is to assure that all individuals who work in the hospital demonstrate knowledge and skill to fulfill their assigned responsibilities; to assure qualifications, health status, and facility orientation of individuals providing direct patient care are verified by the appropriate process for the individual’s affiliation or employment. Each member of the hospital staff is assigned clinical and managerial responsibilities based on educational preparation, applicable law and regulation, and an assessment of current competence. Components of the competency system include an initial Competency Assessment /Skill Validation. In collaboration with Education, the department supervisors, managers and/or directors are responsible for ensuring staff competency. On 12/4/24 at 1018 hours, during an observation in the medical/surgical telemetry unit, Patient 2 was observed positioned to the right side with wedge supporting on the back. The patient had a pair of waffle boots on the heels. On 12/4/24 at 1018 hours, during the concurrent interview with RN 3 regarding to the patient’s wound treatment, RN 3 stated Patient 2 had the following wound treatment order for the left heel and left 5th toe: apply betadine (antiseptic) soaked gauze to the wound bed. The treatment scheduled three times a week. The last treatment was completed on 12/3/24. Patient 2’s medical record was reviewed with the DQM on 12/4/24 at 1525 hours. Review of the Nurses Notes dated 12/3/24 at 2205 hours, showed RN 2 documented the assessment for Patient 2. Review of the Night Shift Assignment dated 12/3/24, showed RN 2 and LVN 1 were assigned for nine patients. On 12/4/24 at 1525 hours, the DQM was interviewed for RN 2’s competency. The DQM stated RN 2 was from a registry agency. RN 2 worked as the contracted staff. RN 2 was not the hospital employee and would not have the same hiring process as the hospital’s employee. The DQM stated to verify RN 2’s qualification and competency, the hospital would be getting personnel information from the cooperate and previous RN 2’s worked the hospital. On 12/5/24 at 1117 hours, a telephone interview was conducted with the Education Manager. When asked for the registry agency RN’s requirement regarding the direct patient care. The Education Manager stated the registry nurses had to be trained by the hospital staff. This was the corporate office’s policy. They were not able to work on the floor without completing their competency. The registry RN should be trained by the hospital staff who was the first group using the registry RN. On 12/5/24 at 1125 hours, during a follow-up interview with the DMQ, the DQM stated they did not have any documents to show RN 2’s qualification or competency provided by corporate office or other hospital. The DQM confirmed on 12/3/24, RN 2 was assigned and providing direct patient care in the medical/surgical telemetry unit without verification of the competency as per the P&P. The House Supervisor for that shift would be responsible to verify the RN’s competency.”

“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 adhere to the hospital’s P&Ps as evidenced by: 1. The nursing staff did not turn and reposition one of two sampled patients (Patient 1) every two hours as per the hospital’s P&P. 2. The hospital’s P&P related to Wound Care Team Assessment was not reviewed at least every three years as per the corporate’s P&P. 3. The hospital’s P&P related to Skin and Wound Care Program Overview was not reflected the hospital’s current practice. These failures posed the potential to result in poor health outcomes to the patients. Findings: 1. Review of the hospital’s P&P titled Core: Clinical Guidelines for Pressure Injury dated June 2022 showed the standard interventions for all patients can include but are not limited to repositioning orders (minimum every two hours turn). Unstageable pressure injury is defined as an obscured full-thickness skin and tissue loss which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by shough or eschar. On 12/4/24 at 0851 hours, Patient 1’s closed medical record was reviewed with the DQM. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 11/29/23. Review of the Nurse Notes dated 11/29/23 at 1656 hours, showed Patient 1 was evaluated for a community acquired pressure injury to the coccyx. The patient had an unstageable pressure injury to the coccyx area measuring 7 cm (length) x 5.5 cm (width) x unable to determine the wound depth. Review of the reposition document showed the following: * On 12/07/23 at 1616 hours to 2040 hours, Patient 2 was on the right side. * On 12/23/23 at 2021 hours to 12/24/23 at 0018 hours, Patient 2 was turned to the right. The DQM confirmed the findings. On 12/4/24 at 1233 hours, during an interview with RN 1, RN 1 stated the patients who could not perform their own self-care or had a pressure injury, the CNA and nursing staff would turn the patients every two hours and the CNA would document the turning in the patients’ medical records. 2. On 12/5/24 at 1105 hours, the DQM provided the Corporate Policy titled Policy on Policies. Review of the Corporate Policy titled Policy on Policies dated 12/18/23, showed the policy owners must review policies at least every three years or more frequently as needed. Review of the hospital’s P&P titled Core: Wound Care Team Assessment showed the P&P was released on June 2021. The DQM confirmed this P&P was overdue for review and there was no updated P&P for Wound Care Team Assessment. 3. Review of the hospital’s P&P titled Core: Skin & Wound Care Program Overview dated June 2023 showed reassessment of wound characteristics is completed with each dressing change. On 12/5/24 at 1356 hours, an interview was conducted with RN 3, a wound care RN. RN 3 reviewed the hospital’s P&P and Patient 1’s medical record. RN 3 stated the patient’s wound care dressing change was done every day by the wound care vocational nurse or a LVN. The LVN was not able to reassess for the patient’s wound but collected the data related to the wound appearance. RN 3 stated this P&P was not reflected their current practice.”

“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: 39796 Based on interview and record review, the hospital failed to ensure the performance evaluations were conducted annually for RN 3, RN 4, LVN 2, LVN 3, and CNA 2 as per the hospital’s P&P. This failure created the increased risk of unsafe care for the patients receiving services in the hospital. Findings: Review of the hospital’s P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose includes to provide a method to measure the employee’s performance based on the objective data and to validate competency on an ongoing basis. A summary of the employee’s initial and ongoing competency validation is maintained in the employee ’ s education file. The annual competency validation section showed the competency is an ongoing process and is achieved at least annually or more frequently if the needs indicate or are required by the regulatory agency. Annual skills are ongoing and should be completed throughout the given year. Review of the Employee Handbook (undated) showed the site management team may conduct an evaluation near the completion of the introductory period and after that once a year. On 8/23/24 at 1206 hours, an interview and concurrent record review was conducted with the COO/CCO and Education Manager. Review of the personnels’ files for RN 3, RN 4, LVN 2, LVN 3, and CNA 2 showed the following: * Review of RN 3’s personnel file showed RN 3’s DOH was 5/17/16, and the annual performance evaluation was compleleted on 6/7/22. RN 3’s personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital’s P&P. * Review of LVN 2’s personnel file showed LVN 2’s DOH was 3/8/22, and the performance evaluation was compleleted on 6/9/22. LVN 2’s personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital’s P&P. * Review of CNA 2’s personnel file showed CNA 2’s DOH was 8/27/01, and the performance evaluation was compleleted on 6/16/22. CNA 2’s personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital’s P&P. * Review of RN 4’s personnel file showed RN 4’s DOH was 10/25/22. However, RN 4’s personnel file did not show any documented evidence of the performance evaluations. * Review of LVN 3’s personnel file showed LVN 3’s DOH was 9/20/22. However, LVN 3’s personnel file did not show any documented evidence of the performance evaluations. An 8/23/24 at 1453 hours, the Education Manager was informed and acknowledged the above findings. On 8/23/24 at 1619 hours, a follow-up interview was conducted with the COO/CCO and Education Manager. They were asked if the policy was followed. The COO/CCO and Education Manager reviewed the hospital’s P&P and Employee handbook, and stated no. They were informed and acknowledged the findings.”