Central Valley Specialty Hospital

“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: 45977 Based on interview and record review, the hospital failed to ensure nursing staff developed and maintained individualized care plans reflecting the needs of the patients and care to be provided for one of 32 sampled patients (Patient (Pt) 10), when the nurses did not address the specific problems of noncompliance with interventions and measurable goals that met the needs of Pt 10. This failure had the potential for inconsistent care delivery for Pt 10 and the potential for Pt 10 to not receive necessary medical care which could negatively affect patient well-being. Findings: During a concurrent interview and record review on 7/28/26 at 10:05 a.m. with Charge Nurse (CN) 1, Pt 10’s “Electronic Medical Record [EMR a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans],” “History & Physical [H&P an assessment from physician including medical history and exam],” dated 5/21/26, the “Face Sheet [FS a document that contains a summary of a patients’ personal information],” undated, and the “Care Plans,” undated were reviewed. The H&P indicated Pt 10 was admitted on 5/21/26 at 4:11 p.m. for wound care, management of chronic (a condition that last a long time) medical problems and acute rehabilitation. The H&P indicated Pt 10 had a history of paraplegia (unable to move lower part of body), bilateral below the knee amputations, neurogenic bladder (loss of bladder control due to nerve damage) and multiple Stage 4 pressure ulcers (areas of damaged deep skin and tissue damage that also involves the muscle and bone) involving the buttocks and thighs, resulting in surgical debridement (medical cleaning of a wound to remove dead/infected tissue) and osteomyelitis (bone infection). CN 1 stated, Pt 10 had a history of noncompliance with medical care, which included refusing to relieve the pressure on his ulcers by being repositioned. CN 1 stated, the nurses had created a care plan with the problem focus of noncompliance. CN 1 stated, the interventions listed for Pt 10 were actually goals. CN 1 stated, the nurses should have created interventions consistent with encouraging the patient to be compliant such as explain the risks and benefits of following the medical plan. CN 1 stated, it was important to have care plans individualized to the patient. CN 1 stated, patients often forget about what could happen if they were noncompliant with care and nurses needed to encourage them to follow the medical plan. During an interview on 7/30/26 at 11:25 a.m. with the Director of Nursing (DON), the DON stated, she expects the nurses to develop the care plan with individualized interventions. The DON stated, this was important as it guided the care of the patient and helped the patient to get better. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan,” dated 1/25, the P&P indicated “ ... Nursing care plans will be completed for every patient to assist in compliance. The elements of care planning include: ... a. Assessment ... b. Problem Identification ... c. Intervention ... d. Evaluation ... e. Communication. ... Identify any barriers to patient learning, document teaching methods ... “ During a review of the facility’s record titled, “Registered Nurse [RN]-Acute, Job Description,” dated 1/25, the record indicated “ ... POSITION SUMMARY ... In collaboration with the physician, the RN assures implementation of the assessment plan, evaluation, and follows up the plan of care for the patient population. ... Interprets assessment data and information to develop a nursing care plan which contains problem identification, nursing diagnosis, nursing orders, approaches, interventions, short/long term goals, and discharge planning ...” During a review of a professional reference article titled, “Why are care plans important in healthcare?,” located at https://biologyinsights.com/why-are-care-plans-important-in-healthcare, dated January 13, 2026, the article indicated “ ... care plans are a cornerstone of effective healthcare delivery. They provide a structured approach to patient care by outlining individualized goals, interventions, and evaluation criteria ... Initiating care plans early is essential for delivering consistent, high-quality, and patient-focused care across all healthcare environments ...Standardized documentation of the patient’s status prevents critical information from being overlooked during these vulnerable handoffs. By clearly outlining the agreed-upon approach, the care plan prevents conflicting interventions or unnecessary delays in treatment. Maintaining this high level of consistency in routine care is important for process efficiency and safeguarding the patient’s stability across various care environments ...””

“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: 49538 Based on interview and record review, the facility failed to ensure all employees adhered to the hospital’s policies and procedures (P&P) and nursing standards of practice when: 1. Five of five sampled registered nurses (RN 1, RN 2, RN 3, RN 4, and RN 5), did not receive an annual training on Emergency Preparedness according to the facility’s P&P titled, “Emergency Preparedness Staff Training.” This failure had the potential for employees to be unprepared in the event of an emergency and affect the safety of patients and staff. 2. Licensed nurses did not date the opening of two quality control solutions (a liquid used to ensure devices are accurate) for one of two sampled glucometers (a device for measuring the concentration of sugar in the blood) in accordance with the hospital’s P&P titled “Glucose Monitoring Quality Control.” This failure potentially placed patients at risk for inadequate blood glucose monitoring and management and could negatively affect physical and emotional wellbeing of patients that were already vulnerable. Findings: 1. During a concurrent interview and record review on 7/30/26 at 9 a.m. with the Human Resources Manager (HRM) and the Medical Assistant (MA), RN 1, RN 2, RN 3, RN 4, and RN 5’s “employee files,” were reviewed. RN 1’s employee file indicated the last Emergency Preparedness training was on 6/4/24. RN 2’s employee file indicated the last Emergency Preparedness training was on 2/11/25. RN 3’s employee file indicated the last Emergency Preparedness training was on 12/6/22. RN 4’s employee file indicated the last Emergency Preparedness training was on 6/27/23. RN 5’s employee file indicated the last Emergency Preparedness training was on 4/22/25. The MA stated employees should receive Emergency Preparedness training annually. The MA stated Emergency Preparedness training had not been included in the facility’s annual skills lab for the past two years and should have been included. The HRM stated it was important for employees to have an annual Emergency Preparedness training for safety purposes, as it ensured employees knew where to locate things like the gas shutoff, where emergency exits were, and where to meet during an emergency. During an interview on 7/30/26 at 11:23 a.m. with the Director of Nursing (DON), the DON stated she expected employees to receive Emergency Preparedness training every year and to follow the policy. The DON stated it was important to complete this training annually, so employees knew where everything was located, such as where exits are, and where to move patients. During a review of the facility’s P&P titled, “Emergency Preparedness Staff Training,” revised 7/2022, the P&P indicated, “ ... POLICY: All Hospital employees will receive specific training upon hire and annually in their individual and department roles during both internal and external disasters ... PROCEDURE: ... The Safety Officer is responsible for the content of the training to ensure that all employees know their roles as outlined in the Emergency Preparedness Plan. It is the responsibility of the Safety Officer to work with the Emergency Preparedness Manager to ensure that this training covers all employees annually and obtain appropriate documentation. Training will include: Specific Roles and responsibilities during emergencies, The information and skills required to perform duties during emergencies, The backup communication system used during disasters and emergencies, and How supplies and equipment are obtained during disasters or emergencies ...” During a review of a professional reference from the Occupational Safety and Health Administration (OSHA) titled, “Emergency Preparedness and Response: Getting Started,” undated, the professional reference indicated, “ ... Develop a Plan Ahead of Time. Many disasters are no-notice events, meaning that there is no warning before they occur. These types of events do not allow time for people to gather even the most basic necessities. Therefore, pre-planning is critical ... Emergency evacuation plans are developed to ensure the safest and most efficient evacuation. The evacuation plan must identify when and how workers are to respond to different types of emergencies ... Before an emergency occurs: ... Develop a workplace evacuation plan, post it prominently on each floor, and review it periodically to ensure its effectiveness. Identify and train floor wardens, including back-up personnel, who will be responsible for sounding alarms and helping to evacuate workers. Conduct emergency evacuation drills periodically ... What should workers know before an emergency occurs? Be familiar with the worksite’s emergency evacuation plan ... Understand who to contact in an emergency, as well as the specific procedures they will be expected to use ...” 2. During a concurrent observation and interview on 7/28/26 at 12:10 p.m. with Charge Nurse 1 (CN 1) and CN 2, on the second floor, at nurses’ station 1, the two glucometer control solutions (a high and low result solution) were observed to have no readable dates labeled on the bottles. The bottles have a blank field for the day the bottle was opened and the field for when the bottle should be discarded. CN 1 validated there were no readable dates on either glucometer solution bottles. CN 1 stated, the staff should label when the bottle was opened and 90 days after that date, label the bottle with a discard date. CN 1 stated a nurse should not use the quality control solutions, throw the bottles away and get new quality control solutions. CN 2 stated, if the quality control solutions were expired, then the results from the glucometer could be inaccurate and it could affect patient safety. During an interview on 7/30/26 at 11:25 a.m. with the Director of Nursing (DON), the DON stated, she expects the nurses to use the quality controls correctly and not use expired quality controls while using the glucometers. The DON stated, this could affect the readings and affect patient care. During a record review of the facility’s P&P titled, “Glucose Monitoring Quality Control,” dated 4/2024, the P&P indicated, “ ... Purpose ... To ensure accuracy of results when utilizing the [BRAND NAME] Blood Glucose Testing System to perform monitoring of patient blood glucose. ... Testing ... when opening a new bottle of [Quality Control] Material, the open date and expiration date will be written on the bottle ... Corrective Action: ... Corrective action for quality control results outside the tolerance limits include: ... 2. Ensure the control solutions have not exceeded their expiration date. ... 3. Write current date on the bottle label when opening a new bottle. Discard all unused solution 90 days after opening ...” During a review of the facility’s Glucometer “Operators Manual (OM)”, undated, the OM indicated, “ ... control tests verify the performance of the [BRAND NAME] meter and test strips ... Observe the following guidelines to obtain optimal quality control results ... When opening a new bottle, write the discard date on the bottle label. Each bottle of control solution is stable for 90 days after opening or until the expiration date printed on the label, whichever comes first ... “”

“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: 45929 Based on interviews and record review, the facility failed to maintain a current nursing care plan when: 1. Patient (Pt) 6 had hemodialysis (a procedure that removes waste products and excess fluid from the blood when kidneys are no longer functioning properly) ordered on 10/15/24, started on 10/16/24 and did not have a care plan reflecting Pt 6 needs for dialysis until 10/17/24. 2. Patient (Pt) 15 had an order for comfort care dated 10/2/24, and did not have a care plan reflecting Pt 15’s needs for comfort care until 10/8/24. These failures had the potential for Pt 6 and Pt 15 to not receive needed care. Findings: 1. During a review of Pt 6’s “History & Physical (H&P)”, dated 10/13/24, the “H&P” indicated Pt 6 was a 65-year-old with a history of coronary artery disease (CAD, narrowed blood supply to the heart due to plaque buildup), diabetes (when the body does not produce enough insulin to regulate blood sugar), chronic kidney disease stage IV (CKD, the stage before complete kidney failure)and septic shock (a life-threatening condition when infection leads to dangerously low blood pressure). During an observation on 10/16/24 at 1150 in Pt 6’s room, Pt 6 was receiving hemodialysis performed by Registered Nurse (RN) 1. During a concurrent interview and record review on 10/17/24 at 9:20 a.m. with the Director of Nursing (DON), pt 6’s “Care Plan (CP)” (undated) was reviewed. The “CP” did not include a plan of care for CKD or hemodialysis. The DON stated she did not see a plan of care for CKD or hemodialysis for Pt 6. During a review of Pt 6’s “Dialysis Order Set (DOS)”, dated 10/15/24, the “DOS” was signed by the physician on 10/16/24. During an interview on 10/18/24 at 9:13 p.m. with House Supervisor (HS) 1, HS 1 stated hemodialysis was added to Pt 6’s “CP” on 10/17/24 after it was viewed by the DON at 9:20 a.m. During a review of the facility’s policy and procedure titled, “Nursing Care Plan (NCP)”, dated 8/2024, the “NCP” indicated, “ ... Nursing care plans will be completed for every patient to assist in compliance ... Nursing care plan begins with the assessment of the patient ... with attention to the key diagnosis and medication ...”. 40583 2. During a review of Pt 15’s “History & Physical (H&P”, dated 5/10/24, the “H&P” indicated, “ ...Patient is a 48-year-old female who initially presented to outside hospital with gunshot wound to abdomen ...found to have multiple small bowel injuries ...patient was found on the floor pulseless code blue (patient in critical condition and needs immediate medical attention) ...patient most likely has anoxic brain injury (brain is deprived of oxygen causing brain cells to die in about 4 minutes) ...overall prognosis is extremely poor ...”. During a review of Pt 15’s clinical document titled, “Physician Orders for Life-Sustaining Treatment (POLST)”, dated 10/2/24, indicated, “ ...Comfort Focused Treatment - primary goal of maximizing comfort ...no artificial means of nutrition ...”. During a review of Pt 15’s clinical document titled, “Problem List (Nursing Care Plan (NCP))”, dated 10/8/24, the “NCP” indicated, “ ...Problem ...Comfort Care ...Pt will be treated as he/she & family have determined for end of life care ...Pt will experience a comfortable death as pain free as possible ...”. During a concurrent interview and record review with house supervisor (HS) 1, on 10/18/24 at 1:22 p.m., HS 1 stated Pt 15’s comfort care was started on 10/2/24. HS 1 acknowledged Pt 15’s “NCP” for comfort care was not added until 10/8/24. HS 1 explained the “NCP” for comfort care should have been initiated a soon as Pt 15 was put on comfort care. HS 1 explained the importance was to ensure nurses were aware of what type of care to provide, and consistency in care and communication. HS 1 further explained the risk of not having the “NCP” was Pt 15 could potentially receive medications that had been discontinued and could get unnecessary labs and pokes (blood draw). During a review of the facility’s policy and procedure titled, “Nursing Care Plan (NCP)”, dated 8/2024, the “NCP” indicated, “ ... Nursing are plans will be completed for every patient to assist in compliance ... Nursing care plan begins with the assessment of the patient ... with attention to the key diagnosis and medication ...”.”

“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: 45929 Based on interviews and record review, the facility failed to follow their policies and procedures when 5 of 27 patients (Patient [Pt] 3, Pt 5, Pt 7, Pt 24, Pt 12) had no documentation of patient repositioning in the medical record at least every two hours per policy. These failures place patients at risk for skin related injuries. Findings: 1. During a review of Pt 7’s “History & Physical (H&P)”, dated 9/12/24, the “H&P” indicated Pt 7 was 33-year-old with a history of alcoholism and methamphetamine abuse resulting in an intracranial hemorrhage (bleeding in the brain) and obstructive hydrocephalus (when the flow of cerebrospinal fluid [CSF, fluid surrounding the brain and spinal cord] is blocked in the brain) and a stroke. The “H&P” indicated Pt 7 could not follow directions, had tracheostomy and was ventilator (a machine that helps a person breathe by moving air into and out of their lungs) dependent. During a concurrent interview and record review on 10/17/24 at 10:10 a.m. with the Director of Nursing (DON), Pt 7’s “Physical Assessment (PA, contains documentation of patient assessments and activity)”, dated 10/10/24 to 10/17/24, was reviewed. The “PA” indicated no documentation of Pt 7’s position/repositioning on 10/10/24 from 12:00 a.m. to 6:00 a.m. the “PA” indicated, “ ... 06:47 [6:47 a.m.] ... 12 HOUR CHART CHECK COMPLETE ... Turning schedules completed q2 hr [every two hours] ...”. The DON stated the nurses complete an end of shift retrospective documentation (12-hour chart check) indicating the patients were repositioned every two hours and the actual documentation is written is on a white dry-erase board in the patient’s room for families to see. The DON stated nurse’s aides could document patient’s position/repositioning in the patient’s permanent medical record under the “PA”. The DON stated there was no documentation of Pt 7’s position/repositioning between 10/10/24 at 4:00 p.m. to 10/11/24 at 11:11 a.m. except the 12-hour chart check at 6:47 a.m. The “PA” indicated Pt 7 was repositioned on 10/13/24 at 8:00 p.m. and 10/14/24 at 1:47 a.m. The “PA” indicated, “ ... 07:03 [7:03 a.m.] ... 12 HOUR CHART CHECK COMPLETE: Chart documentation for Shift Completed. I&O’s [intake and output], BM’s [bowel movements] & Vital signs are documented, Problem List/Care Plans addressed ...” The DON stated there was no shift documentation of every two-hour repositioning on the 12-hour chart check. The “PA” indicated no position/repositioning of Pt 7 between 10/14/24 at 4:00 p.m. and 10/15/24 at 8:00 a.m. and the 12-hour chart check on 10/14/24 at 6:00 p.m. did not address repositioning. During an interview on 10/18/24 at 8:10 a.m. with the DON, the DON stated the white board was not part of the patient’s permanent record. The DON stated the 12-hour chart check was not an adequate reflection of when each patient was repositioned and how patient was positioned. The DON stated the facility needed to change the charting to allow the nurses to document when they reposition a patient. 2. During a review of Patient (Pt) 24’s “H&P”, dated 10/10/24, the “H&P” indicated Pt 24 was a 76 year old with acute respiratory failure secondary to amyotropic lateral sclerosis (ALS, a fatal disease that attacks nerve cells in the brain and spinal cord) with generalized weakness in his arms and legs, and is ventilator ( a medical device that helps patients breathe by moving air into and out of their lungs) dependent. During a concurrent interview and record review on 10/17/24 at 2:45 p.m. with House Supervisor (HS) 2, Pt 24’s “PA”, dated 10/14/24 to 10/16/24, were reviewed. The “PA” indicated Pt 24 was repositioned on 10/14/24 at 4:00 p.m. HS 2 stated the next documented repositioning was on 10/15/24 at 8:00 a.m. The “PA” indicated Pt 24 was repositioned on 10/15/24 at 4:00 p.m. HS 2 stated the next documented repositioning was on 10/15/24 at 10:00 p.m. and the next documented repositioning was on 10/16/24 at 4:00 a.m. HS 2 stated the next documented repositioning was on 10/16/24 at 8:00 a.m. 3. During a review of Pt 5’s “H&P”, dated 8/27/24, indicated Pt 5 was a 45-year-old with a past medical history of quadriplegia (paralyzed in the arms and legs) due to a gunshot wound to the neck. During a review Pt 5’s “PA”, dated 9/19/24 to 9/20/24, was reviewed. The “PA” indicated Pt 5 was repositioned on 9/19/24 at 4:00 a.m. and the next documented repositioning was on 9/19/24 at 8:00 a.m. The “PA” indicated Pt 5 was repositioned on 9/19/24 at 4:00 p.m. and the next documented repositioning was on 9/19/24 at 8:00 p.m. The “PA” indicated Pt 5 was repositioned on 9/20/24 at 4:00 p.m. and the next documented repositioning was at 10:00 p.m. 4. During a review of Pt 3’s “H&P”, dated 8/30/24, the “H&P” indicated Pt 3 was a 59-year-old with a history of a stroke and a spinal cord abscess, with no sensation in the legs and left arm. During a concurrent interview and record review on 10/18/24 at 1:15 p.m. with the DON, Pt 3’s “PA”, dated 9/8/24 to 9/17/24, was reviewed. The “PA” indicated Pt 3 was repositioned on 9/8/24 at 6:00 p.m. The DON stated the next documented repositioning was on 9/9/24 at 8:00 a.m. The “PA” indicated Pt 3 was repositioned on 9/10/24 at 6:00 p.m. The DON stated the next documented repositioning was on 9/10/24 at 10:00 p.m. The “PA” indicated Pt 3 was repositioned on 9/11/24 at 5:00 a.m. The DON stated the next documented repositioning was on 9/11/24 at 8:00 p.m. The “PA” indicated Pt 3 was repositioned on 9/12/24 at 4:00 a.m. The DON stated the next documented repositioning was on 9/12/24 at 8:00 a.m. The “PA” indicated Pt 3 was repositioned on 9/12/24 at 4:00 p.m. The DON stated the next documented repositioning was on 9/13/24 at 5:00 a.m. and the next on 9/13/24 at 8:00 p.m. The “PA” indicated Pt 3 was repositioned on 9/15/24 at 4:00 a.m. The DON stated the next documented repositioning was on 9/15/24 at 8:00 p.m. The “PA” indicated Pt 3 was repositioned on 9/17/24 at 5:30 a.m. The DON stated the next documented repositioning was on 9/17/24 at 1:00 p.m. During a review of the facility’s policy and procedure titled, “Skin Care, Assessment and Maintenance of (SC)”, dated8/2024, “SC” indicated, “ ... Purpose ... To maintain optimal skin integrity ... Policy ... all bedfast patients shall be turned every 2 hours ... General Statements ... Documentation will become a permanent part of the patient record ... Decrease Pressure ... Turn and position every two hours ...”. During a review of the facility’s policy and procedure titled, “Documentation Standards for Clinical Services DS)”, dated 8/2024, “DS” indicated, “ ... PURPOSE ... ensuring accurate, consistent, and timely documentation for every patient ... All patient encounters, interventions, and assessments must be documented as soon as practicable after the service is rendered ... Documentation must be clear, concise, and complete, reflecting the patient’s status, care provided, response to treatment, and any changes in the care plan . All entries must be made directly into the EHR [electronic health record] ... and must adhere to hospital-specific formats and templates to ensure uniformity .... Document all treatments, interventions, and responses ...”. During the review of a professional reference titled, “Pressure Injuries (PI)”, dated 2024, “PI” indicated, “ ... Pressure injuries can develop if you must stay in bed or aren’t able to move and aren’t turned, and positioned correctly, or often enough ...A pressure injury develops when pressure cuts off the blood supply to the skin for a long period of time. Lack of blood flow to the skin leads to skin cells dying ...”. 40583 5. During a review of Pt 12’s “History & Physical (H&P)”, dated 9/12/24, the H&P indicated Pt 12 was a 30-year-old with a history of testicular cancer with metastasis (The spread of cancer cells from the place where they first formed to another part of the body) to C2 (Second cervical vertebrae of the spine (bones supporting the neck and head)) resulting in quadriparesis (a condition that causes muscle weakness in all four limbs). The H&P further indicated a history with a left femoral (large blood vessel) deep vein thrombosis (DVT a blood clot that forms in a vein deep within the body, usually in the lower leg or thigh). During a concurrent interview and record review with house supervisor (HS) 1, on 10/18/24, at 11:15 a.m., Pt 12’s “PA”, dated 10/1/24 to 10/7/24, was reviewed. The PA did not show documented evidence Pt 12’s position was changed on the following dates and times: 10/1/24 no documentation for repositioning at 0200, 0400, 0600, 1800; 10/2/24 no documentation for repositioning at 0600, 1800, 2000; 10/3/24 no documentation for repositioning at 0000, 0200, 0400. Patient turned to right side at 1000 & 1200. No documentation for repositioning at 1800 & 2200. 10/4/24 documentation indicated Pt 12 was turned to his right side at 0000 & 0200. No documentation for repositioning at 0400, 0600, 1800 & 2000; 10/5/24 documentation did not indicate Pt 12’s position placement at 1800; and 10/6 no documentation for repositioning at 0600, was repositioned to left side at 0400 & 0800. No documentation for repositioning at 1600. HS 1 explained Pt 12 should have been turned q (every) 2 hours for the dates and times listed above and HS 1 acknowledged that Pt 12 was not turned q 2 hours. During a review of the facility’s policy and procedure titled, “Documentation Standards for Clinical Services DS)”, dated 8/2024, “DS” indicated, “ ... PURPOSE ... ensuring accurate, consistent, and timely documentation for every patient ... All patient encounters, interventions, and assessments must be documented as soon as practicable after the service is rendered ... Documentation must be clear, concise, and complete, reflecting the patient’s status, care provided, response to treatment, and any changes in the care plan . All entries must be made directly into the EHR [electronic health record] ... and must adhere to hospital-specific formats and templates to ensure uniformity .... Document all treatments, interventions, and responses ...”. During the review of a professional reference titled, “Pressure Injuries (PI)”, dated 2024, “PI” indicated, “ ... Pressure injuries can develop if you must stay in bed or aren’t able to move and aren’t turned, and positioned correctly, or often enough ...A pressure injury develops when pressure cuts off the blood supply to the skin for a long period of time. Lack of blood flow to the skin leads to skin cells dying ...”.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 40583 Based on interviews and record review, the facility failed to follow their policies and procedures when one, patient, Pt 12’s, subcutaneous (medication given into the subcutaneous fat under the skin) injectable blood thinning medication, was administered without consistently rotating sites of administration. This failure placed Pt 12 at risk for excessive bruising, skin trauma, and infection at the injection sites. Findings: During a review of Pt 12’s “History & Physical (H&P)”, dated 9/12/24, the H&P indicated Pt 12 was a 30-year-old with a history of testicular cancer with metastasis (The spread of cancer cells from the place where they first formed to another part of the body) to C2 (Second cervical vertebrae of the spine (bones supporting the neck and head)) resulting in quadriparesis (a condition that causes muscle weakness in all four limbs). The H&P further indicated a history with a left femoral (large blood vessel) deep vein thrombosis (DVT a blood clot that forms in a vein deep within the body, usually in the lower leg or thigh). During a concurrent interview and record review with house supervisor (HS) 1, on 10/17/24, at 10:45 a.m., Pt 12’s “Medication Administration Record (MAR - contains medications administered, site locations, and who administered the medication)”, dated 9/12/24 to 10/17/24, was reviewed. The MAR indicated, “Enoxaparin (an anticoagulant (type of medication to prevent blood clots) medication used to prevent DVT’s) ...40 MG (Milligrams a unit of measure) INJ (injection) ...0.4 ML (Milliliters a unit of volume) Solution ...Route: SUBCUTANEOUS (under the skin) ...Frequency: BEDTIME ...Times: 2200 (10 PM) ...” The medication was documented as administered in the following sites, on the following dates, and time: 9/12/24 2200 Abdomen 9/13/24 2200 Abdomen 9/18/24 2200 Abdomen 9/19/24 2200 Abdomen 9/20/24 2200 Abdomen 9/26/24 2200 Right Upper Arm 9/27/24 2200 Right Upper Arm 9/29/24 2200 Abdomen 9/30/24 2200 Abdomen 10/3/24 2200 Abdomen 10/4/24 2200 Abdomen 10/5/24 2200 Abdomen 10/7/24 2200 Abdomen 10/8/24 2200 Abdomen 10/9/24 2200 Abdomen 10/10/24 2200 Abdomen 10/11/24 2200 Abdomen 10/12/24 2200 Abdomen 10/13/24 2200 Left Upper Arm 10/14/24 2200 Left Upper Arm 10/15/24 2200 Abdomen 10/16/24 2200 Abdomen The HS 1 stated the sites of administration on the above dates and times should have been alternated and were not. HS 1 explained by not alternating sites it can cause excessive bruising or skin issues like lipohypertrophy (little indentations). HS 1 further explained the importance of alternating sites was to reduce the chance of excessive trauma, possible infection, and to make sure the patients skin is intact. During a review of a facility document titled, “Nursing Huddle Topics,” dated for the weeks of 7/14/24, 8/11/24, and 9/8/24, the “Nursing Huddle Topics,” indicated, “Sub Q (subcutaneous) injections ...Effective immediately all nurses will document the location of abdominal sub q injections in the Nursing Daily Assessment ...Injections should be rotated ...Nurses will look at the previous documentation where the injection was administered so that the site can be rotated ...” During a review of a professional reference titled, “Highlights of Prescribing Information ...enoxaparin (HPIE) ...”, revised 4/2022, “HPIE” indicated, “ ...Subcutaneous Injection Technique ...Alternate injection sites between left and right ...abdominal wall ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45929 Based on observations, interviews, and record review, the facility failed to maintain its infection prevention and control program when: 1. A clean and sanitary environment was not maintained when white dry deposits were found on a drain plate on a coffee maker used for patients, visitors, and staff; and, 2. A dietary trainee (DT) 1 did not don appropriate personal protective equipment (PPE gown, gloves, mask, face shields) when entering a room with patients on enhanced precautions (patients in room with communicable illnesses) requiring staff to don gloves, mask, and gown. These failures resulted in potential cross-cross contamination (the physical transfer of harmful bacteria from one person, object or place to another) and spread of infection to patients, visitors and staff. Findings: 1. During a concurrent observation and interview on 10/16/24 at 12:00 p.m. with the Quality Officer (QO) in the first-floor nourishment room, a coffee maker had dry white deposits on the drain tray. The QO stated the maintenance department completes a deep clean (inside parts) the coffee maker monthly and checks it daily. The QO stated the white deposits could not have happened overnight. During a concurrent observation and interview on 10/16/24 at 12:05 p.m. with the Facility’s Operations Manager (FOM) in the nourishment room, FOM stated Environmental Services (EVS) checks and cleans the outside of the coffee maker daily. The FOM stated a log of the daily cleaning was not maintained. During a review of the facility’s policy and procedure titled, “Infection Prevention and Control System (IPC)”, dated 2/5/24, the “IPC” indicated, “ ... [Facility Name] maintains an organized, hospital-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among patients, visitors, and health care workers ... The hospital (Organization) shall have a process in place, as required and/or recommended by the Centers for Disease Control (CDC) and related professional organizations, to maintain a sanitary environmental for the hospital, patients, staff and others ... EVS ... Daily assignments are given to staff, i.e. which floor/area assignment, which are monitored at random intervals and sites, to ensure efficacy ... Follow up is performed by the EVS supervisor/manager/Director upon completion of the task assigned ... Maintenance/ Plant Ops - Assists in the review of, monitoring of and preventative maintenance of ventilation system and water quality controls. Water Quality Testing is ... monitored quarterly ... Infection Control ... Surveillance activities: Environmental rounds ... Perform random and monthly EOC [environment of care] rounds in conjunction with either Quality or EVS staff ... Assists in audits of food preparation areas, and sanitation processes within the facility ...”. During the review of a professional reference titled, “Hard Water Scaling Linked to Bacteria growth in Homes (HW)”, dated 1/9/14, “HW” indicated, “ ... research by the School of Sustainable Engineering at Arizona State University has found that hard water scaling normally found in the pipes of homes is an active environment for harmful bacterial growth ... hard water- water containing high levels of calcium and magnesium ... hard water results in scale formation ... and that provides a perfect home for bacteria. This can significantly increase exposure to pathogenic bacteria such as Legionella, which can cause Legionnaires disease [a serious type of pneumonia] ... Colonization of plumbing by disease-causing bacteria is well-documented, especially in hospital buildings and hotels ... Unless the minerals that cause scaling are entirely removed ...people are at risk of bacterial infections ...”. 40583 2. During a concurrent observation and interview, with DT 1, on 10/16/24, at 12:02 p.m., DT 1 was observed entering Room 275 without donning PPE. On the wall, outside of Room 275, there was a green sign indicating, “Enhanced Precautions”, with the sign indicating gown, gloves, and a mask are required prior to entering. DT 1 exited Room 275 and explained she had been informed about the process for entering rooms on “Enhanced Precautions”, by her supervisor and stated not donning the PPE was her fault. During an interview with house supervisor (HS) 1, on 10/16/24, at 12:08 p.m., HS 1 stated her expectations were for staff to don gown, gloves, and a mask before entering a room with patients on “Enhanced Precautions”. HS 1 explained wearing the correct PPE was important due to the risk for cross-contamination to and to ensure staff and patients are safe. A review of the facility’s policy and procedure titled, “Infection Prevention and Control System (IPC)”, dated 2/5/24, the “IPC” indicated, “ ...compliance with use of Isolation Precautions Signage & PPE ... compliance with appropriate and well visualized isolation designation on the sign, appropriate availability of an isolation cart and contents to meet the needed PPE standard ...the nursing department will evaluate areas such as: Correct isolation signage posted, Correct disinfection wipes located within the patient room ...adequate PPE supply within vicinity ...”. A review of facility document, posted outside of Room 275, titled, “Green Enhanced Precautions”, dated 8/5/23, the “Green Enhanced Precautions”, indicated, “ ...Stop Check With Nurse Before Entering ...Put On Gown ...Put On Gloves ...Put On A Face Mask ...PPE MUST BE WORN BY ALL WHO ENTER ROOM ...”.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 45977 Based on interview and record review the facility failed to obtain a History and Physical (H&P) (a term used to describe a doctor’s examination of the patient) record for one (Patient 9) of 21 patients sampled within 24 hours after an admission in accordance with hospital policy and procedure. This failure had the potential for the medical team not having the most up to date information during the care of the patient. Findings: During a concurrent interview and record review, on 8/15/2024 at 9:25 a.m., with Staff Registered Nurse (RN 1), Patient 9’s medical record was reviewed. Patient 9 had been admitted to the hospital on 7/22/2024 at 10:08 pm for management of stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheal bleeding (blood around a tube inserted the neck to aid with breathing) and mechanical ventilator (a machine that helps with breathing) care. Patient 9 had a medical H&P completed on 7/26/2024 at 9:24 a.m. During an interview on 8/16/24, at 9:55 a.m., with the Chief Medical Officer (CMO), the CMO stated, per hospital policy, the H&P should be done within 24 hours of admission. The CMO stated, it appears the H&P was not completed within 24 hours but closer to 96 hours. The CMO stated, the H&P needs to present for the medical team have the information to care for the patient. During a review facility’s policy and procedure (P&P) titled, “Concurrent Audits of Medical Records”, 4/1/2013, the P&P indicated “... New admissions will be checked daily to verify a History & Physical is on the chart within 24 hours of admission ... “”

“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: 45977 Based on observation, interview, and record review, the hospital failed to ensure all licensed nurses adhered to the hospital’s policy and procedures (P&P) when the Wound Care Nurse Supervisor (WCS) did not document communication, recommendations and consultation with the provider for wound care in accordance with the hospital’s P&P’s titled “Wound Care Team Policy” and “Wound Care Nurse Job Description” for one of one sampled patients (Patient (Pt) 6). This failure potentially placed patients at risk of wounds not being treated with the whole medical team. Findings: During a concurrent interview and record review, on 8/13/2024 at 2:50 p.m. with Staff Registered Nurse (RN 1), Pt 6’s medical record was reviewed. Pt 6 had been admitted to the hospital on 10/23/2023 at 8:00 pm for intravenous antibiotics (medications through the veins), acute rehabilitation, hemodialysis (therapy used to replace kidney function of filtering the blood of waste products), management of multiple wounds and mechanical ventilation (therapy used for assisting with breathing). Pt 6 had orders placed on 10/17/2023 for a wound consult by the Wound Consult Team. The wound care team took pictures and assessed the wounds of Pt 6 on 10/24/23 at 4:00 p.m using a document titled, “Photographic Wound Documentation.” Thirteen wounds were identified and assessed for type of wound, measurements, drainage, odor, color, and location. No recommendations were found in the medical record about communication of the wound care team with the provider. RN 1 validated no wound care progress notes were in the electronic medical record. During a concurrent interview and record review, on 8/13/2024 at 3:15 p.m. with Wound Care Supervisor (WCS), Pt 6’s medical record was reviewed. WCS stated, he assessed the wounds of Pt 6 and was involved with taking the pictures on 10/24/23 at 4:00 p.m. using the form, “Photographic Wound Documentation.” WCS stated, no other progress notes are made in the medical record for communication with the provider about any recommendations. WCS stated, he talks to the doctor of the patient and enters the orders into the electronic medical record but does not document the communication. During a follow up concurrent interview and record review, on 8/16/2024 at 10:50 a.m. with Wound Care Supervisor (WCS) and Chief Executive Officer (CEO), the record titled, “Wound Consult Audit,” not dated, was reviewed. WCS stated, a book with the recommendations were written on the “Wound Consult Audit”. WCS stated, the book allows the nurses to see the current recommendations for the patient. WCS stated, no progress notes are made in the medical record for patients with the recommendations for other members of the medical team. The CEO stated, the medical record should have recommendations and a treatment plan as per the policies of the organization. The CEO stated, any communication with the doctor should be documented in the medical record. The CEO stated, the recommendations by the Wound Consult Team should be documented as it allows for other members of the medical team to see the plan of care. The CEO stated, documenting in the medical record allows for collaboration and communication amongst the whole medical team. During a record review, the record titled, “Wound Care Nurse Job Description,” dated 9/1/2015, indicated,” ... The Wound Care Nurse is responsible for implementing, coordinating, monitoring managing the hospital wound care program. ... Implements wound care program to include patient care protocols, documentation tools ... Identifies patient’s needs and communicates that need to the patient’s physician. ... “. During a record review, the facility’s P&P titled, “Wound Care Team Policy,” dated 8/2021, indicated, “ ... Wound Care Program will be managed by a Wound Care Team acting in conjunction with an interdisciplinary team. Each discipline will have a vital role in wound management. Expected actions will include assessment, planning, implementation, documentation and re-assessment of care. ... C. The team will include representatives from each of the following disciplines. Responsibilities include: ... 1. Wound Care Team: ... d. Consult with physicians and initiate appropriate wound care protocols. ... h. Make recommendations for appropriate surfaces based on assessment ...””

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 45977 Based on interview and record review the facility failed to electronically sign orders in accordance with hospital policy and procedure for one (Pt 10) of 21 sampled patients. This failure had the potential for the medical team not having the most up to date information during the care of the patient. Findings: During a concurrent interview and record review, on 8/15/2024 at 10:31 a.m., with Staff Registered Nurse (RN 1), Patient 10’s medical record was reviewed. Patient 10 had been admitted to the hospital on 7/15/2024 at 6:58 pm for intravenous (through the vein) antibiotics (medications used to treat infections) and management of a surgical wound of his left foot. Pt 10 had orders placed in the computer on 7/15/24 at 9:05 p.m. for Admelog (insulin medication to help with blood sugar levels) per hypoglycemic (low blood sugar) protocol 7/16/24 at 1:27 a.m., for foley (a tube inserted in the bladder to allow for drainage of urine) care every shift, and 7/15/24 @ 9:05 p.m. for glucagon (a medication for treating low blood sugars) 1 mg (milligram) as need for glucose (blood sugar) levels less than 55 mg/dL (milligrams per deciliter) (normal range is 70 to 100 mg/dL). All three orders were electronically signed by the provider on July 24, 2024, at 11:31 a.m., which is about 8 days after being entered into the computer. During an interview on 8/16/24, at 9:55 a.m., with the Chief Medical Officer (CMO), the CMO stated, per hospital policy, telephone and verbal orders should be signed within 48 hours after the order was given and put into the computer. The CMO stated, the orders for Pt 10 were not signed until after eight days from when the orders were placed in the electronic medical record by the nurse and probably were not signed by the provider due to the provider being on leave. The CMO stated, it is expectation that another provider should have been assigned to review and sign the orders within 48 hours. During a review facility’s policy and procedure (P&P) titled, “Concurrent Audits of Medical Records”, 4/1/2013, the P&P indicated, “... Medical Records should notify physicians promptly regarding unsigned orders to meet regulatory requirements. An unsigned order report shall be generated and printed daily. Orders unsigned within 48 hours of issuance shall be tracked and the physician shall be notified. ...””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 41166 Based on observation, and record review of facility policies and procedures (P&P) and interview with staff, it was determined that the facility failed to maintain drug storage areas in accordance with acceptable standards of practice when: 1. One normal saline (NS, 0.9% sodium chloride solution, a mixture of salt and water) 100 milliliters (ml, unit of measurement) IV (intravenous, into the vein) bag of was stored out of the manufacturer wrapper and undated; 2. a. One NS 1 liter (L, unit of measurement) IV bag was identified in a bin with three half-normal saline (1/2 NS, 0.45% sodium chloride solution, a mixture of salt and water) 1 L IV bags; and b. Three NS 500 ml IV bags were identified in a bin labeled “D5W (dextrose 5% in water, a mixture of sugar and water) / 0.45% NS 1 L”; and 3. a. One NS 250 ml IV bag was found hanging and undated for Patient 12; and b. One NS 100 ml IV bag was found hanging and undated for Patient 21. These failures had the potential to result in administration of outdated or incorrect medications. Findings: 1. During a tour of the facility’s pharmacy on 8/13/24 at 10:42 a.m. with the Director of Pharmacy (DOP), one NS 100 ml IV bag was observed in a storage bin, out of the manufacturer’s wrapper, undated and available for patient use. During an interview on 8/13/24 at 10:58 a.m. with the DOP, the DOP stated, the NS 100 ml IV bag was good for 30 days when removed from outer packaging and should have been dated. Review of the manufacturer instructions on the NS 100 ml IV bag’s outer packaging, provided by the facility, indicated, “Do not remove unit from overwrap until ready for use. Use all units promptly when pouch is opened.” During a review of the facility’s P&P titled, “Security of Medication Storage Areas,” revised April 2024, the P&P indicated, “No product will be stored in a manner likely to cause it to become damaged, etc., or otherwise render it unusable.” 2. During a tour of the facility’s pharmacy on 8/13/24 at 10:45 a.m. with the DOP: a. One NS 1 L IV bag was identified in a storage bin with three half-NS 1 L IV bags; and b. Three NS 500 ml IV bags were identified in a storage bin labeled “D5W / 0.45% NS 1 L.” During an interview on 8/13/24 at 11 a.m. with the DOP, the DOP stated, it was important to store medications in properly labeled bins to avoid pulling the wrong medication. Further review of the facility’s P&P titled, “Security of Medication Storage Areas,” revised April 2024, indicated, “ ...Products should be stored in properly labeled areas, bins, etc. to promote ease in selecting products efficiently and without error.” 3. a. During a concurrent observation and interview on 8/13/24 at 2 p.m. with the House Supervisor (HS 1), one undated NS 250 ml IV bag was identified hanging on a pole at bedside, for Patient 12. The HS 1 acknowledged the NS 250 ml IV bag was undated and stated, “[The bag] should be dated.” b. During a concurrent observation and interview on 8/13/24 at 2:30 p.m. in the Overflow Unit with LVN 1, one undated NS 100 ml IV bag was identified hanging on a pole at bedside, for Patient 21. LVN 1 acknowledged the NS 100 ml IV bag was undated and should have been dated. During an interview on 8/15/24 at 3:41 p.m. with the DOP, he stated, the expectation was if the IV bag was in use, then it should have been dated with an expiration date.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 41166 Based on observation and interview, the facility failed to ensure a wound treatment cart containing a medication used to treat wounds was locked and secured to prevent unauthorized access to the medication. This failure had the potential to result in access to the medication by unauthorized personnel. Finding: During a concurrent observation and interview on 8/13/24 at 2:22 p.m., with the Director of Pharmacy (DOP) and the Wound Care Supervisor (WCS), a wound treatment cart was identified unlocked and unattended in the hallway on the second floor. The wound treatment cart contained five SilvaSorb (medication used to treat wounds) 42.5 gram (g, unit of measurement) tubes. The Director of Pharmacy (DOP) stated, the expectation was for a cart containing medications to be locked and secured. The WCS acknowledged he forgot to lock the cart and stated, “I usually lock [the cart].” During a review of the facility’s policy and procedure (P&P) titled, “Security of Medication Storage Areas,” revised April 2024, the P&P indicated, “All medication carts shall remain locked at all times when not attended. This shall include the time required for a nurse to enter a patient’s room to administer medication.””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 41166 Based on observation, interview, and record review, the hospital failed to ensure that all unusable or expired medications were segregated and not available for patient use in accordance with the manufacturer’s recommendations, and hospital policies and procedures when: 1. A single dose 45 millimole (mmol-unit of measure) per 15 milliliter (ml- unit of measure) partially used and resealed injection vial of potassium phosphate injection (medication given in the vein used to treat low phosphorus in the blood) with an expiration date of 8/29/24, was available for patient use; 2. Five 5-ml oral tacrolimus (medication used to prevent organ transplant rejection) 1milligram (mg-unit of measure)/ml syringes with expiration dates 7/30/24 was not separated from four non-expired medications in a bin. These failures had the potential to result in patient harm due to potentially subtherapeutic (ineffective) medications. Findings: 1. During an observation on 8/13/24 at 10:48 a.m. with Director of Pharmacy (DOP) in the pharmacy, a 45 mmol/15ml partially used and resealed injection vial of potassium phosphate labeled “single dose” was observed stored on the pharmacy shelf, with an expiration date of 8/29/24, available for patient use. During an interview on 8/13/24 at 11:00 a.m. with DOP acknowledged the potassium phosphate vial was a single dose vial and stated single dose meant one time use and once punctured, the contents of the vial could not be stored or reused. DOP stated repeated use could compromise the sterility of the medication. During a review of Center for Disease Control and Prevention (CDC), a nationally recognized organization the protects the public’s health, an article titled “Proper Use of Single-Dose and Multi-dose Vials, retrieved 8/22/24, from https://www.cdc.gov/injection-safety/media/pdfs/Injection-Safety-For-Healthcare-P.pdf, the article indicated, “A single-dose vial (SDV) is approved for use on a single patient for a single procedure or injection. SDV typically lack an antimicrobial preservative (used to prevent growth of bacteria). Do not save leftover medication from these vials. Harmful bacteria can grow and infect a patient.” 2. During a concurrent observation and interview on 8/13/24 at 11:28 a.m. with DOP in the pharmacy, five 5 ml tacrolimus 1 mg/ml unit dose syringes for Patient (PT) 20 with an expiration date of 7/30/24 were observed stored and not separated from four non-expired 5 ml tacrolimus 1 mg/ml unit dose syringes in a bin, for the same patient. DOP acknowledged expired medications should be separated and discarded and stated it was important, so the expired medications are not accidentally administered to patients. DOP stated PT 20 was discharged on 7/5/24 and all nine tacrolimus 1mg/ml syringes should have been discarded and not stored. During a review of the hospital’s Policy and Procedure (P&P) titled, “Security of Medication”, revised 4/24, the P&P indicated, “No expired or otherwise unusable drugs may be stored with active inventory. These drugs must be segregated in an area that would preclude their inadvertent use.””

“REPORTING ABUSES/LOSSES OF DRUGS CFR(s): 482.25(b)(7) Abuses and losses of controlled substances must be reported, in accordance with applicable Federal and State laws, to the individual responsible for the pharmaceutical service, and to the chief executive officer, as appropriate. This Standard is not met as evidenced by: 41166 Based on interview and record review, the hospital failed to implement its policy and procedure (P&P) for destruction of controlled drugs (drugs tightly controlled by federal government with high potential for addiction and abuse) when licensed staff did not appropriately document the destruction of two diazepam (medication commonly used for anxiety) 10 milligram (mg- unit of measure) tablets and one morphine (medication used for pain) 2 mg per milliliter (ml- unit of measure) syringe. These failures had the potential for drugs to disappear from the hospital without accountability and unauthorized use. Findings: During a concurrent interview and record review on 8/14/24 at 2:47 p.m., with Director of Pharmacy (DOP), the hospital’s automated dispensing cabinet (ADC) discrepancy report for controlled drugs, dated 7/1/24 to 7/31/24, was reviewed. The report indicated that on 7/26/24 at 10:59 p.m., a discrepancy was documented at nursing station 1’s ADC for one unaccounted morphine 2mg/ml syringe, and on 7/3/24 at 11:11 a.m., a discrepancy was documented at nursing station 4’s ADC for two unaccounted diazepam 10 mg tablets. DOP acknowledged there was no documentation on the ADC report indicating that nursing staff returned or destroyed the unaccounted morphine and diazepam tablets. DOP explained that during pharmacy investigation on 8/1/24, nursing staff stated she accidentally pulled two morphine 2 mg/ml syringes instead of one for Patient (PT) 7, wasted the extra syringe at bedside with another nurse, but did not document the destruction of the controlled drug on the ADC. DOP acknowledged nursing staff did not record or document the destruction of the extra morphine 2mg/ml syringe or return the medication to pharmacy to be destroyed with a pharmacist, at the time of the incident on 7/26/24. For the two unaccounted diazepam 10 mg tablets, DOP explained that during pharmacy investigation on 7/9/24, nursing staff stated she accidentally pulled seven diazepam 10 mg tablets instead of five for PT 8, wasted the two extra tablets with another nurse, but did not document the destruction of the controlled drug on the ADC. DOP acknowledged nursing staff did not record or document the destruction of the two diazepam 10 mg tablets or return the medication to the pharmacy to be destroyed with a pharmacist, at the time of the incident on 7/3/24. During an interview on 8/15/24 at 3:43 p.m., with DOP, DOP stated nursing staff was expected to document destruction of any controlled drug on the ADC. DOP stated it was important to appropriately document wastage and destruction for controlled drugs to prevent potential diversion or theft. During a review of the hospital’s P&P titled, “Controlled Drug Distribution”, revised 7/24, the P&P indicated, “Destruction of partial doses of controlled drugs must be done and recorded by two registered nurses. Destruction of other controlled drugs must be done according to federal law and in the presence of two pharmacists or pharmacist and registered nurse. The record of such destruction will be done on approved form or log.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources transmission of infection when: 1. Staff did not clean and maintain the floors and drains to prevent contamination, in three of three sampled rooms (Hospital Supply, Medication Rooms and Soiled Utility room). Clean patient care supplies were found on shelves close to the contaminated floor, drains were found to have grey debris and missing caulking (a sealant used to fill in between cracks) and shelves were propped up using a roll of medical dressing gauze (a fabric used to cover patient wounds and keep them clean and protected from infection). 2. Staff did not ensure proper infection control practices were implemented during a wound care treatment for one of one sampled patient (Patient (Pt) 17). These failures placed all patients and staff at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. 3. Nurses applied tape over and around the top and opening of the glucometer (a device for measuring the concentration of glucose in the blood) preventing the cleaning and disinfecting of two of two sampled Glucometers in accordance with the hospital’s P&P titled “Equipment Cleaning -- [Brand Name of glucometer] Glucometers.” This failure had the potential to place patients and staff who access glucometers at risk for cross contamination. Findings: 1. During a concurrent observation and interview, on 8/13/24, at 10:30 a.m., with the Director of Nursing (DON), and House Supervisor (HS) 2, on the third floor, in the clean storage room, next to the nurses’ station, a shelf of a shelving units for medical supplies was noted to be less than two inches from the floor. The DON stated, a mop could not fit under the shelving unit to clean underneath. The DON stated, the floors should be swept and mopped daily and as needed, including under the shelving units. The DON stated, supplies could be cross contaminated from the debris on the floor and affect the hospitals infection control. During a concurrent observation and interview, on 8/13/24, at 11:33 a.m., with the DON, and HS 1, on the second floor, in the Soiled Utility room, on the south hall, the two drains floor drains were observed to have grey debris and caulking that was black around the opening. The DON stated, the drains should have been cleaned on more than just a daily basis. The DON stated, the drains should have been cleaned and maintained to allow for easy cleaning as the missing caulking made it more difficult to clean. During a concurrent observation and interview, on 8/13/24, at 2:25 p.m., with the DON, and the Quality Manager (QM) 1, on the first floor, in the clean storage room, on the south hall, the bottom shelf for medical supplies was observed not attached to one of the braces and was held up from the floor by a four-inch roll of medical gauze. The medical gauze had some yellowing around the edges. The DON stated, the shelf should have been fixed and not held up by medical supply gauze. The DON stated, this was unacceptable as the gauze would absorb the mop water as staff cleaned the floor and would be a source of possible infection and cross contamination to patients. During a concurrent observation and interview, on 8/15/24, at 1:00 p.m., with the Chief Executive Officer, QM, the Infection Control Manager (IPM), the Director of Facility Operations (DFO), and the Director of Environmental Services (DEVS), the findings, and pictures of the first, second and third floor were reviewed. a. Third floor, cleaning supply room, the shelf of a shelving units for medical supplies was noted to be less than 2 inches from the floor. The DEVS stated, the staff are unable to clean under the shelving unit if it is not high enough for a broom and mop to fit underneath. The IPM stated, cross contamination could occur if the room was not cleaned. b. Second floor, in the Soiled Utility room, on the south hall, the two drains in the room on the floor. The DFO stated, the caulking around the drains should be replaced and the floor drains should be in a color that will allow staff to determine if they have been cleaned. The DEVS stated, the cleaning staff would not be able to notice the difference between clean and dirty based on what has been done so far. The IPM stated, the drains need to be addressed by maintenance as the drains do not appear clean, even after the staff have cleaned the drains. c. First floor, in the clean storage room, on the south hall, the bottom shelf of a shelving unit for medical supplies. The DFO stated, the shelf was fixed when it was brought to his attention. The DFO stated, broken shelves should be reported so that staff can fix them. The IPM stated, the gauze would absorb water and allow for bacteria to grow. The IPM stated, this would be a cross contamination issue and put people in possible harm. During a review of the facility’s policy and procedure titled, “Environmental Services - Cleaning Schedule”, effective date 3/2023, the policy indicated, “ ... Facility will have quality control checks and inspections periodically using a daily, bi-monthly schedule for regular services Dust mopping, wet mopping, and vacuuming where needed. ... These areas of service will be provided, but not limited to on a regular basis, patient rooms, nurse’s stations, dinning/activity rooms, core areas, utility rooms, ... and common areas. ... 22. Floor - polished ... The complete floor including all edges, comers and main floor spaces must have a uniform shine and be visibly clean with no blood and body substances, dust, dirt, debris, spillages or scuff marks. ... Furnishings and fixtures ... 28. Low surfaces ... All surfaces must be visibly clean with no blood and body substances, dust, dirt, debris, adhesive tape or spillages. ... “ During a review of facility’s policy and procedure titled, “Infection Prevention and Control System,” effective date 12/18/17, the policy indicated, “ ... Hospital maintains an organized, hospital-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among patients, visitors and health care workers ... EVS [Environmental Services] : ... Surveillance is conducted for compliance in which all components of room cleaning are conducted in randomized observation. Findings are used to identify opportunities for improvement ... Materials/Central Supply: ... Assists, supports, and complies with the policies and procedures that outline the appropriate cleaning, storage, disinfection, sterilization and disposal of equipment to reduce the risk of infections associated with reusable equipment, devices or supplies. ... Maintenance/ Plant Ops: ... Assist in environmental rounds and report any new renovations planned and/or in need of repair or under construction, to ensure a sanitary environment and to allow for evaluation of infection risk of patient population and staff. ... Infection Control: ... Surveillance activities: Environmental rounds ... Perform random and monthly EOC [environmental] rounds in conjunction with either Quality or EVS [environmental services] staff. “ During a review of the document titled, “Biofilms”, undated, retrieved from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, the document indicated “Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)” 2. During an observation on 8/15/24 at 1:05 p.m. in Pt 17’s room, Licensed Vocational Nurse (LVN) 4 introduced herself and briefly explained the procedure to the patient. Afterwards, LVN 4 performed hand hygiene and donned a new pair of gloves prior to placing the unopened wound care supplies on a clean bedside table. The wound care supplies included a Q-Tip, a roll of Kerlix (a bandage made up of woven gauze that is fluff dried), foam dressing, two normal saline packets, normal saline syringes clear cups for liquid, bordered gauze, and gauze pads. LVN 4 then elevated the patient’s bed and turned the patient to the left side. LVN 4 opened a normal saline packet, placed gauze in the clear cups and put normal saline to saturate the gauze. LVN 4 removed the previous dressing and placed the used dressing in the trash bin by the bedside table. LVN 4 used the wet gauze from the clean cups to clean the inside of the wound from the inside of the wound to the outside. LVN 4 removed her gloves and placed them in the trash bin. LVN 4 put on new gloves and opened the roll of Kerlix and used two Normal Saline syringes to place on the Kerlix. LVN 4 removed a Q-Tip from its wrapping and used the Q-Tip to pack the wet Kerlix gauze into the wound. LVN 4 stated, she stopped packing the wound when packing met with resistance. LVN 4 removed her trauma shears from her scrub pants pocket and cut the excess roll that was not packed into the wound. LVN 4 returned the trauma shears to her scrub pants pocket. LVN 4 applied the foam dressing and dated the dressing. LVN 4 cleaned the bedside table, disposed of the supplies used, removed her gloves, and performed hand hygiene. During an interview on 8/15/24, at 3:53 p.m., with LVN 4, LVN 4 stated, she should have used sterile scissors to cut the excess Kerlix gauze from the dressing and not her personal trauma sheers stored in her pants pocket. During a review of Pt 17’s “History and Physical” dated 7/3/24 at 10:57 p.m., the H&P (History and Physical) indicated, Pt 17 was admitted to the hospital on 7/1/24. The H&P indicated “ ... Management of chronic medical problems, drain care, and wound care. ... history of T12 [thoracic vertebra number 12 -back bone] paraplegia [partial paralysis that usually includes the lower half of the body], secondary to motor vehicle accident in 2018, with nonhealing, chronic pressure ulcer on the right buttock for which he underwent debridement ...” During an interview, on 8/16/2024 at 10:50 a.m., with the Wound Care Supervisor (WCS) and Chief Executive Officer (CEO), The WCS stated, LVN 7 should not have used trauma shears from her pocket to cut the gauze. The WCS stated, she should have used scissors that had been cleaned or single use scissors from a new package. The CEO stated, the nurses should use aseptic techniques when doing dressing changes including using clean scissors and not from their pockets. During a review of the document titled, “Wound Care Nurse Job Description,” dated 9/1/2015, the job description indicated,” ... The Wound Care Nurse is responsible for implementing, coordinating, monitoring managing the hospital wound care program. ... Abides by all safety, infection control, and other guidelines as required. ... 3. Cleans equipment between patient usage. ... “. During a review of the document titled, “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” retrieved from, https://www.cdc.gov/infection-control/hcp/core-practices/index.html dated 4/12/24, “ ...standard precautions (basic level of infection control that is used in patient care) include: ...hand hygiene ...environmental cleaning and disinfection .. Reprocessing of reusable medical equipment between each patient or when soiled...” 3. During a concurrent observation and interview on 8/13/24 at 2:20 p.m. with Quality Manager (QM), on the First floor, at nurses’ station 1 and 2, glucometer 1 and glucometer 2 were observed to have tape around the opening at the top of the machine where the blood is sampled. The QM validated tape was on glucometer 1 and glucometer 2. The QM stated, the tape should not be on the devices as it makes it hard to clean the equipment. The QM stated, the tape should not be on the device and started removing the tape immediately. The QM stated the device can not be cleaned as per the policies of cleaning equipment if tape covers the device. The QM stated cross contamination between patients could occur if the glucometers are not properly cleaned. During a concurrent observation and interview on 8/15/24 at 1:00 p.m. with Infection Control (IP), QM and the Chief Executive Officer (CEO), on the First floor, at nurses station 1 and 2, glucometer 1 and glucometer 2 were observed. The pictures of glucometer 1 and glucometer 2 from 8/13/24 at 2:20 p.m. were shown to IP and the CEO. The QM validated tape was on glucometer 1 and glucometer 2. The IP stated tape should not be on the glucometers as the machines could not be properly cleaned. The IP stated the machines could have bacteria that breeds on the machines and could contaminate patients. The CEO stated the nurses should follow the policy for cleaning the machines and what is indicated in the manufacturer’s guidelines for cleaning the devices. The CEO stated, the machines need to be clean to prevent harm to the patients. During a record review, the facility’s P&P titled, “Equipment Cleaning -- [Brand Name of glucometer] Glucometers,” dated 4/2019, indicated, “ ... To ensure that [Brand Name of Glucometer] are adequately cleaned and disinfected ... policy and procedure as well as manufacture’s guidelines after use. ... Ensure all parts of the machine are wiped down ... “. During a review of facility’s Glucometer “Operators Manual (OM)”, not dated, the OM indicated, “ ... Cleaning and disinfecting the meter is important to prevent the spread of infectious diseases. Follow your facility’s policies and procedures for infection control, which may require more frequent cleaning and disinfecting ... 1. For cleaning, wipe all outside surfaces of the meter thoroughly, taking care to avoid the strip port opening and the data port connector, until they are visibly clean. 2. Discard the wipes in used appropriate biohazard waste container. Disinfection of the meter should be accomplished after use with each patient. Disinfection is a process that destroys pathogens, such as viruses and other microorganisms on the meter surfaces. Disinfecting the meter helps ensure that no infection is passed on when the user or others come in contact with the meter, The meter should be cleaned prior to disinfection ... l. For disinfection, wipe all outside surfaces of the meter thoroughly, taking care to avoid the strip opening and the data port connector, until they are wet in order to pre-clean the meter, 2. After pre-cleaning, use a second wipe to disinfect the meter using the same process. 3. Allow the meter surfaces to remain wet for ONE FULL MINUTE. Allow the meter to air dry completely before use or before docking the meter. ... “”