Kindred Hospital South Bay

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48342 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by the facility ’ s failure to: 1. Ensure physician orders were obtained prior to continuing clinical treatments when a nurse provided an invasive procedure, nasogastric tube continuous low intermittent suction to 1 of 46 patient (Patient 3) without a corresponding physician ’ s order. This deficient practice had the potential to result in improper clinical care and patient harm (Refer to A-0395). 2. Initiate or update a nursing care plan (a written action plan that documents a patient ’ s individual needs, risks, and goals to ensure consistent, quality care) for 6 of 30 sampled patients (Patient 14, Patient 15, Patient 17, Patient 22, Patient 23, and Patient 27). This deficient practice had the potential to result in Patient 14, 15, 17, 22, 23, and 27 not receiving the appropriate level of care and not meeting the specific needs for the identified patient concerns (Refer to A-0396). 3.A. Ensure nursing services implemented their policies and procedures regarding pressure injury (PI - skin injury caused by constant pressure) prevention for two (Patient 20 and Patient 24) of 30 sampled patients, when Patient 20 and Patient 24 ’ s clinical record reflected Patient 20 and Patient 24 were not repositioned and turned at least every two hours. This deficient practice had the potential for Patient 20 and Patient 24 ’ s pressure injuries to worsen and may have caused Patient 20 and Patient 24 to suffer from pain and develop additional pressure injuries (Refer to A-0398). B. Ensure that pain was assessed and/or reassessed for three of 30 sampled patients (Patient 13, Patient 23, and Patient 24) in accordance with the facility ’ s policy and procedure (P&P, the guiding set of rules and directions used to achieve consistent, desired outcomes or goals). This deficient practice had the potential to result in worsening symptoms, ineffective treatment, and delayed recovery for Patient 13, Patient 23 and Patient 24 (Refer to A-0398). C. Ensure nursing staff implemented physician orders for one (Patient 25) of 30 sampled patients, when facility gave Patient 25 liquid when only ice chips were ordered. This deficient practice had the potential to place patients at risk for harm by failing to provide care in accordance with physician orders which may result in aspiration pneumonia (breathing in something other than air into your lungs), the need for higher level of care, and other adverse patient outcomes (Refer to A-0398). D. Manage or treat symptoms of moderate pain assessed by the facility ’ s staff for one of 30 sampled patients (Patient 15) on multiple occasions. This deficient practice had the potential to result in worsening symptoms, delayed diagnosis of a missed underlying issue, distrust in healthcare due to ineffective management, and distress for Patient 15 (Refer to A-0398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48342 Based on observation, interview and record review, the facility failed to ensure that two (Patient 26, and Patient 27) of 30 sampled patient’s grievances (a formal, informal written or verbal complaint that is made to the hospital by the patient, or the patient’s representative, regarding the patient’s care) were managed in accordance with its grievance policy and procedure (P&P). This deficient practice had the potential to prevent patients and their representatives from receiving timely written notification of the hospital’s investigation, findings, and resolution of grievances, as required by the hospital’s grievance process and the conditions of participation for patient rights. Findings: During a review of Patient 26 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 3/31/2026, indicated, Patient 26 was admitted to the facility for acute and chronic respiratory failure (a condition where your blood does not have enough oxygen). During a review of Patient 27 ’ s “H&P” dated 4/30/2026, indicated, Patient 27 was admitted to the facility for neoplasm (an abnormal growth of tissue in the body, sometimes referred to as a tumor) related pain. During a concurrent interview, and record review for Patient 26 and Patient 27 on 06/25/2026 at 11AM with the Director of Quality (DOQ), the “Grievance Log” was reviewed. The log indicated that Patient 26 ’ s representative wrote a letter, and it was filed under a complaint by the DOQ not a grievance. The DOQ stated “Yes, this should be a grievance, but I took it as a complaint, therefore no grievance letter was sent out. I assumed that the situation was handled when Patient 26 was transferred out of the hospital”. The log also indicated that a Patient Representative for Patient 27 reported verbally an incident for abuse. During an interview and record review for Patient 27 on 06/26/26 at 1:50PM with the Chief Clinical Officer (CCO), the facilities “Abuse & Neglect Checklist” was reviewed. The CCO stated that “A grievance letter was not sent out, and we did not report to CDPH, I will take full responsibility as the CCO”. During a review of the facilities “Quality Performance Improvement Plan” (QAPI- data driven approach to improve the quality of care by the facility) dated 2026. The QAPI plan indicated the following: “Ensuring that processes for identifying and managing serious and sentinel patient safety events are defined and implemented”. During a review of the facility ’ s P&P titled, “Abuse & Neglect” dated 2/2025. The P&P indicated the following: 6. “Reports that are taken from patients and/or families and logged on the complaint and grievance form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the Chief Executive Officer.” During a review of the facility ’ s P&P titled, “Patient Complaint/Grievance Process” dated 6/2017. The P&P indicated the following: v. 3) “timely patient and/or family communication” i. “Once an action has been taken:” i. “Assure the complaining part is aware of the investigation results and actions taken” k. “If the resolution is unsatisfactory, or if the investigation/resolution will exceed 7 days:” i. “Send a “bridge” letter acknowledging the issue and providing a brief status report on the issue and efforts to address the issue. A bridge letter requires a final response when the investigation is complete”. During a review of the facility ’ s P&P titled, “Patient Complaints and Grievances” dated 4/2026. The P&P indicated the following: 2. “Facility will inform Patients/Family of the process to file a complaint and/or Grievance.” 3. “Facility will make all reasonable attempts to resolve Grievances and provide a written response to the patient or authorized representative within seven (7) days of 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 closed. During a review of the facility ’ s P&P titled, “Patient Complaint/ Grievances Process” dated 6/2017. The P&P indicated the following: “Definitions” “Complaint: A verbal complaint that is made by a patient, or on a patient’s behalf” “Grievance: A written or verbal complaint by a patient, or the patient ’ s representative regarding any aspect of the patients care 5. DQM (Director of Quality and Management) Responsibilities b. Determine whether the issue is a complaint or grievance and check appropriate box.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48342 Based on interview, and record review the facility failed to provide a written notice of its grievance (a formal, informal written or verbal complaint that is made to the hospital by the patient, or the patient’s representative, regarding the patient’s care) decision to the patient or the patient’s representative for two (Patient 26 and Patient 27) of 30 sampled patients whose concerns met the definition of grievance. This deficient practice had the potential to prevent patients and their representatives from receiving timely written notification of the hospital’s investigation and resolution of grievances and information regarding their right to pursue further review if dissatisfied with the hospital’s decision. Findings: During a review of Patient 26 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 3/31/2026, indicated, Patient 26 was admitted to the facility for acute and chronic respiratory failure (a condition where your blood does not have enough oxygen). During a review of Patient 27 ’ s “H&P” dated 4/30/2026, indicated, Patient 27 was admitted to the facility for neoplasm (an abnormal growth of tissue in the body, sometimes referred to as a tumor) related pain. During a concurrent interview, and record review for Patient 26 and Patient 27 on 06/25/2026 at 11AM with the Director of Quality (DOQ), the “Grievance Log” was reviewed. The log indicated that Patient 26 ’ s representative wrote a letter, and it was filed under a complaint not a grievance. The DOQ stated “Yes, this should be a grievance, but I took it as a complaint, therefore no grievance letter was sent out. I assumed that the situation was handled when Patient 26 was transferred out of the hospital”. The log indicated that a Patient Representative for Patient 27 filed an incident for abuse. During an interview and record review for Patient 27 on 06/26/26 at 1:50PM with the Chief Clinical Officer (CCO), the facilities “Abuse & Neglect Policy” dated 2/2025 was reviewed. The CCO stated that “A grievance letter was not sent out, and we did not report to CDPH, I will take full responsibility as the CCO”. During a review of the facilities “Quality Performance Improvement Plan” (QAPI- data driven approach to improve the quality of care by the facility) dated 2026. The QAPI plan indicated the following: “Ensuring that processes for identifying and managing serious and sentinel patient safety events are defined and implemented”. During a review of the facility ’ s P&P titled, “Abuse & Neglect” dated 2/2025. The P&P indicated the following: 6. “Reports that are taken from patients and/or families and logged on the complaint and grievance form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the Chief Executive Officer.” During a review of the facility ’ s P&P titled, “Patient Complaint/Grievance Process” dated 6/2017. The P&P indicated the following: v. 3) “timely patient and/or family communication” i. “Once an action has been taken:” i. “Assure the complaining part is aware of the investigation results and actions taken” k. “If the resolution is unsatisfactory, or if the investigation/resolution will exceed 7 days:” i. “Send a “bridge” letter acknowledging the issue and providing a brief status report on the issue and efforts to address the issue. A bridge letter requires a final response when the investigation is complete”. During a review of the facility ’ s P&P titled, “Patient Complaints and Grievances” dated 4/2026. The P&P indicated the following: 2. “Facility will inform Patients/Family of the process to file a complaint and/or Grievance.” 3. “Facility will make all reasonable attempts to resolve Grievances and provide a written response to the patient or authorized representative within seven (7) days of 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 closed. During a review of the facility ’ s P&P titled, “Patient Complaint/ Grievances Process” dated 6/2017. The P&P indicated the following: “Definitions” “Complaint: A verbal complaint that is made by a patient, or on a patient’s behalf” “Grievance: A written or verbal complaint by a patient, or the patient ’ s representative regarding any aspect of the patients care 5. DQM (Director of Quality and Management) Responsibilities b. Determine whether the issue is a complaint or grievance and check appropriate box.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48342 Based on interview, and record review the facility failed to ensure an allegation of patient abuse was reported to the California Department of Public Health (CDPH) in accordance with the facility policy and regulatory requirements for one (Patient 27) of 30 sampled patients. This deficient practice delayed external regulatory oversight and compromised the hospital’s patient safety processes for the identification, reporting, and management of abuse allegations. Findings: During a review of Patient 27 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 4/30/2026, indicated, Patient 27 was admitted to the facility for neoplasm (an abnormal growth of tissue in the body, sometimes referred to as a tumor) related pain. During a review of Patient 27 ’ s “Change of Condition Note” dated 5/6/2026. The note indicated Patient 27 alleged abuse (hurt or harmed) by a Certified Nursing Assistant (CNA 1) while being cleaned. The Registered Nurse (RN), Medical Doctor (MD), family, and police were notified. Patient 27 was assessed by RN 4 who documented that Patient 27 was alert, oriented, skin was intact and no physical injury noted. During a concurrent interview, and record review for Patient 27 on 06/25/2026 at 11AM with the Director of Quality (DOQ), the “Grievance Log” was reviewed. The log indicated that Patient 27 had an abuse allegation that was verbally reported to Social Worker (SW1) by a patient representative and then SW1 filed it under a complaint on 5/6/2026. The DOQ stated “I was not at work that day and therefore the responsibilities fell upon the CCO”. During an interview on 6/25/2026 at 2:11PM with the DOQ, the DOQ stated “This abuse allegation was not reported to CDPH, and it’s important we report timely abuse or any incidents to prevent further harm if any did occur”. During an interview and record review for Patient 27 on 06/26/26 at 1:50PM with the Chief Clinical Officer (CCO), the facilities “Abuse & Neglect Policy” dated 2/2025 was reviewed. The CCO stated that “A grievance letter was not sent out, and we did not report to CDPH, I will take full responsibility as the CCO”. During a review of the facilities “Quality Performance Improvement Plan” (QAPI- data driven approach to improve the quality of care by the facility) dated 2026. The QAPI plan indicated the following: “Domain one is to provide care that is safe, reliable and meets regulatory standards”. “Compliance with mandatory reporting requirements”. During a review of the facility ’ s policy and procedure (P&P) titled, “Abuse & Neglect” dated 5/2025, the P&P indicated the following: 9. “Team members must comply with all mandatory reporting laws and must notify the appropriate state or local agencies as applicable”. “The alleged violations are reported in the following timeframes: -No later than 2 hours after the allegation is made if the allegation involves abuse or serious bodily injury”.”

“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: 48342 Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained prior to continuing clinical treatments when a nurse provided an invasive procedure (any treatment or test where the body is entered by breaking the skin), nasogastric tube (tube insert through the nose into the stomach) continuous low intermittent suction (combines steady, mild vacuum pressure with automatic on-off cycling) to a one of 46 patient (Patient 3) without a corresponding (matching) physician ’ s order. This deficient practice had the potential to result in improper clinical care and patient harm. Findings: During a review of Patient 3 ’ s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/20/2026, indicated Patient 3 was admitted to facility on 6/20/2026 with diagnosis of small bowel obstruction (SBO, is a partial or complete blockage of the small intestine that prevents food, fluids, and gas from passing) and post underwent exploratory laparotomy (a major open abdominal surgery where a surgeon makes a large incision in the abdomen to visually examine the organs) on 6/17/2026 at outside hospital (OSH). During an observation on 6/23/2026 at 2:20 p.m., Patient 3 was observed lying in bed in a supine position (lying flat on your back with your face and body facing upward) with a nasogastric tube (NGT- tube insert through the nose into the stomach) connected to continuous low intermittent suction (combines steady, mild vacuum pressure with automatic on-off cycling) inserted in the patient ’ s left nostril. The suction tubing was actively removing dark green fluid, which was draining into a connected suction container. During a concurrent record review of the Medication Administration Record (MAR-record use to track drugs given to patients) and interview on 6/24/2026 at 11:13 a.m. with the Charge Nurse (CN1), CN1 stated that there was no physician order noted in the electronic health record (EHR-digital record of a patient medical history). CN1 further stated that there should have been a physician order for patient to have nasogastric tube (NGT) to low intermittent suction at the left naris since it was an invasive procedure (any treatment or test where the body is entered by breaking the skin). This was requiring a physician order. During a concurrent record review of the MAR and interview on 6/24/2026 at 3:20 p.m., with the Charge Nurse (CN1), CN1 stated that after checking Patient 3 ’ s paper chart, no physician order was found for continuous low intermittent suction for this admission. CN1 added that they had contacted the physician to obtain a verbal order. CN1 further stated that the patient had been admitted with continuous low intermittent suction already in place. The nurse should had contacted the physician to obtain an order when admitting the Patient 3. During a concurrent review of Patient 3 ’ s “Patient Transfer and Referral Record (a standardized medical document used to ensure safe, continuous care when a patient moves between healthcare facilities),” dated 6/20/2026 from the outside hospital (OSH), and an interview on 6/24/2026 at 3:30 PM with the Charge Nurse (CN1), it indicated that the OSH transfer documentation included an active medical order for a nasogastric tube (NGT) to low intermittent suction placed in the left naris. CN1 stated that the admitting nurse should have obtained an admitting provider order for continuation of the NGT upon the patient ’ s arrival on 6/20/2026. The facility did not obtain such an order at the time of admission. A review of Nursing Practice Act (NPA, is the body of California law that mandates the Board to set out the scope of practice and responsibilities for registered Nurses) detailed in Business & Professions Code § 2725, indicated that direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist.”

“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: 48342 Based on observation, interview and record review, the facility failed to ensure for six of 30 sampled patients (Patient 14, Patient 15, Patient 17, Patient 22, Patient 23 and Patient 27), an individualized nursing care plan (a document that helps a patient ’ s care team communicate and organize patient care) was initiated or updated in accordance with the facility ’ s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patient 14, Patient 15, Patient 17, Patient 22, Patient 23 and Patient 27 ’ s needs and risks. Findings: 1A. During a review of Patient 14 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/1/2025, the H&P indicated that Patient 14 had a past medical history of type 2 diabetes mellitus (DM II, a disease that causes a buildup of sugar in the blood), severe peripheral vascular disease (PVD, narrowing, blockage, or spasms of the blood vessels), bilateral (both) amputation (surgical removal of a limb or body part) of the legs, amputation of the penis (external male sex organ) with a suprapubic cystostomy (a surgically constructed connection through the abdominal wall into the urinary bladder to allow drainage of urine from the bladder when normal flow is restricted), amputation of the right hand, subdural hematoma (bleeding inside the brain usually caused by a head injury) after a fall with rebleeding (return of bleeding after it has already stopped), end-stage renal disease (ESRD, the final stage of kidney damage [CKD] often requiring kidney replacement therapy to remove waste) on hemodialysis (HD, a machine that filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough), craniotomy (surgical removal of part of the bone from the skull to expose the brain), and encephalopathy (the term used for symptoms that happen when the brain is not working normally). The patient was hospitalized for recent subdural hematoma, severe encephalopathy, and on hemodialysis. During a review of Patient 14 ’ s “Progress Note (a document that records information relevant to the patient ’ s treatment and response to treatment)”, dated 9/8/2025, the progress note indicated that Patient 14 remained anxious, restless, and agitated. Patient 14 was paranoid (an irrational and obsessive distrust of others), uncooperative (not willing to do what someone wants or asks for), and hyperverbal (tending to talk very much). It was recommended to increase Patient 14 ’ s Seroquel (an antipsychotic medication that treats several kinds of mental health conditions) and Haldol (a drug used to treat certain mental and neurological disorders). During a review of Patient 14 ’ s “Progress Note”, dated 9/16/2026, the progress note indicated that Patient 14 was disheveled (marked by disorder or disarray; unkempt), not responding to questions with a blank stare (an expression that shows no understanding or no emotion). Patient 14 was restless and agitated. Patient 14 presented with a flat affect (the inability to show emotion via facial expressions, body language, or tone of voice), pulling on lines (a flexible tube put into a patient ’ s body to get medicine, fluids, blood, or nutrition), and withdrawn (quiet and preferring to be alone). Patient 14 was noted to have poor insight and judgement (define). It was recommended to adjust Patient 14 ’ s medications as needed and to monitor Patient 14 ’ s behaviors. During a review of Patient 14 ’ s “Discharge Summary (a clinical document that outlines a patient ’ s entire hospital stay)”, dated 10/13/2025, the discharge summary indicated that Patient 14 was hospitalized for a subdural hematoma, severe encephalopathy, hemodialysis, chronic obstructive pulmonary disorder (COPD, a condition caused by damage to the airways or other parts of the lung), DM, and multiple amputations. Patient 14 fell at home and was noted to have a subdural hematoma. Patient 14 required a lot of sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs) for agitation (an unpleasant state of extreme arousal). Patient 14 was followed by neurology (define), psychiatry (define), and follow-up with the neurosurgeon (a medical doctor who diagnoses and treats conditions that affect a person ’ s nervous system, including the brain, spinal cord, and nerves). Patient 14 developed multiple drug-resistant (the ability to become unresponsive to one or multiple drugs) urinary tract infections (UTI, an infection in any party of the urinary system). Patient 14 was discharged home with home health (healthcare provided in the patient ’ s home) as requested by the family. During a record review on 6/25/2026 at 3:32 P.M., with Registered Nurse (RN 3), Patient 14 ’ s “Medication Administration Record (MAR, an official log used to document every drug administered to a patient)”, undated, was reviewed. The MAR indicated that Patient 14 was taking lorazepam (a medication that works in the brain to relieve symptoms of anxiety), hydrocodone (a medication for the treatment of moderate to severe pain), Haldol (a powerful antipsychotic [a drug used to treat psychosis] medication used as a chemical restraint to treat certain mental and neurological disorders), oxycodone immediate release (oxycodone IR, a medication used to treat moderate to severe pain quickly), Keppra (a drug used to treat seizures), heparin (a drug that slows the formation of blood clots), saline (a solution of salt and water) for irrigation (washing out an organ, body cavity, or a wound by flushing it with a fluid) of the suprapubic cystostomy, and multiple courses of intravenous (IV, within a vein) antibiotics (medications that fight bacterial infections) for infections (the invasion and growth of germs in the body). During a concurrent interview and record review on 6/25/2026 at 3:50 P.M., with RN 3, Patient 14 ’ s “Care Plans (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care)”, undated, were reviewed. RN 3 stated there was no care plan identifying Patient 14 ’ s pain, agitation, safety (state of being protected from harm or other danger), bleeding (the loss of blood), or urinary elimination needs. During an interview on 6/25/2026 at 4:01 P.M. with RN 3, RN 3 stated that Patient 14 should ’ ve had a care plan addressing Patient 14 ’ s safety needs and agitation due to Patient 14 ’ s psychiatric (dealing with cases of mental illness and its treatment) history, multiple amputations, and Keppra use for seizures (involuntary muscle movements caused by a sudden burst of electrical activity in the brain). RN 3 further stated that having a care plan was important to identify Patient 14 ’ s individual safety needs like seizure precautions (designed to protect a patient from injury and to reduce environmental stimuli that trigger the onset of a seizure) and the need for potential psychiatric holds (an involuntary commitment to a hospital or mental health facility for evaluation and treatment) to prevent harm or injury to Patient 14 as well as to staff and other patients. During an interview on 6/25/2026 at 4:10 P.M. with RN 3, RN 3 stated that Patient 14 should ’ ve had a care plan for Patient 14 ’ s urinary elimination needs based on Patient 14 ’ s history of ESRD on HD and suprapubic cystostomy secondary to a penile amputation (penectomy, a surgical procedure that removes part or all of a patient ’ s penis). RN 3 stated that having a care plan was important for monitoring Patient 14 ’ s ability to produce urine as needed to determine HD removal (the amount of fluid to be filtered and removed from a patient ’ s blood during hemodialysis), and to monitor urine clarity (a visual check of the urine ’ s appearance) to prevent infections. During an interview on 6/25/2026 at 4:17 P.M. with RN 3, RN 3 stated that Patient 14 should ’ ve had a care plan for pain due to Patient 14 having multiple complaints of pain and receiving several medications for pain. RN 3 stated that having a care plan was important to identify potential causes of Patient 14 ’ s symptoms, monitor the effectiveness (achieving the desired result or goal) of the treatment ordered and received, improve Patient 14 ’ s symptoms and recovery, and to establish trust in the healthcare providers ability to manage care. During an interview on 6/25/2026 at 4:29 P.M. with RN 3, RN 3 stated that Patient 14 should ’ ve had a care plan identifying Patient 14 ’ s risk for bleeding due to Patient 14 ’ s history of subdural hematoma, rebleeding, and heparin use. RN 3 stated this was important to monitor for potential rebleeding or new bleeding, monitor laboratory values (the numerical results obtained from diagnostic tests) as bleeding may cause Patient 14 ’ s blood count (a group of blood tests that measure the number and size of cells in the blood) to drop, and to monitor for unexplained bruising (a mark on the skin caused by blood trapped under the surface). During a review of the facility ’ s policy and procedure (P&P, a policy is a rule or guiding principle that sets the overall goal, while a procedure is the step-by-step “how-to” instructions required to achieve that goal and stay compliant), titled “CORE: Identification and Reporting of Chemical Restraints”, dated 6/2022, the P&P indicated: 3. Documentation a. Nursing The licensed nurse will: Maintain the patient specific plan of care in the electronic medical record (EMR) and/or paper medical record. During a review of the facility ’ s policy and procedure (P&P), titled “Procedure-Pain Management”, dated 7/2025, the P&P indicated: Nursing Delivery of Care Patient Plan of Care The registered nurse will develop a patient specific plan of care with identification of pain when conducting the patient’s admission assessment and/or anytime during the patient’s hospital stay. A licensed nurse involved in the care of the patient will update the patient specific plan of care as needed. b. The plan of care should consider realistic pain relief goals based on the individual patient’s pain history 1B. During a review of Patient 15 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/12/2025, the H&P indicated that Patient 15 had a past medical history of end-stage renal disease (ESRD, the final stage of kidney damage often requiring kidney replacement therapy to remove waste) on hemodialysis (HD, a machine that filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough), anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin), electrolyte imbalance (the levels of essential minerals in the body are too high or too low), diabetes mellitus (DM, a disease that causes a buildup of sugar in the blood), schizophrenia (a chronic brain disorder that disrupts how a person interprets reality), hypertension (HTN, the force of blood pushing against the artery walls is consistently too high), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, a digestive condition where stomach acid frequently flows backward into the esophagus), seizure disorder (a medical condition defined by recurring, involuntary muscle movements caused by a sudden burst of electrical activity in the brain ), chronic obstructive pulmonary disease (COPD, a long-term lung condition that blocks airflow and makes it difficult to breathe), congestive heart failure (CHF, a chronic condition where the heart muscle is weakened and cannot pump blood efficiently to the rest of the body), cerebral vascular accident (CVA or stroke, a condition where blood flow to part of the brain is suddenly blocked or a blood vessel ruptures), atrial fibrillation (AFib, an irregular heartbeat caused by an electrical signal that causes the heart ’ s upper chambers [atria] to quiver, preventing blood from pumping normally), encephalopathy (a term used for any disease, damage, or malfunction that affects the brain ’ s structure or function), lateral vocal cord paralysis (a condition where a vocal cord becomes stuck in an open or “out to the side” position leaving a gap), hypoxemic respiratory failure (when the lungs cannot properly transfer oxygen into the bloodstream), pericardial effusion (a buildup of excess fluid surrounding the heart [in the pericardial sac]) post pericardiocentesis (a medical procedure that uses a needle to drain excess fluid buildup from the protective sac surrounding the heart), cardiopulmonary arrest (the sudden, unexpected stopping of effective heart function and normal breathing), and traumatic brain injury (TBI, a disruption in normal brain function caused by sudden, external physical force). Patient 15 was “ill-appearing”. During a review of Patient 15 ’ s “Discharge Summary (a clinical document that outlines a patient ’ s entire hospital stay)”, dated 5/14/2026, the discharge summary indicated that Patient 15 had multiple falls from the bed, was nonverbal (communication or behavior that occurs without the use of spoken or written words), and bedbound (a person that spends most or all of their time in bed due to illness, injury, or physical limitations) during the hospital course. During a review of Patient 15 ’ s “Psychiatric Progress Note” (document use to track symptoms changes, medication effectiveness, treatment goals and safety), dated 1/12/2026, the progress note indicated that Patient 15 demonstrated marked withdrawal (a noticeable detachment or distancing from social activities, relationships, or reality) and significant physical debility (a state of physical weakness, lack of stamina, or loss of strength) with intermittent periods of increased motor restlessness (an uncontrollable, often involuntary urge to move the body or specific body parts to release inner tension) and irritability (a state of feeling easily annoyed, impatient, or frustrated) reported by nursing, suggestive of episodic anxiety (a response to stress, feelings of fear, or worry that comes and goes in sudden, temporary waves) or internal distress (a state of mental suffering, anxiety, or unease). During a review of Patient 15 ’ s “Psychiatric Progress Note”, dated 1/13/2026, the progress note indicated that Patient 15 was unresponsive to verbal stimuli (a spoken word, written text, or communicated instruction that prompts a physical, mental, or behavioral reaction) with absent engagement (complete lack of participation, interest, or emotional investment in a task, activity, or relationship), appearing somnolent (feeling sleepy, drowsy, or inclined to fall asleep). Patient 15 had recently attempted self-extubation (when a patient intentionally removes their own breathing tube [endotracheal or tracheostomy tube]) and exhibited intermittent irritability, psychomotor agitation (a feeling of intense, anxious restlessness that makes a person unable to sit still), and restlessness, suggestive of fluctuating mental status (a person ’ s level of awareness, thinking, or alertness changes significantly over the course of hours or days) possibly influenced by underlying medical acuity (the real reason behind the severity and urgency of a patient ’ s condition) or delirium (a sudden, severe state of confusion and altered awareness). During a concurrent interview and record review on 6/24/2026 at 9:50 A.M., with Registered Nurse (RN 3), Patient 15 ’ s “Vital Signs (measurable indicators of the body ’ s basic functions)”, was reviewed. RN 3 stated that there were multiple episodes of reported, moderate pain (pain that is distracting, interferes with a person ’ s daily activities, and is difficult to ignore) and/or assessed pain (a formal measurement and evaluation of a patient ’ s physical and emotional experience of pain), using the FLACC pain assessment tool (a scale used to measure pain in infants, young children, or non-verbal patients observing Face, Legs, Activity, Cry, and Consolability). RN 3 stated that Patient 15 ’ s pain was either not treated or treated with acetaminophen and not reassessed; and/or had no documented non-pharmacological interventions (non-chemical methods used to prevent, treat, or manage health conditions; instead of relying on medication) acknowledging Patient 15 ’ s symptoms of pain. During a record review on 6/24/2026 at 10:10 A.M. with RN 3, Patient 15 ’ s “Medication Administration Record (MAR, an official log used to document every drug administered to a patient)”, undated, was reviewed. The MAR indicated that Patient 15 was administered (given) acetaminophen (a medication used to relieve mild to moderate pain and reduce fever), heparin (an injectable anticoagulant [blood thinner] used to prevent blood clots or keep existing clots from getting larger), lorazepam (a medication primarily used for the short-term relief of severe anxiety, panic attacks, and insomnia, as well as to prevent seizures), Keppra (a medication used to control and prevent seizures), labetalol (a medication used to treat high blood pressure), and amlodipine (a medication used to treat high blood pressure and prevent chest pain) during the hospital course. During a concurrent interview and record review on 6/24/2026 at 10:23 A.M. with RN 3, Patient 15 ’ s “Care Plans (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care)”, undated, were reviewed. RN 3 stated that there was no care plan initiated for Patient 15 ’ s pain and risk for bleeding needs. During an interview on 6/24/2026 at 10:40 A.M. with RN 3, RN 3 stated that there should have been a care plan initiated for pain due to Patient 15 having multiple episodes of verbalized (spoken words) and/or assessed (evaluated) moderate to severe symptoms of pain. RN 3 further stated that pain could contribute to undesired behaviors (any action or response that is inappropriate, harmful, or goes against acceptable rules, norms, or personal goals); therefore, having a care plan was important for appropriate management and treatment of Patient 15 ’ s pain. RN 3 stated a care plan facilitates identification of the potential cause of symptoms (any feeling or physical change a person experience that indicates an illness or medical condition), monitors the effectiveness (achieving the desired result or goal) of interventions rendered, and incorporates the patient ’ s preference for pain relieve in their plan of care to establish trust in the healthcare providers ability to manage symptoms. RN 3 stated failure to acknowledge Patient 15 ’ s pain and provide appropriate treatment may have escalated Patient 15 ’ s behaviors of withdrawal and irritation due to discomfort. During an interview on 6/24/2026 at 10:53 A.M. with RN 3, RN 3 stated that a care plan should have been initiated identifying Patient 15 ’ s risk (the possibility of something harmful or damaging occurring) for bleeding (a medical state where a person is more likely than normal to experience uncontrolled blood loss) due to Patient 15 ’ s history of AFib and Heparin use. RN 3 further stated that Heparin was often used for AFib to prevent blood clots (a mass or lump of liquid blood that transformed into a solid or gel to stop bleeding) from forming in the heart, and may also be used for deep vein thrombosis (DVT) prophylaxis (the preventative measures taken to stop the formation of blood clots in the deep veins of the body) in patients with limited mobility (any physical condition that makes it difficult for a person to move, walk, or climb stairs easily). RN 3 stated that there was no indication for use noted for Patient 15; however, based on Patient 15 ’ s heparin use and history, a plan of care should have been initiated to monitor Patient 15 ’ s risk and prevent further complications (unexpected problem). During a review of the facility ’ s policy and procedure (P&P), titled “Procedure-Pain Management”, dated 7/2025, the P&P indicated: Nursing Delivery of Care Patient Plan of Care The registered nurse will develop a patient specific plan of care with identification of pain when conducting the patient’s admission assessment and/or anytime during the patient’s hospital stay. A licensed nurse involved in the care of the patient will update the patient specific plan of care as needed. b. The plan of care should consider realistic pain relief goals based on the individual patient’s pain history During a review of the facility ’ s P&P, titled “CORE: Interdisciplinary Assessment and Reassessment”, dated 6/2023, the P&P indicated: PROCEDURE Licensed, qualified staff assess each patient’s care needs throughout the patient’s hospital stay and provide patient specific care at the time based on assessment data. The assessment framework is structured around two components: Initial screening and assessment/reassessment of each patient as appropriate to the clinical discipline and individual patient condition changes. Nursing Department c. The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient’s goals and the nursing care to be provided to meet the patient specific needs. 1C. During a review of Patient 17 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/21/2026, the H&P indicated that Patient 17 presented with a history of cerebrovascular accident (CVA or stroke, a condition where blood flow to part of the brain is suddenly blocked or a blood vessel ruptures) with residual left-sided weakness (a lasting reduction in muscle strength, control, or sensation on the left side of the body), atrial fibrillation (AFib, an irregular heartbeat caused by an electrical signal that causes the heart ’ s upper chambers [atria] to quiver, preventing blood from pumping normally), metastatic prostate cancer (advanced or stage IV cancer that has spread from the prostate gland to other parts of the body), dysphagia (difficulty swallowing), repeat urinary tract infections (UTI, an infection in any part of the urinary system, which includes the kidneys, bladder, ureters, and urethra), sepsis (the body ’ s extreme, life-threatening response to an infection), anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin) related to chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and lose their ability to filter waste and excess fluid from the blood), hyperlipidemia (having abnormally high levels of fat [lipids] in the blood), anxiety (the body ’ s natural response to stress, feelings of fear, or worry about what might happen next), gastroesophageal reflux disease (GERD, a digestive condition where stomach acid frequently flows backward into the esophagus), hypothyroidism (a condition where the thyroid gland doesn ’ t produce enough thyroid hormones), benign prostatic hyperplasia (BPH, medical term for an enlarged prostate), congestive heart failure (CHF, a chronic, progressive condition where the heart ’ s muscle is too weak or stiff to pump enough oxygen-rich blood to the rest of the body) with an ejection fraction (EF, the percentage of blood pumped out of the heart ’ s main chamber with every heartbeat) of 40%, cataract (clouding of the eye ’ s natural lens), hypertension (HTN, the force of blood pushing against the artery walls is consistently too high), and pneumonia (an infection of the lungs that causes the small air sacs to become inflamed and filled with fluid or pus). Patient 17 had a past surgical history of cataract removal (a surgery to replace a cloudy eye lens with a clear artificial one) and transurethral resection of the prostate (TURP, a surgery that removes excess prostate tissue that is pressing on the urethra and blocking urine flow). During a review of Patient 17 ’ s “Vital Signs (measurable indicators of the body ’ s basic functions)”, Patient 17 had repeated, persistent, critically low blood pressure readings (hypotension, any blood pressure [BP] measurement below 90/60 which means the heart is not pumping blood with enough force to deliver oxygen to vital organs, placing a person at risk of shock) requiring vasoactive infusions (continuous intravenous [IV] medications used to actively manage blood pressure, heart rate, and blood flow) for survival. Multiple random blood pressure reading observations included: 6/9/2026 at 12:53 P.M. – Blood pressure (BP) 49/37 millimeters of mercury (mm Hg, measurement used to measure pressure, normal between 90/50 to 120/80 mm Hg) 6/9/2026 at 1:29 P.M. – BP 64/50 mm Hg 6/14/2026 at 6:45 A.M. – BP 73/47 mm Hg 6/14/2026 at 9:18 A.M. – BP 77/40 mm Hg 6/14/2026 at 5:26 P.M. – BP 75/36 mm Hg 6/22/2026 at 6:18 A.M. – BP 74/43 mm Hg 6/22/2026 at 5:10 P.M. – BP 67/40 mm Hg 6/24/2026 at 6:43 A.M. – BP 88/44 mm Hg During a concurrent interview and record review on 6/25/2026 at 2:00 P.M., with Registered Nurse 3 (RN 3), Patient 17 ’ s “Medication Administration Record (MAR, an official log used to document every drug administered to a patient)”, undated, was reviewed. The MAR indicated that Patient 17 was receiving norepinephrine (a continuous intravenous [IV] medication given to rapidly raise dangerously low blood pressure), vasopressin (a continuous, controlled IV drip of synthetic antidiuretic [a substance that suppresses urine formation] hormone given to critically ill patients to rapidly increase and stabilize dangerously low blood pressure), apixaban (an anticoagulant, or blood thinner that prevents blood clots from forming or getting larger), hydrocodone (a potent opioid [narcotic] pain reliever and cough suppressant), levothyroxine (a synthetic [lab-made] hormone used to treat an underactive thyroid gland [hypothyroidism]), hydralazine (a medication used to treat high blood pressure and heart failure), and clonidine (a medication that works by calming the nervous system primarily used to treat hypertension) during this hospitalization. During a concurrent interview and record review on 6/25/2026 at 2:22 P.M., with RN 3, Patient 17 ’ s “Care Plans (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care)”, undated, were reviewed. RN 3 stated there was no care plan initiated for Patient 17 ’ s persistent, critically low blood pressure readings which places Patient 17 at risk for cardiac output (the total volume of blood the heart pumps every minute) deficiency or perfusion (the body ’ s process of delivering oxygenated blood and nutrients to tissues and organs through the circulatory system) needs. During an interview on 6/25/2026 at 2:31 P.M., with RN 3, RN 3 stated that a care plan should have been initiated for Patient 17 ’ s hypotension (low BP) and risk for ineffective tissue perfusion (a decrease in blood flow to the body ’ s tissues) or decreased cardiac output (when your heart doesn ’ t pump enough blood to meet your body ’ s basic needs). RN 3 stated that a care plan was important to effectively monitor Patient 17 ’ s BP and titrate (to gradually adjust or measure something in small, precise steps to reach a specific target) administration of Patient 17 ’ s vasoactive infusions to maintain a systolic blood pressure (SBP, the top number in a blood pressure reading. It measures pressure exerted on the artery walls when the heart beats and pushes blood into the body) above 90 mmHg and a mean arterial pressure (MAP, the average pressure in the arteries that tells the doctors how well blood is flowing to vital organs like the brain and kidneys) above 60 mmHg. RN 3 further stated that a plan of care was important to identify other interventions required to maintain Patient 17 ’ s stabilization, that may have resulted as a complication of having hypotension (i.e. monitoring laboratory results, checking oxygen saturation/increased vital signs monitoring, administration of fluids to restore volume, etc.), and to maintain consistency of care to achieve stabilization for Patient 17 during a critical period. During a review of the facility ’ s P&P, titled “CORE: Interdisciplinary Assessment and Reassessment”, dated 6/2023, the P&P indicated: PROCEDURE Licensed, qualified staff assess each patient’s care needs throughout the patient’s hospital stay and provide patient specific care at the time based on assessment data. The assessment framework is structured around two components: Initial screening and assessment/reassessment of each patient as appropriate to the clinical discipline and individual patient condition changes. Nursing Department c. The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient’s goals and the nursing care to be provided to meet the patient specific needs. 2A. During a review of Patient 22 ’ s “History and Physical,” (H&P, a formal and complete assessment of the patient and the problem), dated 06/17/2026, the “H&P” indicated, Patient 22 was admitted to the facility on 06/17/2026 with medical history including but not limited to, diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder, chronic g tube (gastrostomy tube, a surgical opening fitted with a device to allow feedings to be administer directly to the stomach, common for people with swallowing problems) dependence. The H&P indicated, “Per EMS and facility report patient was nonverbal (communication, actions, or methods that do not rely on spoke or written words) and had a seizure like activity.” The “H&P” further indicated Patient 22 ’ s medications included but were not limited to, Valproic Acid [a medication that acts to prevent seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] 750 milligrams (mg, a metric unit of measurement, used for medication dosage and/or amount), every eight hours via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administer directly to the stomach, common for people with swallowing problems). During a review of Patient 22 ’ s Nursing Admission note (a comprehensive clinical document completed when a patient enters a healthcare facility, establishing the patient ’ s baseline health status and identifying immediate care needs), dated 06/18/2026, Patient 22 ’ s nursing admission note indicated, “Expressions of ideas and wants: Rarely/never expresses self or speech is very difficult to understand,” and “Understanding verbal content: Rarely/never understands.” During a concurrent interview and record review on 06/24/2026 at 3:21 p.m. with Registered Nurse (RN) 1, Patient 22 ’ s current electronic medical record was reviewed. RN 1 verified Patient 22 ’ s care plans did not include a care plan for seizures or a care plan addressing a method of communication applicable to patient 22 ’ s nonverbal status. RN 1 stated, “If there is no care plan, we are not addressing the disease process or providing proper treatment according to the patient ’ s condition.” RN 1 stated the care plan process begins on admission and missed opportunities to initiate a care plan means the patients ’ needs aren ’ t being fully addressed. During a concurrent interview and record review on 06/26/2026 at 10:00 a.m. with RN 2, the electronic medical record was reviewed. RN 2 verified in the electronic medical record Patient 22 was receiving Valproic Acid for Patient 22 ’ s history of seizures. RN 2 verified in the electronic medical record there was no current care plan for seizures. RN 2 stated not having a care plan related to a Patient 22 ’ s situation makes it easy for the staff to not have a focus on the interventions, in this case seizure precautions for Patient 22. 2B. During a review of Patient 23 ’ s “Nursing Admission” note (document use to establish patient ’ s baseline upon entering healthcare facility), dated 06/19/2026, the nursing admission note indicated, Patient 23 was admitted to the facility on 06/19/2026 at 5:00 p.m. During a review of Patient 23 ’ s Physician “Progress Note” (an essential clinical document that records changes in a patient ’ s health status, treatment responses, and ongoing care plans), dated 06/23/2026, the progress note indicated Patient 23 was admitted to the facility for the co-morbidities (the presence of two or more distinct medical conditions or diseases occurring in the same person at the same time) including but not limited to, bacteremia (the presence of bacteria in the bloodstream), end-stage renal disease (ESRD, irreversible kidney failure), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and the condition of being hard of hearing (mild to severe hearing loss; some can still hear sounds, but it is hard to understand speech clearly). During a concurrent interview and record review on 06/24/2026 at 2:21 p.m. with Registered Nurse (RN) 1, Patient 23 ’ s current electronic medical record was reviewed. RN 1 verified Patient 23 ’ s care plans did not include a care plan for ESRD (irreversible kidney failure), dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), infection (the invasion and multiplication of harmful organisms within the body), glucose (simple sugar – the body ’ s primary source of energy from food) monitoring, and fluid intake and output (the measurement of all fluids entering and leaving the body, measurements crucial in dialysis patients who may not have the ability to rid themselves of excess fluid). RN 1 stated, “If there is no care plan, we are not addressing the disease process or providing proper treatment according to the patient ’ s condition.” RN 1 stated the care plan process begins on admission and missed opportunities to initiate a care plan means the patients ’ needs aren ’ t being fully addressed. During an observation and interview on 06/25/2026 at 1:57 p.m. with Patient 23 at Patient 23 ’ s bedside, Patient 23 stated she needed her hearing aids to talk to surveyor. Patient 23 could not find her hearing aid battery and proceeded to use her cell phone and asked surveyor to use voice dictation to speak with her (Patient 23). During a review of the facility ’ s policy and procedure (P&P) titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” released 06/2023, the P&P indicated: “A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient ’ s goals and the nursing care to be provided to meet the patient specific needs.” “Patients are re-evaluated by a licensed nurse at a minimum every 12 hour 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 ...” 3. During a review of Patient 27 ’ s “History & Physical” (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination)” dated 4/30/2026. The H&P indicated Patient 27 was admitted to the facility for neoplasm (an abnormal growth of tissue in the body, sometimes referred to as a tumor) related pain. During a review of Patient 27 ’ s “Change of Condition Note” (document any changes from a patient ’ s baseline health) dated 5/6/2026. The note indicated Patient 27 alleged abused (hurt or harmed) by a Certified Nursing Assistant (CNA 1) while being cleaned. The Registered Nurse (RN), Medical Doctor (MD), family, and police were notified. Patient 27 was assessed by RN 4 who documented that Patient 27 was alert, oriented, skin was intact and no physical injury noted. During a concurrent interview and record review on 6/25/2026 at 2:11PM with RN1, Patient 27 ’ s “Plan of Care” (POC) was reviewed. The POC indicated that there was no update by RN4 after the alleged abuse. RN1 stated “It is important to document a care plan after a significant change in the patient’s condition so we can prevent these things from happening again, it is the expectation that we as RNs document, if it ’ s not documented then that means it’s not done, we cannot just rely on hearsay, documentation is key”. During a concurrent interview and record review on 6/26/2026 at 10:11AM with RN4, the “Care Plan” dated 5/6/2026 was reviewed. RN 4 stated “I do not see free from abuse on the care plan, as a RN it is important that we update care plans so it doesn ’ t happen again and we can keep track of what happened.” During a review of the facility ’ s “Registered Nurse Job Description” dated 1/2025. The Job description indicated the following: Documents patient admission assessment and reassessments, patient care plans and other pertinent information, completely in the patients medical record according to nursing standards and policies. Develops nursing care plan of assigned patient on admission, updates plan of care as needed and ensures plan of care is coordinated with patient, family, and other members of the team. Revises the plan of care as indicated by the patient ’ s response to treatment and evaluates overall plan daily for effectiveness. During a review of the facility ’ s policy and procedure (P&P) titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated 06/2023, the P&P indicated: i. “Documentation of assessments, care plan updates, nutrition interventions and nutrition education is completed in the medical record.” During a review of the facility ’ s policy and procedure (P&P) titled, “Abuse & Neglect” dated 5/2025, the P&P indicated the following: 8. “Team members must initiate and document a care plan to ensure the patients safety”.”

“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: 48342 Based on interview and record review, the facility failed to ensure: A Ensure nursing services implemented their policies and procedures regarding pressure injury (PI – skin injury caused by constant pressure) prevention for two (Patient 20 and Patient 24) of 30 sampled patients, when Patient 20 and Patient 24 ’ s clinical record reflected Patient 20 and Patient 24 were not repositioned and turned at least every two hours. This deficient practice had the potential for Patient 20 and Patient 24 ’ s pressure injuries to worsen and may have caused Patient 20 and Patient 24 to suffer from pain and develop additional pressure injuries. B. Ensure that pain was assessed and/or reassessed for three of 30 sampled patients (Patient 13, Patient 22, and Patient 23) in accordance with the facility ’ s policy and procedure (P&P, the guiding set of rules and directions used to achieve consistent, desired outcomes or goals). This deficient practice had the potential to result in worsening symptoms, ineffective treatment, and delayed recovery for Patient 13, Patient 22 and Patient 23. C. Ensure nursing staff implemented physician orders for one (Patient 25) of 30 sampled patients, when facility gave Patient 25 liquid when only ice chips were ordered. This deficient practice had the potential to place patients at risk for aspiration and develop pneumonia (breathing in something other than air into your lungs), the need for higher level of care, and other adverse patient outcomes. D. Manage or treat symptoms of moderate pain assessed by the facility ’ s staff for one of 30 sampled patients (Patient 15) on multiple occasions. This deficient practice had the potential to result in worsening symptoms, delayed diagnosis of a missed underlying issue, distrust in healthcare due to ineffective management, and distress for Patient 15. Findings: A.1. During a review of Patient 20 ’ s “History and Physical (H&P-a formal and complete assessment of the patient and the problem), dated 05/15/2025, the H&P indicated, Patient 20 was admitted the facility with diagnosis of a large cerebrovascular accident (CVA, a stroke, loss of blood flow to a part of the brain) with craniectomy (a major surgical procedure in which a surgeon permanently removes a section of the skull and leaves the opening unclosed) and subsequent cranioplasty (a surgical procedure that repairs or reshapes a skull defect), post operative respiratory failure [a severe surgical complication defined as prolonged mechanical ventilation (a life support system that uses a machine called a ventilator to assist or completely take over a patient ’ s breathing) or unplanned reintubation (sudden placement of a breathing tube down the throat)], large sacral (a triangular bone at the base of the spine) decubitus (injuries to the skin and underlying tissue caused by prolonged, unrelieved pressure on the body), hypertension (HTN, high blood pressure), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 20 ’ s Nursing Admission note (a comprehensive clinical document completed when a patient enters a healthcare facility, establishing the patient ’ s baseline health status and identifying immediate care needs), dated 5/16/2025, indicated Patient 20 arrived at the facility with a known pressure injury (PI – skin injury caused by constant pressure) in the sacrum (a large triangular bone located at the base of the spine) and right ischial tuberosity [the lower, rounded bony projections of the hip bones] (stage 4, a pressure injury staging indicating a severe wound that extends through the skin into the underlying tissues, exposing muscle, tendons, ligaments, or bones). During a review of Patient 20 ’ s Physician Order, dated 08/03/2025, the order indicated: Reposition (place something in a new or different position) ...start 08/03/2025 at 6:00 p.m., every two hours. During a concurrent interview and record review on 06/24/2026 at 11:54 a.m. with Registered Nurse (RN) 1, Patient 20 ’ s repositioning flow sheets (tool use to track when bedbound patients are turned) dated 08/03/2025 and 08/05/2025 were reviewed. The flow sheets indicated: On 08/05/2025 from 4:00 p.m. to 7:58 p.m. Patient 20 was on her left side for 3 hours and 58 minutes in same position. RN 1 stated every two-hour repositioning allows for checks to make sure there is no moisture or pressure points. RN 1 stated much damage skin can occur if repositioning isn ’ t completed frequently. RN 1 stated when repositioning isn ’ t completed when it should be, a patient can get more skin damage if the patient already has a pressure injury in place. 2. During a review of Patient 24 ’ s H&P, dated 06/01/2026, the H&P indicated Patient 24 was admitted to the facility for sepsis (a life threatening blood infection), septic shock (a severe, life threatening stage of sepsis), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing)., hypertension (HTN, high blood pressure), intubation (a medical procedure where a tub is inserted into the body to keep the airway open and deliver oxygen), ventilatory support (a medical device used to help support or replace breathing), and subsequent tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe). During a review of Patient 24 ’ s “Admission Nursing” note (a comprehensive clinical document completed when a patient enters a healthcare facility, establishing the patient ’ s baseline health status and identifying immediate care needs), dated 06/02/2026, indicated Patient 24 “Admission wound assessment – Pressure injury: sacrum,” and “Roll left to right: partial/moderate assistance.” During a review of Patient 24 ’ s Physician Order, dated 06/02/2026, indicated: Reposition, start 06/02/2026, every two hours. During a concurrent interview and record review on 06/24/2026 at 10:08 a.m. with RN 1, Patient 24 ’ s turning and repositioning flow sheet was reviewed. The flow sheet indicated: a. On 6/19/2026 at 1:46 a.m.: positioned to right side. On 6/19/2026 at 3:34 a.m.: positioned self. Right, left, or supine (the body position of lying on the back with the face upward) position not indicated. On 06/19/2026 at 6:39 a.m.: repositioned to supine position Patient 24 was on her right side in same position for 3 hours and 5 minutes between Repositioning on 6/19/2026 from 3:34 a.m. to 6:39 a.m.. b. On 06/19/2026 at 9:18 a.m.: repositioned to left side. On 06/19/2026 at 12:00 p.m.: repositioned to supine position. Patient 24 was on her left side for 2 hours and 42 minutes between repositioning on 6/19/2026 from 9:18 a.m. to 12:00 p.m.. c. On 6/21/2026 at 4:00 a.m.: repositioned to supine position. On 6/21/2026 at 8:00 a.m.: repositioned to right side. Patient 24 was on her back (supine position) for 4 hours between repositioning on 6/21/2026 from 4:00 a.m. to 8:00 a.m. . During an interview on 06/24/2026 at 11:54 a.m. with Registered Nurse (RN) 1, RN 1 stated much damage skin can occur if repositioning isn ’ t completed frequently. RN 1 stated when repositioning isn ’ t completed when it should be, a patient can get more skin damage if the patient already has a pressure injury in place. During a review of the facility ’ s guidelines regarding skin care titled, “Medline. Skin Health, Wound and Skin Treatment Guidelines, ScionHealth” copyright 2025, the guidelines did not indicate a turning or repositioning guidelines. B.1. During a review of Patient 13 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/3/2025, the H&P indicated that Patient 13 was admitted for altered mental status (any sudden or noticeable change in a person ’ s normal thinking, awareness, or alertness) status post (s/p, “after” or “following”) septic shock (a severe, life-threatening immune response to an infection causing dangerously low blood pressure and organ failure), secondary to (caused by) pneumonia (an infection of the lungs that causes the small air sacs to become inflamed and fill with fluid or pus). Patient 13 had a past medical history of chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and lose their ability to filter waste and excess fluid from the blood), multiple myocardial infarctions (MI, medical term for heart attack; when blood flow to part of the heart is blocked, usually by a blood clot), cerebrovascular accident (CVA or stroke, 9/21/2017, a condition where blood flow to part of the brain is suddenly blocked or a blood vessel ruptures). During a record review on 6/24/2026 at 1:50 P.M., with Registered Nurse (RN 3), Patient 13 ’ s “Medication Administration Record (MAR, an official log used to document every drug administered to a patient)”, undated, and “was reviewed. The MAR indicated that Patient 13 received colchicine (a medication primarily used to treat and prevent gout [a painful form of inflammatory arthritis]), allopurinol (a medication used primarily to prevent gout attacks and kidney stones), morphine sulfate (a potent prescription painkiller [opioid, a powerful class of drugs that block pain signals] for treating pain) one-time only, oxycodone immediate release (IR, a fast-acting prescription opioid pain medication) from 10/3/2025 through 10/10/2025, and acetaminophen (a common medication used to relieve mild to moderate pain and reduce fever) as needed for mild pain (1-4) during the hospitalization period, amongst other medications. During a concurrent interview and record on 6/24/2026 at 2:00p.m., RN 3 review of Patient 13 ’ s Medication Administration Record (MAR) indicated: Patient 13 received morphine intravenously (IV, given directly into a vein), one-time, on 10/20/2025 at 3:47 P.M., for a pain score of nine out of 10 (9/10) on the numeric pain scale (an 11-point tool used to measure pain intensity from 0 “no pain” to 10 “worst pain imaginable”). RN 3 stated the reassessment (the act of evaluating or estimating something again) was performed at 4:25 P.M. with a pain score of 0/10. RN 3 stated reassessment was not required due to the medication being a “one-time order” (a medical instruction from a healthcare provider to give a medication or treatment exactly once) that does not require reassessment, despite documentation of Patient 13 having a pain score of 9/10 prior to medication administration. Patient 13 also had a pain score of 4/10 utilizing the FLACC pain scale (an observational tool used to measure pain in patients who cannot verbally communicate. It stands for Face, Legs, Activity, Cry, and Consolability) with acetaminophen given at 8:59 A.M. and reassessed at 9:57 A.M. with a pain score of 0/10. On 10/14/2025 at 6:10 A.M., Patient 13 received acetaminophen for a pain score of 4/10. Reassessment was performed at 8:25 A.M. with a pain score of 0/10 documented. On 10/6/2025 at 10:34 A.M., Patient 13 was assessed to have a pain score of 8/10 utilizing the visual pain scale (a communication tool that helps a person describe their level of pain. It uses a straight line or series of drawn faces. The faces may be pointed to or marked at the exact spot that matches how much pain is felt). RN 3 stated there were no interventions documented for treatment. The next assessment was documented at 1:42 P.M. with a pain score of 0/10. On 11/1/2025 at 9:00 A.M. Patient 13 had a wound-related pain score of 4/10 with oral (by mouth) acetaminophen given. Reassessment was performed at 9:30 A.M., with a score of 0/10. Patient 13 had a pain score of 4/10 at 2:30 P.M. with acetaminophen given. Reassessment was performed at 3:30 P.M. with a pain score of 2/10 documented. Patient 13 had pain again at 8:33 P.M. with acetaminophen given for a pain score of 5/10. Reassessment was performed at 9:10 P.M. with a pain score of 0/10 documented. RN 3 stated that there were no other interventions offered or administered despite repeated reports or assessments of pain. On 11/2/2025 at 5:40 A.M., Patient 13 had a wound-related (any physical discomfort, aching, or stinging sensation directly caused by a break in the skin or underlying body tissue) pain score of 6/10 documented. Reassessment was performed post acetaminophen at 6:10 A.M. with a numeric pain score of 0/10 documented due to Patient 13 sleeping. At 10:15 P.M. Patient 13 again had a pain score of 4/10. RN 3 stated there are no interventions documented. The next pain assessment was performed at 2:00 A.M. on 11/3/2025. On 11/10/2025 at 10:04 A.M. Patient 13 had a pain score of 4/10 with acetaminophen administered. Reassessment was performed at 12:42 P.M. with a pain score of 0/10 due to Patient 13 sleeping. On 11/11/2025 at 8:50 A.M., Patient 13 had a pain score of 4/10. Acetaminophen was administered with reassessment performed at 11:21 A.M., Patient 13 had a pain score of 0/10 due to sleeping During an interview on 6/24/2026 at 2:40 P.M., with Registered Nurse 3, RN 3 stated that reassessment of an oral (taken by mouth) medication should be performed one hour after administration of the medication and 30 minutes after administration of an intravenous (IV, given directly into a vein) medication. RN 3 stated that reassessment was important to evaluate the effectiveness (the degree to which something successfully produces a desired result or achieves a specific goal) of a medication given and for management of the patient ’ s symptoms. RN 3 further stated that reassessment allows for additional interventions to be trialed to assist with pain management. During a concurrent interview and record review on 6/24/2026 at 2:50 P.M., with RN 3 and Wound Nurse (WN 1), Patient 13 ’ s “Wound Notes (medical records that are used to track how a wound is healing over time), were reviewed. WN 1 stated based on record review, Patient 13 ’ s sacral wound became unstageable (a wound or pressure ulcer is too heavily covered by dead tissue to determine its true depth) on 10/24/2025 despite ongoing treatment. Patient 13 ’ s left ischial tuberosity (a bony bump at the very bottom of the pelvis; commonly known as the “sit bone”, it is the part of the body that bears the body ’ s weight when sitting) became unstageable on 10/24/2026 and the right ischial tuberosity became a stage 3 wound (involves full-thickness tissue loss, a deep crater-like sore broken all the way through, exposing the underlying later of fat) on 11/19/2026. WN 1 stated that Patient 13 had mixed vascular extremity wounds and wounds to the buttock present on admission. WN 1 stated Patient 13 ’ s wounds became worse and/or new wounds developed, despite aggressive treatment, due to Patient 13 ’ s multiple comorbidities (the presence of two or more distinct medical or psychological conditions occurring in the same person at the same time) and medical condition. WN 1 stated that pain is subjective and different for each individual but would like to assume that there may be pain related to a patient having wounds. WN 1 stated the facility ’ s other wound nurse would have more knowledge about Patient 13 ’ s wound treatments and progress but was unfortunately not available for interview. During an interview on 6/24/2026 at 3:31 P.M., with RN 3, RN 3 stated that additional pain interventions should have been offered or the need for additional interventions assessed, due to Patient 13 ’ s history of multiple medical conditions that could cause pain, the development of worsening wounds, and the repeated reports/assessments of moderate to severe pain. RN 3 stated that acetaminophen was typically used for mild, sporadic (something that happens irregularly, occasionally, or in scattered instances without a constant pattern) pain, but for repeated, persistent symptoms, the need for additional interventions should have been assessed. RN 3 stated that Patient 13 ’ s pain was not always reassessed according to the facility ’ s policy of 30 minutes after IV medication administration and one hour after oral medication administration. RN 3 further stated that reassessing interventions too soon or too late could result in inaccurate conclusions and delayed diagnosis of the true cause for symptoms, as medications require time to effectively work. During a review of the facility ’ s policy and procedure (P&P, define), titled “Procedure-Pain Management”, dated 7/2025, the P&P indicated: PROCEDURE: Assessments of Patients 1. The Registered Nurse performs a pain assessment during the patient admission assessment. Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient’s medical record. 4. Ongoing Assessments/Reassessments by licensed nursing staff: Pain is assessed at least every shift during regular shift assessments, with patient complaints of pain, as needed related to patient’s treatment(s)/patient condition, after analgesic administration and other pain interventions. Reassessment of pain is conducted through: Evaluation and documentation of response to pain interventions Progress toward pain management goal including functional ability. Side effects of treatment Risk factors for adverse events caused by the treatment. When pain is identified, nursing assessment and documentation in the patient medical record includes the pain scale rating, location, duration, intensity, and character. Nursing judgment and patient condition determine if patient vital signs and other signs and symptoms (as noted in b. iv. Assessments of Patients) associated with the patient’s pain are assessed and documented by the licensed nurse. Reassessment of pain relief interventions vary according to patient level of pain and patient status, pain relief interventions performed by the nurse and/or pharmacological agent administered and route of administration, nursing judgment and according to physician orders if present. Recommended timeframes for reassessment of effectiveness of pain relief may include: 30-minute reassessment - IM injection and IV medication 1 hour reassessment - oral medication and non-pharmacological interventions The licensed nurse shall communicate the adequacy of pain management and/or changes in pain significance to the physician at admission and as needed based on assessment and reassessment data. The registered nurse ensures that the plan of care is updated, and interventions are specific to the patient ’ s pain needs. Failure to relieve pain is reported as soon as possible to the physician and other staff as needed using the facility specific communication process (e.g., SBAR). 2. During a review of Patient 22 ’ s “History and Physical,” (H&P, a formal and complete assessment of the patient and the problem), dated 06/17/2026, the “H&P” indicated, Patient 22 was admitted to the facility on 06/17/2026 with medical history including but not limited to, diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder, chronic g tube (gastrostomy tube, a surgical opening fitted with a device to allow feedings to be administer directly to the stomach, common for people with swallowing problems) dependence. During a review of Patient 22 ’ s “Nursing Admission” note (a comprehensive clinical document completed when a patient enters a healthcare facility, establishing the patient ’ s baseline health status and identifying immediate care needs), dated 06/18/2026, the nursing note indicated, Patient 22 ’ s “Expressions of ideas and wants: Rarely/never expresses self or speech is very difficult to understand,” “Understanding verbal content: Rarely/never understands,” and “Communication: No speech.” During a concurrent interview and record review on 06/24/2026 at 3:29 p.m. with Registered Nurse (RN) 1, Patient 22 ’ s Medication Administration Record (MAR), dated 06/20/2026 was reviewed. The MAR indicated, on 6/20/2026 at 5:55 a.m., acetaminophen (a widely used over-the-counter medication that relieves mild to moderate pain and reduces fever) 650 milligrams (mg, a metric unit of measure used for medication dosage and/or amount) was administered via feeding tube liquid as needed for mild pain scale score 1-4. RN 1 verified there was no post pain medication administration pain scale score reassessment recorded. 3.During a review of Patient 23 ’ s physician “Progress Note” (an essential clinical document that records changes in a patient ’ s health status, treatment responses, and ongoing care plans), dated 06/23/2026, the progress note indicated Patient 23 was admitted to the facility for the co-morbidities (the presence of two or more distinct medical conditions or diseases occurring in the same person at the same time) including but not limited to, bacteremia (the presence of bacteria in the bloodstream), end-stage renal disease (ESRD, irreversible kidney failure), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and the condition of being hard of hearing (mild to severe hearing loss; some can still hear sounds, but it is hard to understand speech clearly). During a review of Patient 23 ’ s “Nursing Admission” note, dated 06/19/2026, the nursing admission note indicated, Patient 23, “Expressions of ideas and wants: Without difficulty with speech that is clear and easy to understand,” “Understands: clear comprehension without cues or repetitions,” and “Communication: appropriate speech, clear.” During an observation and interview on 06/25/2026 at 1:57 p.m. with Patient 23 at Patient 23 ’ s bedside, Patient 23 stated she needed her hearing aids to talk to surveyor. Patient 23 could not find her hearing aid battery and proceeded to use her cell phone and asked surveyor to use voice dictation to speak with her (Patient 23). During a concurrent interview and record review on 6/24/2026 at 2:21 p.m. with RN 1, Patient 23 ’ s “Medication Administration Record (MAR),” dated 06/21/2026, 06/22/2026, and 06/23/2026 was reviewed. The MAR indicated: a. On 06/21/2026, for the 8:59 p.m. Hydromorphone (a potent narcotic analgesic) 1 mg intravenous (IV, administered directly into the blood stream) administration, a pre-pain medication administration assessment indicated Patient 23 had a numerical pain scale score of 9. The MAR indicated on 6/21/2026 at 9:29 p.m. Patient 23 ’ s post pain medication administration pain as “effective (Verbalization)” with no numerical pain scale score indicated. b. On 6/22/2026 for the 5:05 p.m. Hydromorphone 1mg IV administration, a pre-pain medication administration assessment indicated Patient 23 had a numerical pain scale score of 10. The MAR indicated on 6/22/2026 at 5:35 p.m. Patient 23 ’ s post pain medication administration pain as “effective (PT stated no discomfort and pain)” with no numerical pain scale score indicated. c. On 6/23/2026 for the 5:01 p.m. Hydromorphone 1mg IV administration, a pre-pain medication administration assessment indicated Patient 23 had a numerical pain scale score of 9. The MAR indicated on 06/23/2024 at 5:31 p.m. Patient 23 ’ s post pain medication administration pain as “effective (PT verbalization)” with no numerical pain scale score indicated. During an interview on 06/24/2026 at 3:29 p.m. with RN 1, RN 1 stated regarding different pain scale score tools, using different pain scale scoring, “You need to have the consistency when using pain scale scores. Using the same pain score minimizes doubt to what you are assessing,” and “If you don ’ t perform a post pain medication administration assessment using the same scale you used first, you will not know if the medication was truly effective.” During a review of the facility ’ s policy and procedure (P&P) titled, “Procedure-Pain Management,” last reviewed 07/2025, the P&P indicated: The pain scale selected is to be the same for both pre and post interventions. The Registered Nurse performs a pain assessment during the patient admission assessment. Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient ’ s medical record. Three examples of recommended Pain Scales are Numeric Pain Scale, Visual Pain Rating Scale, and FLACC Pain Scale. “Numeric Pain Scale. The licensed nurse asks the patient to rate their pain intensity on a scale of 0-10, where 0 represents no pain and 10 represents the most intense pain.” “Visual Pain Rating Scale. For patients unable to use the 0-10 Numeric Pain Scale, the licensed nurse explains that each face represents a person who is happy or sad depending on how much or how little pain he or she has.” “FLACC [F= Face, L=Legs, A=Activity, C=Cry, and C=Consolability] Pain Scale. The licensed nurse assess/observes the patient, interprets the paint ’ s pain level according to the FLACC Pain Scale according to the nursing observations and documents the score in the patient medical record.” C. During a review of Patient 25 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 3/2026, indicated, Patient 25 was admitted to the facility for functional decline ( a decrease in a person ’ s physical and mental capabilities), acute kidney injury(AKI- when kidneys cant filter waste from the blood) , and has a Gastrointestinal tube (G-tube)(a small tube in the belly that brings nutrition directly to the stomach) do to having dysphagia (Difficulty swallowing). During a review of Patient 25 ’ s “Physician Orders” dated 3/26/2026, indicated that Patient 25 could have 1 cup of ice chips per shift for 90 days. During a review of Patient 25 ’ s “Intake & Output Flowsheet” (use to track a patient ’ s fluid balance) dated 4/21/2026. The flowsheet indicated Registered Nurse 5 (RN5) gave oral liquid in the amount of 600ml (metric unit of volume) at 12:41p.m., and oral liquid in the amount of 300ml at 6:50p.m. During a concurrent interview and record review on 6/24/2026 at 2:17p.m. with RN6, Patient 25 ’ s “Diet Orders” (instruction detailing the specific food and drink a patient required) were reviewed. RN6 stated “I do not see any current diet order, but it should have been placed. Diet orders are a part of our nursing Situation, Background, Assessment, and Recommendation (SBAR –used in healthcare to transfer information) report. The consequences of giving a dysphagia (difficulty in swallowing) patient liquid can be aspiration (inhaling something into the airway). The nurse should have called the Medical Doctor (MD) to get order clarification. During a review of the facility ’ s “Registered Nurse Job Description” dated 1/2025. The Job description indicated the following: “Receives physician orders, ensures transcription is accurate and documents completion.” “Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/ healthcare errors”. D. During a review of Patient 15 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/12/2025, the H&P indicated that Patient 15 had a past medical history of end-stage renal disease (ESRD, the final stage of kidney damage often requiring kidney replacement therapy to remove waste) on hemodialysis (HD, a machine that filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough), anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin), electrolyte imbalance (the levels of essential minerals in the body are too high or too low), diabetes mellitus (DM, a disease that causes a buildup of sugar in the blood), schizophrenia (a chronic brain disorder that disrupts how a person interprets reality), hypertension (HTN, the force of blood pushing against the artery walls is consistently too high), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, a digestive condition where stomach acid frequently flows backward into the esophagus), seizure disorder (a medical condition defined by recurring, involuntary muscle movements caused by a sudden burst of electrical activity in the brain ), chronic obstructive pulmonary disease (COPD, a long-term lung condition that blocks airflow and makes it difficult to breathe), congestive heart failure (CHF, a chronic condition where the heart muscle is weakened and cannot pump blood efficiently to the rest of the body), cerebrovascular accident (CVA or stroke, a condition where blood flow to part of the brain is suddenly blocked or a blood vessel ruptures), atrial fibrillation (AFib, an irregular heartbeat caused by an electrical signal that causes the heart ’ s upper chambers [atria] to quiver, preventing blood from pumping normally), encephalopathy (a term used for any disease, damage, or malfunction that affects the brain ’ s structure or function), lateral vocal cord paralysis (a condition where a vocal cord becomes stuck in an open or “out to the side” position leaving a gap), hypoxemic respiratory failure (when the lungs cannot properly transfer oxygen into the bloodstream), pericardial effusion (a buildup of excess fluid surrounding the heart [in the pericardial sac]) post pericardiocentesis (a medical procedure that uses a needle to drain excess fluid buildup from the protective sac surrounding the heart), cardiopulmonary arrest (the sudden, unexpected stopping of effective heart function and normal breathing), and traumatic brain injury (TBI, a disruption in normal brain function caused by sudden, external physical force). Patient 15 was “ill-appearing”. During a review of Patient 15 ’ s “Discharge Summary (a clinical document that outlines a patient ’ s entire hospital stay)”, dated 5/14/2026, the discharge summary indicated that Patient 15 had multiple falls from the bed, was nonverbal (communication or behavior that occurs without the use of spoken or written words), and bedbound (a person that spends most or all of their time in bed due to illness, injury, or physical limitations) during the hospital course. During a review of Patient 15 ’ s “Psychiatric Progress Note” (tracks symptom changes, medication effectiveness, treatment goals and safety), dated 1/12/2026, the progress note indicated that Patient 15 demonstrated marked withdrawal (a noticeable detachment or distancing from social activities, relationships, or reality) and significant physical debility (a state of physical weakness, lack of stamina, or loss of strength) with intermittent periods of increased motor restlessness (an uncontrollable, often involuntary urge to move the body or specific body parts to release inner tension) and irritability (a state of feeling easily annoyed, impatient, or frustrated) reported by nursing, suggestive of episodic anxiety (a response to stress, feelings of fear, or worry that comes and goes in sudden, temporary waves) or internal distress (a state of mental suffering, anxiety, or unease). During a review of Patient 15 ’ s “Psychiatric Progress Note”, dated 1/13/2026, the progress note indicated that Patient 15 was unresponsive to verbal stimuli (a spoken word, written text, or communicated instruction that prompts a physical, mental, or behavioral reaction) with absent engagement (complete lack of participation, interest, or emotional investment in a task, activity, or relationship), appearing somnolent (feeling sleepy, drowsy, or inclined to fall asleep). Patient 15 had recently attempted self-extubation (when a patient intentionally removes their own breathing tube [endotracheal or tracheostomy tube]) and exhibited intermittent irritability, psychomotor agitation (a feeling of intense, anxious restlessness that makes a person unable to sit still), and restlessness, suggestive of fluctuating mental status (a person ’ s level of awareness, thinking, or alertness changes significantly over the course of hours or days) possibly influenced by underlying medical acuity (the real reason behind the severity and urgency of a patient ’ s condition) or delirium (a sudden, severe state of confusion and altered awareness). During a concurrent interview and record review on 6/24/2026 at 9:50 A.M., with Registered Nurse (RN 3), Patient 15 ’ s “Vital Signs (measurable indicators of the body ’ s basic functions)”, was reviewed. The vital signs observed included: On 4/9/2026 at 8:00 P.M., Patient 15 reported a pain score of four out of 10 (4/10), utilizing the numeric pain scale. RN 3 stated there were no interventions provided and the next assessment was at 11:18 P.M. with a continued report of 4/10 pain. RN 3 stated there were no interventions provided based on documentation. On 5/2/2026 at 8:00 P.M., Patient 15 had a pain score of 4/10 using the numeric pain scale. RN 3 stated there were no interventions administered. Patient 15 continued with a 4/10 pain score at 11:10 P.M. On 5/3/2026 at 4:00 A.M., Patient 15 had a pain score of 4/10 using the numeric pain scale. RN 3 stated there were no documented interventions administered for management of pain. Patient 15 had a numerical pain score of 4/10 on 5/3/2026 at 8:00 P.M. and 11:34 P.M. There were no pharmacological or non-pharmacological interventions administered to manage Patient 15 ’ s symptoms documented. On 5/7/2026 at 8:00 P.M., Patient 15 had a numerical pain score of 4/10. Patient 15 also had a numerical pain score of 4/10 at 11:04 P.M. RN 3 stated that Patient 15 ’ s pain assessments were performed every four hours as ordered, but no interventions were rendered to manage Patient 15 ’ s pain. On 5/8/2026 at 4:00 A.M., 8:00 P.M., and 11:10 P.M., Patient 15 had a numerical pain score of 4/10 consistently with no interventions rendered. RN 3 stated that there were multiple episodes of reported, moderate pain (pain that is distracting, interferes with a person ’ s daily activities, and is difficult to ignore) and/or assessed pain (a formal measurement and evaluation of a patient ’ s physical and emotional experience of pain), using the FLACC pain assessment tool (a scale used to measure pain in infants, young children, or non-verbal patients observing Face, Legs, Activity, Cry, and Consolability), the visual pain scale (a communication tool that helps a person describe their level of pain. It uses a straight line or series of drawn faces. The faces may be pointed to or marked at the exact spot that matches how much pain is felt), or the numeric pain scale (an 11-point tool used to measure pain intensity from 0 “no pain” to 10 “worst pain imaginable”). RN 3 stated that Patient 15 ’ s pain was not treated or treated with acetaminophen and not reassessed; and/or had no documented non-pharmacological interventions (non-chemical methods used to prevent, treat, or manage health conditions; instead of relying on medication) acknowledging Patient 15 ’ s symptoms of pain. During a record review on 6/24/2026 at 10:10 A.M. with RN 3, Patient 15 ’ s “Medication Administration Record (MAR, an official log used to document every drug administered to a patient)”, undated, was reviewed. The MAR indicated that Patient 15 was administered (given) acetaminophen (a medication used to relieve mild to moderate pain and reduce fever), heparin (an injectable anticoagulant [blood thinner] used to prevent blood clots or keep existing clots from getting larger), lorazepam (a medication primarily used for the short-term relief of severe anxiety, panic attacks, and insomnia, as well as to prevent seizures), Keppra (a medication used to control and prevent seizures), labetalol (a medication used to treat high blood pressure), and amlodipine (a medication used to treat high blood pressure and prevent chest pain) during the hospital course. On 3/28/2026 at 9:00 A.M., Patient 15 had a visual pain score of 4/10 assessed. Acetaminophen was administered with reassessment performed at 10:00 A.M. with a visual pain score of 0/10 documented due to Patient 15 sleeping. Patient 15 had acetaminophen ordered for the duration of their hospitalization. During an interview on 6/24/2026 at 10:40 A.M. with RN 3, RN 3 stated that Patient 15 ’ s multiple reports of pain and lack of interventions was concerning, as pain could contribute to undesired behaviors (any action or response that is inappropriate, harmful, or goes against acceptable rules, norms, or personal goals) due to feelings of helplessness (the feeling or state of being powerless and unable to change a difficult situation) and hopelessness (the feeling of having no hope, coupled with belief that things will never get better or cannot be solved), and result in distrust (lack of trust or confidence in someone or something) of healthcare due to failure to manage symptoms. RN 3 stated failure to address Patient 15 ’ s pain and provide appropriate treatment had the potential to result in worsening symptoms and delayed diagnosis of a missed underlying cause. During a review of the facility ’ s policy and procedure (P&P, define), titled “Procedure-Pain Management”, dated 7/2025, the P&P indicated: PROCEDURE: Assessments of Patients 1. The Registered Nurse performs a pain assessment during the patient admission assessment. Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient’s medical record. When pain is identified, nursing assessment and documentation in the patient medical record includes the pain scale rating, location, duration, intensity, and character. Nursing judgment and patient condition determine if patient vital signs and other signs and symptoms (as noted in b. iv. Assessments of Patients) associated with the patient’s pain are assessed and documented b the licensed nurse. The licensed nurse will use pain control measures (within state specific scope of practice) before pain becomes severe. This may include but is not limited to the selection and implementation of a variety of measures (pharmacological, non- pharmacological and interpersonal) to facilitate pain relief and avoid pain exacerbation as appropriate to specific patient needs. Examples of pain control measures may include but are not limited to: Assist patient in self-turning a minimum of every two hours. Use pillows for support and positioning as needed. Instruct patient to splint abdomen before coughing and deep breathing exercises. Use distraction techniques to reduce fear and anxiety such as talking with the patient, music or TV. Instruct patient in relaxation techniques and visual imaging. Medicate prior to potentially painful treatments, ambulating or initiating other activities that may cause or exacerbate pain. Medicate for pain as ordered. Offer heat or cold applications to area if ordered by the physician. Reduce or eliminate factors that precipitate or exacerbate pain experience. d. Consult the physician if measures are unsuccessful and/or if current complaint and/or symptoms are significantly changed or different from the patient’s past experience of pain.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 48342 Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when the Cook thawed raw chicken in the refrigerator for up to three days, exceeding the facility ’ s safe thawing limit of two days. This deficient practice had the potential to increase bacterial growth during the thawing process, placing all patients who consume food prepared by the facility at risk for foodborne illness. . Findings: During a concurrent interview and observation in the kitchen on 6/23/2026 at 11:32 AM, with the Cook, two pieces of frozen raw chicken breast were observed thawing inside a plastic bag placed in a bowl on the bottom shelf of the refrigerator, located between the grill and the sink near the window. The chicken had no label indicating the date and time thawing began. When asked how long the chicken had been thawing, the Cook stated that they are allowed a maximum of 3 days to thaw frozen food in the refrigerator. During an interview on 6/25/2026 at 11:32 AM with Infection Preventionist (IP1), IP1 stated that according to the facility ’ s guideline, raw frozen chicken should be thawed for no more than two days, not three. IP1 provided the applicable guideline during the interview. During an interview on 6/26/2026 at 11:00 AM with the Cook, she stated that she believed raw chicken was allowed to thaw in the refrigerator for up to three days. The Cook further stated that the potential outcome of extended thawing time is bacterial growth, which could cause foodborne illness in patients. During a review of the food storage guideline provided by the Infection Preventionist (IP1), it was noted that the maximum allowable time for storing raw chicken in the refrigerator is two days. A review of facility policy and procedures titled “Thawing Food”, dated 7/2023, indicated that the policy is to sure that proper handling of food through the thawing phase to present risk of microorganism growth that may result in food contamination and food borne illness ...thaw in the refrigerator that has an interior temperature ....most items require 24-48 hours to thaw properly ...”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 48342 Based on interview and record review the facility failed to ensure infection control policies and procedures regarding Employee Health Services were implemented when the facility failed to ensure one of five sampled physicians (MD) 1 had annual influenza (a highly contagious viral infection that attacks the respiratory system) vaccination (the process of getting a shot or taking medicine to build your body ’ s defense against a disease) status documentation in his file since the year 2021. This deficient practice had the potential to result in putting patients at risk for transmissions of infections within the facility. Findings: During a concurrent interview and record review on 06/26/2026 at 10:30 a.m. with Credentialing Coordinator (CC) 1 and the Lead Credentialing Coordinator (CC) 2, Medical Doctor (MD) 1 ’ s medical credentialing file was reviewed. MD 1 ’ s file indicated the last influenza (a highly contagious viral infection that attacks the respiratory system) vaccine documentation indicated “2021.” CC 1 could not indicate if the “2021” indicated MD 1 receiving the vaccination or declining the vaccination. CC 2 stated the credentialing department does not monitor immunizations or performs audits to monitor immunizations. CC 2 stated it would the facility ’ s Employee Health Department who would better be able to address immunization status or requirements. During an interview on 6/26/2026 at 11:30 a.m. with the Director of Quality (DOQ), DOQ stated it would be the facility ’ s Employee Health Nurse who is tasked with entering immunizations for all staff and physicians into the facility records. The DOQ stated the facility no longer had a designated Employee Health nurse on-site in the facility ’ s Employee Health department but rather used, when necessary, an Employee Health nurse from another General Acute Care Hospital (GACH, General Acute Care Hospital) 2. The DOQ stated attempts were made to contact the Employee Health nurse from the GACH 2 but no replies were received. During an interview on 6/26/20226 at 1:52 p.m. with the Human Resource Manager (HRM), HRM stated that she did not have access to physician requirements for immunizations. HRM stated it would be the Employee Health nurse who could provide the records. During a concurrent interview and record review on 6/26/2026 at 2:00 p.m. with the Registered Nurse Manager (RNM) 1, the facility ’ s policy and procedure (P&P) titled “CORE: Employee Immunizations, H-IC-05-002,” released 11/2023, original date 09/2004, was reviewed. The P&P indicated: 1. Annual immunization documentation is required for all employees, physicians and LIPs or contractors. 2. Declination of vaccination or inability to provide proof of vaccination requires a signed declination to be included in the employee health file. 3. All Declination of Influenza Vaccination for Medical Contradiction forms must be maintained in the employee health medical file (or immunization file for contracted service staff or other non-employees). RNM 1 stated it would be the Employee Health nurse who would provide the influenza documentation. RNM 1 stated there is no Employee Health nurse employed for the facility who can obtain the information at this time. A review of the facility ’ s second policy and procedure regarding employee health and immunizations titled, “Employee Immunization, SAU-IC-04-01,” released 10/2022, original date 08/31/2014, indicated: 1. “Definitions, Health Care Personnel ...includes physicians ...”. 2. Employees are offered the inactivated influenza vaccine (a type of vaccine that contains a virus or bacteria that has been killed or rendered inactive, so they cannot replicate or cause disease) on an annual basis and provided the Vaccine Information Sheet for the influenza vaccine being given. 3. If the employee refuses the vaccine, the declination (refusal) of vaccination form should be signed by the employee and then be placed in the employee ’ s health file. 4. “Unvaccinated Employee Exposure to Vaccine Preventable Diseases. Community Exposure. If the employee is vaccinated and exposed to a communicable disease (illnesses that spread from one person to another) within the community such as chicken pox (a highly contagious infection), the employee should immediately notify his/her Manager and Infection Preventionist.” During an interview on 6/26/2026 at 2:30 p.m. with the Infection Control Preventionist (ICP) 1 and Infection Preventionist (IP) 2 present, the ICP 1 stated she did not have access to employee immunization files. The ICP 1 stated it would be the Employee Health nurse who could better answer questions regarding immunization requirements for staff and physicians. ICP 1 stated any monitoring or auditing of employee immunization records would not be performed by ICP 1 and advised surveyor to ask the Employee Health nurse for further clarification. ICP 1 stated she did not oversee matters regarding employee immunizations unless an issue was brought to her attention by the Employee Health nurse. ICP 1 stated she did not know who the assigned Employee Health nurse was.”