Sonoma Specialty Hospital

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 51484 Based on interview and record review, the facility failed to provide accurate patient information to a receiving hospital for 1 of 30 sampled patients (Patient 1) when Patient 1’s Physician Order for Life Sustaining Treatment (POLST - a document signed by the physician that states the type of treatment for end of life care) did not reflect the wishes of Patient 1 and their family member whom was also Patient 1’s health care decision maker. This failure caused confusion surrounding Patient 1’s preferences and physician’s orders for end of life care, which resulted in a receiving hospital not honoring Patient 1’s wishes and potential emotional distress for Patient 1’s family. Findings: A review of Patient 1’s History & Physical (H&P), dated 11/6/25, the H&P indicated, Patient 1 was admitted to hospital on 11/5/25 with diagnoses that included left heel wound, Peripheral Vascular Disease (a progressive blood circulation disorder where the vessels narrow or become blocked), paroxysmal atrial fibrillation ( a type of irregular heart rhythm), stage 4 chronic kidney disease (severe kidney damage), high blood pressure, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), hypothyroidism (abnormally low activity of the thyroid gland), and acute respiratory failure (rapid, critical failure of the lungs to oxygenate blood or eliminate carbon dioxide). During an interview with Registered Nurse (RN) 1 on 2/2/26 at 12:35 p.m., RN 1 stated if there was “Code Blue” (a medical emergency when the heart or breathing stops) or a change in the patient’s condition, they followed the most current POLST. RN 1 stated there was a binder at the nurses’ station with the most current POLST in it. During a review of Patient 1’s orders, dated and signed on 11/5/25, Medical Doctor (MD) 1 ordered full code status (life-saving procedures performed to restore heartbeat and breathing). During a review of Patient 1’s POLST, dated and signed on 11/7/25, the POLST indicated “Attempt resuscitation [life-saving procedures performed to restore heartbeat and breathing] and Full Treatment [primary goal for prolonging life by all medically effective means].” During a review of Patient 1’s orders, dated 11/20/25, the orders indicated, MD 2 changed the code status to Do Not Resuscitate (DNR-Allow Natural Death). During a review of Patient 1’s Physician Progress Note (PPN), dated 11/30/25, the PPN indicated Patient 1’s heath care agent confirmed patient was a DNR with selective treatment and brought a POLST form dated 5/8/25 supporting DNR status and the POLST was given to staff to scan for placement in the medical record of Patient 1. During a review of Patient 1’s POLST, dated and signed on 5/8/25, the POLST indicated “Do Not Attempt Resuscitation/DNR, Selective Treatment (goal of treating medical conditions while avoiding burdensome measures), and Artificially Administered Nutrition (Trial period of artificial nutrition, including feeding tubes).” During a review of Patient 1’s Nursing Progress Note (NPN), dated 12/15/25, the NPN indicated Patient 1 had an episode of bradycardia (slow heart rate) and staff initiated a code blue. The event transitioned to a rapid response (emergency response initiated when patients’ condition worsens rapidly). The NPN included, “[Patient 1] has two POLST one DNR signed and dated 5/8/25 and a POLST full code signed and dated 11/7/25. Went off the most recent POLST dated 11/7/25”. The NPN continued, (MD 3 gave the order for Patient 1 to be sent out for further evaluation and Patient 1 left the building on 12/15/25 at 3:27 a.m. During a review of Patient 1’s POLST sent to the receiving hospital on 12/15/25, dated and signed on 11/7/25, the POLST indicated “Attempt resuscitation” and “Full Treatment.” During a review of Patient 1’s ED (Emergency Department) Progress Note from the receiving hospital, dated 12/15/25 at 6:23 a.m., the note indicated, Patient 1 was placed on a ventilator (device used medically to support or replace the breathing of a person), intubated (a tube is inserted through the mouth into the airway to maintain an open airway, allowing mechanical ventilation), and initiation of a central line (a long, flexible tube inserted into a large vein, usually in the neck, chest, or groin, with the tip resting near the heart). An untimed addendum to the note stated Patient 1’s health care agent , “confirmed DNR/DNI [Do not intubate], this was relayed to ICU (Intensive Care Unit) for further management as [Patient 1] was already transferred to ICU”. During an interview with Assistant Director of Nursing (ADON) on 2/2/26 at 4:35 p.m., the ADON stated staff used the most recently dated POLST on record. She acknowledged the confusion arising from the most recently scanned POLST with the older date of 5/8/25 (ordering DNR) and the most recently dated POLST of 11/7/25 (ordering Full Code). The ADON stated a new POLST reflecting Patient 1’s and the daughter’s wishes of DNR should have been ordered and scanned to make it clear to staff the desired POLST. During an interview with the Telemetry Clerk (TC) on 2/4/26 at 12:00 p.m., TC stated if there were multiple POLSTs in the binder, he would send the most recent dated one. During an interview with MD 1 on 2/4/26 at 1:25 p.m., MD 1 stated, “There should have been a new POLST created that day. That was not done”. During the review of the facility’s policy and procedure (P&P) titled, “POLST”, dated 10/15/25, the P&P indicated, “3. Conflict Resolution. If there is a discrepancy between POLST ... 1. The most recent medical order takes precedence 2. The provider must clarify immediately ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35598 Based on interviews and record reviews, the facility failed to ensure a patient’s right to receive care in a safe setting for 1 of 30 sampled patients (Patient 1) by not adhering to its policies and protocols regarding sepsis (a widespread infection with life threatening organ dysfunction) screening and assessment, escalation, and treatment when the hospital failed to recognize the signs and symptoms of Patient 1’s clinical deterioration (characterized by low blood pressure, no urine output, poor oral intake, and vomiting) and did not escalate care or initiate aggressive treatment and rescue for sepsis and septic shock over a 25-hour period (Refer to A-0144). This failure resulted in Patient 1’s clinical deterioration and a delay in transfer to a higher level of care within the hospital and delayed transfer to another facility capable of managing her life threatening symptoms. This failure contributed to Patient 1’s death due to septic shock approximately 18 hours post transfer to an outside facility. The cumulative effect of these systemic problems resulted in the hospital’s inability to comply with the statutorily mandated Conditions of Participation for Patient Rights.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 50619 Based on interviews and record reviews, the hospital failed to provide quality medical care to 1 of 30 sampled patients (Patient 1), when Medical Doctors (MDs) did not follow policies, procedures, and bylaws related to sepsis (a widespread infection with life threatening organ dysfunction) treatment and rescue interventions when: 1. The hospital’s MDs delayed transfer to a higher level of care (Intensive Care Unit- a specialty unit to manage patients who require constant monitoring and life support) despite clear signs of clinical deterioration which included low blood pressure, anuria (no urine output), poor oral intake, and vomiting; symptoms consistent with septic shock (the most severe stage of sepsis), which persisted for 25 hours (Refer to A-0347), and 2. The hospital’s MDs failed to transfer Patient 1 to a facility better equipped to provide lifesaving interventions including stable intravenous (IV- a catheter inserted into a vein to provide fluids and medications) access for fluid resuscitation (rapidly replacing fluids during shock/ sepsis to restore blood pressure to ensure organ function) (Refer to A-0347). The failures led to Patient 1’s clinical deterioration, causing a delay in transfer to a higher level of care within the hospital and transfer to another facility capable of managing her life threatening symptoms. This ultimately contributed to Patient 1’s death from septic shock approximately 18 hours after being transferred to an outside facility. The cumulative effect of these systemic problems resulted in the hospital’s inability to comply with the statutorily mandated Conditions of Participation for Medical Staff.”

“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: 50619 Based on interviews and record reviews, the facility failed to follow its policies and procedures and did not provide quality nursing care for five of 30 sampled patients (Patients 1, 2, 3, 8, and 13) when: 1. Nursing staff failed to conduct complete and accurate sepsis (a widespread infection with life-threatening organ dysfunction) screenings for Patients 1, 2, 3, and 13, which included a full set of vital signs, proper use and documentation of sepsis screening tools and escalation to a medical doctor as indicated (Refer to A-0398); and, 2. Nursing staff failed to ensure medications were administered in accordance with medical doctor orders for Patients 2, 8, and 13 (Refer to A-0405). These failures resulted in inaccurate and incomplete sepsis screenings, which may have precluded nursing staff and medical doctors from recognizing and appropriately responding to changes in Patients 1, 2, 3, and 13’s conditions. Further, the nursing staff failed to recognize the urgency of Patient 1’s prolonged clinical deterioration, which included low blood pressure, anuria (no urine output), poor oral intake, and vomiting, all consistent with sepsis and septic shock (the most severe stage of sepsis) for 25 hours. This oversight contributed to Patient 1 developing septic shock (dangerously low blood pressure and organ failure and expiring approximately 18 hours after being transferred to another hospital. These failures also placed Patients 2, 8 and 13 at potential risk of experiencing adverse side effects, worsening symptoms, deteriorating health conditions, the development of new complications, and even death when medications were not administered according to medical doctors’ order parameters. The cumulative effect of these systemic problems resulted in the hospital’s inability to comply with the statutorily-mandated Condition of Participation for Nursing Services.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50619 Based on interview and records review, the facility failed to ensure that one of 30 sampled patients (Patient 1), who experienced clinical deterioration (low blood pressure, no urine output, low oral intake, and vomiting), received appropriate and timely rescue interventions. Patient 1, later diagnosed with sepsis (a widespread infection with life-threatening organ dysfunction) had signs and symptoms of sepsis and septic shock (most severe stage of sepsis marked by dangerously low blood pressure and organ failure) for 18 hours prior to being transferred to the intensive care unit (ICU- a specialty unit for critically ill patients) and then transferred out to another hospital better equipped to provide life saving interventions. This failure resulted in Patient 1 developing septic shock and expired after a delayed transfer to another facility, approximately 18 hours post transfer. The State Agency (SA) determined the facility’s noncompliance with one or more requirements of participation had contributed to Patient 1’s death and was likely to cause serious injury, serious harm, serious impairment, or death to other patients. On 10/14/25 at 8:28 p.m., the SA provided the CMS (Centers for Medicare and Medicaid Services) Immediate Jeopardy (IJ) Template to the Chief Nursing Officer (CNO) and Chief Operating Officer (COO) and verbally informed them that IJ existed related to Medical Staff tag A-0347 [42CFR 482.22 (b)], Patient Rights tag A-0144 [42CFR 482.13(c)(2)], and Nursing Services tag A-0398 [42CFR 482.23(b)(6)] that began on 8/25/25 at 5:00 p.m. The hospital developed and submitted an acceptable action plan that addressed the IJ situation, and the immediacy was removed onsite on 10/15/25 at 10 a.m. The hospital implemented immediate corrective actions to address the issues. The survey team validated the facility’s corrective actions, and the facility provided an acceptable IJ removal plan. The IJ was lifted onsite on 10/15/25 at 1:30 p.m. The facility remained out of compliance at A-0144, A-0347, and A-0398. Findings: During a review of Patient 1’s “History and Physical (H&P),” dated 8/8/25, the H&P indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. During Patient 1’s hospital stay, she was able to wean off dialysis and produce her own urine.. During a record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1’s Nursing Progress Notes (NPN) and Vital Signs (VS), dated 8/25/25, 8/26/25 and 8/27/25 were reviewed and revealed the following: Patient 1’s VS on 8/25/25 at 12:48 p.m., indicated Patient 1’s blood pressure (BP) was 123/88 (normal blood pressure reading is at or below 120/80). Patient 1’s VS indicated on 8/25/25 at 9:00 p.m., Patient 1’s BP dropped to 83/58. At 10 p.m., Patient 1’s VS indicated BP was 88/49. The NPN indicated medical doctor (MD) 1 was notified at 10 p.m. of Patient 1’s low BP and low urine output. MD 1 ordered to encourage fluids (orally) and if unable to drink fluids to start an intravenous (IV-fluids given directly into the bloodstream) line. The NPN indicated Patient 1 complained of difficulty swallowing. At 11:30 p.m., Patient 1 had normal saline (NS) IV fluids started at 75 ml/hr (milliliter per hour- a measure of volume flow rate). Patient 1’s VS and NPN indicated on 8/26/25 from 12 a.m. to 5:30a.m., Patient 1’s VS were as follows: 12 a.m. BP 82/47, heart rate (HR, the number of times the heart beats per minute [bpm]) was 102 (Normal heart rate is 60-100 bpm) 1 a.m. BP 84/52 2 a.m. BP 71/56 3 a.m. BP 76/40 4 a.m. BP 71/46 5 a.m. BP 76/42 5:15 a.m. BP 64/44 5:30 a.m. BP 70/40 At 5:30 a.m., a NPN revealed an on-call MD was notified of continued hypotension (low blood pressure) and low urinary output. An order for oral medication, Midodrine (causes the small arteries and veins throughout your body to tighten or constrict), 10 mg (milligram) tablet to be given one time was noted. During a continued record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1’s NPN and VS, dated 8/26/25 were reviewed, and indicated the following: 6 a.m. BP 84/40 6:27 a.m. BP 113/89, HR 92 At 7 a.m. IV intake 600 ml NS At 8:52 a.m., the Case Manager met at the bedside with Patient 1 and Patient 1’s family member and there was a discussion regarding discharge home or discharge to a skilled nursing facility (SNF). Patient 1 and Patient 1’s family member agreed that Patient 1 would be discharged to a SNF on 8/27/25. At 11:49 a.m., the VS indicated Patient 1’s BP was 78/44. MD 1 was notified of Patient 1’s persistent low BP, and gave a verbal order to administer a 500 ml bolus of NS rapidly through the vein. Additionally, MD 1 instructed to continue the IV NS at a rate of 75 ml/hr, conduct blood tests and cultures to check for infection, and to replace the urinary catheter (a tube inserted into the bladder to drain or collect urine). At 12:15 p.m., Patient 1 had a urinary catheter removed and then another one attempted without urine return. The Resource Nurse (RN) and House Supervisor (HS) were informed and also attempted to place a catheter without urine return, so they consulted with MD 1. At 1:20 p.m., MD 1 ordered another 500 ml bolus of NS for Patient 1. However, Patient 1’s IV leaked, and the HS was notified. At 2:15 p.m., the Case Manager noted that per MD 1, there was a change in condition and that discharge would likely be delayed for 2 days. Transportation was canceled and the skilled nursing facility notified. At 2:30 p.m. progress note indicated, Patient 1’s IV was non-functional, and staff attempted to establish a new IV without success. The HS and Director of Nursing (DON) were informed. At 3 p.m., nursing attempted to place a new urinary catheter , with no urine return, and the urinary catheter was removed. It was noted that Patient 1’s midline IV (a long, thin, flexible tube inserted into a vein in the upper arm to give medication, fluids, or draw blood) access, used for continuous IV fluid, was leaking and could not be used. At 4:30 p.m. the progress note revealed further attempts to place an IV and a urinary catheter for Patient 1 were unsuccessful. An MD made an order for IV placement and nursing staff notified the contracted IV placement company. Patient 1’s IV antibiotic Ceftriaxone was delayed for later that evening due to lack of IV access. At 4:54 p.m., Patient 1 had a 22-gauge (small plastic tube) IV inserted on her left antecubital (front of the elbow) by nursing staff at the facility. At 5 p.m., Patient 1’s midline catheter “appears to be coiled” in the right upper extremity (not usable) and Patient 1’s bed sheet was wet under the left upper extremity (IV site is not usable and leaking). At 5:05 p.m., nursing noted Patient 1’s midline catheter was still leaking. A new IV site was attempted, and a third urinary catheter insertion failed with no urine output. The contracted IV company was contacted for an estimated time of arrival (which was multiple hours). MD 1 was informed. At 7:06 p.m., Patient 1’s BP was 76/49, the nurse noted “Patient [1] remained hypotensive with low urine output throughout the shift. Continuous IVF [IV fluid] NS running at 75 ml/hour, and midodrine 10 mg tablet given. MD [1] is aware of blood pressure and urine output.” At 8 p.m., Patient 1 had a peripheral IV (PIV) placed in the left forearm with a 20-gauge needle, and NS started at 125 ml/hour for re-hydration. . At 8:51 p.m., Patient 1’s BP was 87/44. At 10:19 p.m. Patient 1 was transferred to the ICU. The registered nurse (RN) documented, “Patient [1] was placed on continuous monitoring. Patient [1] appears disoriented ...Blood pressure is currently low 79/52, NS infusing at 125 ml/hour.” Review of Patient 1’s ICU NPN and VS, dated 8/26/25 from 11:50 p.m. to 8/27/25 11:06 a.m. indicated, on 8/26/25 at 11:50 p.m., MD 2 was contacted, and orders were given to administer a NS 1000 ml bolus over one hour and Ceftriaxone (antibiotic, effective against many common types of bacteria that can cause sepsis) 2 grams was given. On 8/27/25 at 12:32 a.m., Patient 1’s B/P was 64/32. At 2:18 a.m., BP 66/46 and Patient 1 became lethargic and restless. At 4:06 a.m., BP 57/37 and Patient 1 had no urine output. At 4 a.m., a bladder scan (an ultrasound image to see how much urine is in the bladder) was performed but no urine volume reading was generated. It was not possible to determine if urine retention was present based on the scan. At 4:28 a.m., MD 2 notified of Patient 1’s completion of the 1000 ml NS bolus. Despite this, Patient 1 continued to experience persistent hypotension with a BP of 57/37, and Patient 1 appeared pale and cool. According to the NPN, MD 2 ordered “Levophed [an emergency medicine used to raise very low blood pressure] infusion to support blood pressure. Supervisor notified.” At 5:19 a.m. Patient 1 had Levophed started at 10 mcg/kg (micrograms per kilogram- a drug dose measurement per body weight) with an increase of BP to 136/84. At 5:20 a.m., BP was 175/110 At 5:22 a.m., BP was 158/99 and Levophed was decreased to 8 mcg/kg. At 5:35 a.m., BP was 130/77 and Levophed was decreased to 6 mcg/kg. At 5:46 a.m., BP was 99/65, and the HR was103. At 5:50 a.m., BP was 83/64, HR was 110, and Levophed decreased to 2 mcg/kg. At 6:59 a.m., BP was 135/77, and HR was 100. At 7:08 a.m., the MD notified that Patient 1 had urinary retention (unable to urinate). Levophed was infusing at a rate of 2mcg/kg, and the leaking urinary catheter was changed. At 7:31 a.m., Patient 1’s BP was 99/61 and HR was at 108. Levophed continued infusing at 2mcg/kg. The note indicated Patient 1 “was very hypotensive still” and “hard to get BP reading due to edema [swelling]”. The note continued NS not running, “per Noc (night) shift nurse told to d/c [discontinue] by noc shift MD”. At 7:50 a.m., Patient 1’s HR was 143 and Levophed at 2mcg/kg continued. At 8:05 a.m., Patient 1’s VS indicated BP was 73/55. Also, at 8:05 a.m., the NPN indicated inability to get BP due to Patient 1’s edema and MD 2 aware. At 9:02 a.m., the BP was 54/64, and HR was 104. At 9:20 a.m., the BP was 80/65, and the HR was 99. At 9:43 a.m., the NPN indicated, “Chunk of something came from Patient [1’s] throat. Not sure what it is. Cousin would like [Patient 1] to go to a higher level hospital. Will inform MD [1].” At 10:05 a.m. the BP was 77/61, and Levophed continued infusing at 2 mcg/kg. At 10:16 a.m., Patient 1’s BP was 75/50. At 10:31 a.m., Patient 1’s BP was 68/42, and Levophed continued infusing at 2 mcg/kg. At 10:38 a.m., the NPN indicated MD 1 requested continuous IV fluids be restarted. Nursing alerted MD 1 about chunks of blood coming from the patient’s throat. MD 1 stated this “was okay and continue to monitor”. The family member wanted Patient 1 to go to a higher level of care hospital, but the note revealed, “per doctor’s orders, we waited.” At 10:57 a.m., Patient 1’s BP was 72/49. At 11 a.m., the dialysis nurse was able to draw blood from Patient 1’s dialysis port (a medical device, inserted into a patient, used to provide access to the bloodstream for dialysis). At 11:06 a.m., Patient 1’s BP was 70/50. At 11:38 a.m., Patient 1 was sent to a higher-level hospital emergency room. The NPN indicated, “Levophed dc’d [discontinued], paramedics said they did not have the right equipment to keep Patient 1 on the Levophed.” Per the NPN at 11:39 a.m., the note indicated Patient 1 was hypotensive, had no [urinary output] at all, her level of consciousness had been changing from the night prior and had become increasingly confused. The note indicated staff was having difficulty getting a BP every 15 minutes and MD 1 was aware. Patient 1 received 750ml out of the 1000ml IVF ordered. The note indicated the Paramedics also had difficulty getting a BP and revealed Patient 1’s extremities were cold and swollen. Patient 1 was given nausea medicine for nausea and vomiting. During a record review of the [higher level of care hospital] document titled, “Discharge Death Summary [Death Summary],” dated 8/28/25 at 11:58 a.m., the “Death Summary” indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (low oxygen levels), and acute kidney injury on 8/27/25, and subsequently died on 8/28/25 at 6:17 a.m. The “Death Summary” indicated the cause of death as septic shock, multiorgan failure, and septic right hip joint with acute kidney injury as a contributing factor to the cause of death. During a concurrent interview and record review on 10/14/25 at 10:25 a.m., with the CNO, Patient 1’s 8/25/25 to 8/27/25 NPN and VS were reviewed. The VS indicated, from 8/25/25 at 9 p.m. until 8/26/25 at 10:19 p.m., Patient 1’s blood pressure dropped, Patient 1 had no urine output, and no IV access, yet stayed on a Medical-Surgical floor (a lower level of care environment for non-critical patients with stable VS). The CNO stated such patients commonly stayed on the Medical- Surgical floor and that nurses received sepsis training during onboarding and annually. During a concurrent interview and record review on 10/14/25 at 2:25 p.m., with MD 1 and DON, Patient 1’s 8/25/25 to 8/27/25 NPN and VS were reviewed. MD 1 stated, “We don’t always have ICU beds, so this type of patient is the norm[al] for the floor [Medical-Surgical nursing unit].” MD 1 indicated Patient 1 was scheduled to be discharged home, and stated, “[Patient 1] was looking fine” and was improving. MD 1 stated Patient 1 was able to be managed safely on the medical surgical unit. MD 1 stated that Patient 1 developed sepsis and the importance was to give IV fluids and antibiotics and that could be done at the facility by a medical surgical nurse. MD 1 stated the patient did not require a transfer to a higher level of care within the facility, for example to the ICU, or to another hospital and Patient 1 was doing fine when he saw her, had normal vital signs, and was scheduled to be discharged home. MD 1 stated Patient 1 had appropriate interventions and did not feel that Patient 1 went too long without intervention, escalation, or IV access because they were trying IV attempts and waiting on the “PICC nurse” (a contracted company available for inserting larger and deeper IV access). During a continued concurrent interview and record review on 10/14/25 at 2:25 p.m., with the DON and MD 1, the DON indicated that he was assisting with Patient 1’s IV placement and was unsuccessful in getting IV access and MD 1 was aware of Patient 1’s status. During a telephone interview on 10/15/25 at 9:50 a.m. with the Corporate Medical Director (CMD), he stated “Many steps were missed in the care of this patient [Patient 1] and that sepsis is a critical condition that requires early intervention.” During a phone interview on 10/16/25 at 2:35 p.m., with RN 2, RN 2 stated she was the day House Supervisor on 8/26/25 but could not recall the event. She indicated that if a patient became hypotensive, the nurse must notify the MD, transfer the patient to ICU if a bed was available, obtain MD orders for IV access, if needed, assess for sepsis protocol criteria (defines how to recognize and manage sepsis and its symptoms), and escalate to the DON and upper management if needed. During a review of the facility’s policy and procedures (P&P) titled, “Patient Rights,” dated 1/24/23, the P&P indicated, “Medical Care ...To receive the care and health services that the hospital is required to provide by law ...Transfers ... To be transferred to another facility ...if the current hospital is unable to provide the level of appropriate medical care appropriate to meet your needs ...” During a review of the facility’s P&P titled, “Sepsis”, dated 11/15/24, the P&P indicated, “To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality ....This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines ...Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory ...Definitions ...Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...Septic Shock: subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher mortality ...SIRS (Systemic Inflammatory Response Syndrome): Two or more of the following. Temperature >38° Celsius or <36° Celsius, HR >90 bpm [respiratory rate] RR>20/min ...SBP (systolic BP) less than 100 ...A score >2 suggests high risk of poor outcome.” Further review of the facility’s P&P titled, “Sepsis”, dated 11/15/24, the P&P indicated, “ ... Positive screen triggers sepsis or septic shock ...Measure lactate level (a lab test which is elevated in sepsis due to lack of oxygen at the cellular level) ...Obtain blood cultures before administering antibiotics ...Administer broad spectrum antibiotics ...Begin rapid administration of 30 mL/kg of ...fluid for hypotension ...Apply vasopressors (medications to increase blood pressure)...Ongoing management within 6 hours ...Reassess hemodynamics (VS- specifically BP), urine output, and tissue perfusion...Recheck lactate if initial elevated ...De-escalate antibiotics based on culture results and infectious disease consultation ...Initiate supportive measures (oxygen, ventilator ...) ...Transfer to higher level of care (ICU) as indicated.””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50619 Based on interview and record review, the medical staff failed to adhere to Governing Body Bylaws to ensure the provision of quality medical care to one of 30 sampled patients (Patient 1) when Patient 1 showed prolonged clinical deterioration, including low blood pressure, anuria (no urine output), poor oral intake, and vomiting, and met clinical criteria for sepsis (widespread infection with life-threatening organ dysfunction caused by infection) while on a medical-surgical floor (a lower level of care environment for non-critical patients with stable vital signs). Patient 1 did not receive timely and appropriate rescue interventions or transfer to a higher level of care with symptoms of septic shock (most severe stage of sepsis with organ failure) for 18 hours prior to transferring to an Intensive Care Unit (ICU- a specialty unit for critically ill patients requiring constant monitoring and life support). The facility’s inability to obtain intravenous (IV- a catheter placed in a vein to provide fluids for hydration) access in a timely manner further delayed critical treatment. Additionally, transfer to an external hospital capable of providing advanced, life-saving interventions was not initiated promptly, contributing to a delay in definitive care. These failures resulted in Patient 1 developing septic shock with multi-organ failure, experiencing prolonged periods of dangerously low blood pressure without IV access for sepsis treatment, and a delayed transfer to both internal and external higher levels of care. These delays and omissions in care significantly contributed to Patient 1’s death. The State Survey Agency (SA) determined the facility’s noncompliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to patients. On 10/14/25 at 8:28 p.m., the SA provided the CMS (Centers for Medicare and Medicaid Services) Immediate Jeopardy (IJ) Template to the Chief Nursing Officer (CNO) and Chief Operating Officer (COO) and verbally informed them that IJ existed related to Medical Staff tag A-0347 [42CFR 482.22 (b)], Patient Rights tag A-0144 [42CFR 482.13(c)(2)], and Nursing Services tag A-0398 [42CFR 482.23(b)(6)] that began on 8/25/25 at 5:00 p.m. The hospital developed and submitted an acceptable action plan that addressed the IJ situation, and the immediacy was removed onsite on 10/15/25 at 10 a.m. The hospital implemented immediate corrective actions to address the issues. The survey team validated the facility’s corrective actions and the facility provided an acceptable IJ removal plan. The IJ was lifted onsite on 10/15/25 at 1:30 p.m. The facility remained out of compliance at A-0144, A-0347, and A-0398. Findings: During a review of Patient 1’s “History and Physical [H&P],” dated 8/25, the H&P indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. The H&P indicated, during Patient 1’s hospital stay, she was able to wean off dialysis and make her own urine. During a record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1’s Nursing Progress Notes (NPN) and Vital Signs (VS), dated 8/25/25, 8/26/25 and 8/27/25 were reviewed and revealed the following: Patient 1’s VS on 8/25/25 at 12:48 p.m., indicated Patient 1’s blood pressure (BP) was 123/88 (normal blood pressure reading is at or below 120/80). Patient 1’s VS on 8/25/25 at 9:00 p.m., indicated Patient 1’s BP dropped to 83/58. At 10 p.m., Patient 1’s VS indicated BP was 88/49. The NPN indicated medical doctor (MD) 1 was notified at 10 p.m. of Patient 1’s low BP and low urine output. MD 1 ordered to encourage fluids (orally) and if unable to drink fluids to start an intravenous (IV-fluids given directly into the bloodstream) line. The NPN indicated Patient 1 complained of difficulty swallowing. At 11:30 p.m., Patient 1 had normal saline (NS) IV fluids started at 75 ml/hr (milliliter per hour- a measure of volume flow rate). Patient 1’s VS and NPN on 8/26/25 from 12 a.m. to 5:30 a.m. indicated the following: 12 a.m. BP 82/47, heart rate (HR, the number of times the heart beats per minute [bpm] ) 102 (Normal heart rate is 60-100 bpm) 1 a.m. BP 84/52 2 a.m. BP 71/56 3 a.m. BP 76/40 4 a.m. BP 71/46 5 a.m. BP 76/42 5:15 a.m. BP 64/44 5:30 a.m. BP 70/40 At 5:30 a.m., a NPN revealed an on-call MD was notified of continued hypotension (low blood pressure) and low urinary output. An order for an oral medication, Midodrine (causes the small arteries and veins throughout your body to tighten or constrict), 10 mg (milligram) tablet to be given one time was noted. During a continued record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1’s NPN and VS, dated 8/26/25 were reviewed, and indicated the following: 6 a.m. BP 84/40 6:27 a.m. BP 113/89, HR 92 At 7 a.m. the total amount of IV NS received over a seven hour period was 600 ml. At 8:52 a.m., the Case Manager met at the bedside with Patient 1 and Patient 1’s family member, and there was a discussion regarding discharge home or discharge to a skilled nursing facility (SNF). Patient 1 and Patient 1’s family member agreed that Patient 1 would be discharged to a SNF on 8/27/25. At 11:49 a.m., the VS indicated Patient 1’s BP was 78/44. MD 1 was notified of Patient 1’s persistent low BP, and gave a verbal order to administer a 500 ml bolus of NS rapidly through the vein. Additionally, MD 1 instructed to continue the IV NS at a rate of 75 ml/hr, conduct blood tests and cultures to check for infection, and to replace the urinary catheter (a tube inserted into the bladder to drain or collect urine). At 12:15 p.m., Patient 1 had a urinary catheter removed and then another one attempted without urine return. The Resource Nurse (RN) and House Supervisor (HS) were informed and also attempted to place a catheter without urine return, so they consulted with MD 1. At 1:20 p.m., MD 1 ordered another 500 ml bolus of NS for Patient 1. However, Patient 1’s IV leaked (not functional), and the HS was notified. At 2:15 p.m., the Case Manager noted that per MD 1, there was a change in condition and that discharge would likely be delayed for 2 days. Transportation was canceled and the skilled nursing facility notified. At 2:30 p.m. the progress note indicated, Patient 1’s IV was non-functional, and staff attempted to establish a new IV without success. The HS and Director of Nursing (DON) were informed. At 3 p.m., nursing attempted to place a new urinary catheter , with no urine return, and the urinary catheter was removed. It was noted that Patient 1’s midline IV (a long, thin, flexible tube inserted into a vein in the upper arm to give medication, fluids, or draw blood) access, used for continuous IV fluid, was leaking and could not be used. At 4:30 p.m. the progress note revealed further attempts to place an IV and a urinary catheter for Patient 1 were unsuccessful. An MD made an order for IV placement and nursing staff notified the contracted IV placement company. Patient 1’s IV antibiotic medication, Ceftriaxone (antibiotic, effective against many common types of bacteria that can cause sepsis), was delayed for later that evening due to lack of IV access. At 4:54 p.m., Patient 1 had a 22-gauge (small plastic tube) IV inserted on her left antecubital (front of the elbow) by nursing staff at the facility. At 5 p.m., Patient 1’s midline catheter “appears to be coiled” in the right upper extremity (not usable) and Patient 1’s bed sheet was wet under the left upper extremity (IV site is not usable and leaking). At 5:05 p.m., nursing noted Patient 1’s midline catheter was still leaking. A new IV site was attempted, and a third urinary catheter insertion failed with no urine output. The contracted IV company was contacted for an estimated time of arrival (which was multiple hours). MD 1 was informed. At 7:06 p.m., Patient 1’s BP was 76/49, the nurse noted, “Patient [1] remained hypotensive with low urine output throughout the shift. Continuous IVF [IV fluid] NS running at 75 ml/hour, and midodrine 10 mg tablet given. MD [1] is aware of blood pressure and urine output.” At 8 p.m., Patient 1 had a peripheral IV (PIV) placed in the left forearm with a 20-gauge needle, and NS started at 125 ml/hour for re-hydration. At 8:51 p.m., Patient 1’s BP was 87/44. At 10:19 p.m. Patient 1 was transferred to the ICU. The registered nurse (RN) documented, “Patient [1] was placed on continuous monitoring. Patient [1] appears disoriented ...Blood pressure is currently low 79/52, NS infusing at 125 ml/hour.” Review of Patient 1’s ICU NPN and VS, dated 8/26/25 from 11:50 p.m. to 8/27/25 11:06 a.m. indicated, on 8/26/25 at 11:50 p.m., MD 2 was contacted, and orders were given to administer a NS 1000 ml bolus over one hour and Ceftriaxone 2 grams was given. On 8/27/25 at 12:32 a.m., Patient 1’s B/P was 64/32. At 2:18 a.m., BP 66/46 and Patient 1 became lethargic and restless. At 4:06 a.m., BP 57/37 and Patient 1 continued to have no urine output. At 4 a.m., a bladder scan (an ultrasound image to see how much urine is in the bladder) was performed but no urine volume reading was generated. It was not possible to determine if urine retention was present based on the scan. At 4:28 a.m., MD 2 was notified of Patient 1’s completion of the 1000 ml NS bolus. Despite this, Patient 1 continued to experience persistent hypotension with a BP of 57/37, and Patient 1 appeared pale and cool. According to the NPN, MD 2 ordered “Levophed [an emergency medicine used to raise very low blood pressure] infusion to support blood pressure. Supervisor notified.” At 5:19 a.m. Patient 1 had Levophed started at 10 mcg/kg (micrograms per kilogram- a drug dose measurement per body weight) with an increase of BP to 136/84. At 5:20 a.m., BP was 175/110 At 5:22 a.m., BP was 158/99 and Levophed was decreased to 8 mcg/kg. At 5:35 a.m., BP was 130/77 and Levophed was decreased to 6 mcg/kg. At 5:46 a.m., BP was 99/65, and the HR was 103. At 5:50 a.m., BP was 83/64, HR was 110, and Levophed decreased to 2 mcg/kg. At 6:59 a.m., BP was 135/77, and HR was 100. At 7:08 a.m., the MD was notified that Patient 1 had urinary retention (unable to urinate). Levophed was infusing at a rate of 2 mcg/kg, and the leaking urinary catheter was changed. At 7:31 a.m., Patient 1’s BP was 99/61 and HR was at 108. Levophed continued infusing at 2 mcg/kg. The note indicated Patient 1 “was very hypotensive still” and “hard to get BP reading due to edema [swelling]”. The note continued, IV NS not running, “per Noc (night) shift nurse told to d/c [discontinue] by noc shift MD”. At 7:50 a.m., Patient 1’s HR was 143 and Levophed at 2 mcg/kg continued. At 8:05 a.m., Patient 1’s VS indicated BP was 73/55. Also, at 8:05 a.m., the NPN indicated an inability to get a BP due to Patient 1’s edema and MD 2 aware. At 9:02 a.m., the BP was 54/64, and HR was 104. At 9:20 a.m., the BP was 80/65, and the HR was 99. At 9:43 a.m., the NPN indicated, “Chunk of something came from Patient [1’s] throat. Not sure what it is. Cousin would like [Patient 1] to go to a higher level hospital. Will inform MD [1].” At 10:05 a.m. the BP was 77/61, and Levophed continued infusing at 2 mcg/kg. At 10:16 a.m., Patient 1’s BP was 75/50. At 10:31 a.m., Patient 1’s BP was 68/42, and Levophed continued infusing at 2 mcg/kg. At 10:38 a.m., the NPN indicated MD 1 requested continuous IV fluids be restarted. Nursing alerted MD 1 about chunks of blood coming from the patient’s throat. MD 1 stated this “was okay and continue to monitor”. The family member wanted Patient 1 to go to a higher level of care hospital, but the note revealed, “per doctor’s orders, we waited.” At 10:57 a.m., Patient 1’s BP was 72/49. At 11 a.m., the dialysis nurse was able to draw blood from Patient 1’s dialysis port (a medical device, inserted into a patient, used to provide access to the bloodstream for dialysis). At 11:06 a.m., Patient 1’s BP was 70/50. At 11:38 a.m., Patient 1 was sent to a higher-level hospital emergency room. The NPN indicated, “Levophed dc’ d [discontinued], paramedics said they did not have the right equipment to keep Patient 1 on the Levophed.” Per the NPN at 11:39 a.m., the note indicated Patient 1 was hypotensive, had no urinary output at all, her level of consciousness had been changing from the night prior and had become increasingly confused. The note indicated staff had difficulty getting a BP every 15 minutes and MD 1 was aware. Patient 1 received 750 ml out of the 1000 ml IVF ordered. The note indicated the paramedics also had difficulty getting a BP and revealed Patient 1’s extremities were cold and swollen. Patient 1 was given medicine for nausea and vomiting. During a record review of [Name of higher level of care hospital] document titled, “Discharge Death Summary,” dated 8/28/25, the “Death Summary” indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (body does not have enough oxygen, leading to low oxygen in the blood), and acute kidney injury on 8/27/25. Patient 1 died on 8/28/25 at 6:17 a.m. The “Death Summary” indicated the cause of death as “septic shock, multi-organ failure, and septic right hip joint (infected hip joint)” with acute kidney injury (a sudden decline in kidney function) as a contributing factor to the cause of death. During a concurrent interview and record review on 10/14/25 at 2:25 p.m., with MD 1 and DON, Patient 1’s 8/25/25 to 8/27/25 NPN and VS were reviewed. MD 1 stated, “We don’t always have ICU beds, so this type of patient is the norm[al] for the floor [Medical-Surgical nursing unit].” MD 1 indicated Patient 1 was scheduled to be discharged home, and stated, “[Patient 1] was looking fine” and was improving. MD 1 stated Patient 1 was able to be managed safely on the medical surgical unit. MD 1 stated that Patient 1 developed sepsis and the importance was to give IV fluids and antibiotics and that could be done at the facility by a medical surgical nurse. MD 1 stated the patient did not require a transfer to a higher level of care within the facility, for example to the ICU, or to another hospital and Patient 1 was doing fine when he saw her, had normal vital signs, and was scheduled to be discharged home. MD 1 stated Patient 1 had appropriate interventions and did not feel that Patient 1 went too long without intervention, escalation, or IV access because they were attempting to get IV access and waiting on the “PICC nurse” (a contracted company available for inserting larger catheters and deeper IV access). During a continued concurrent interview and record review on 10/14/25 at 2:25 p.m., with the DON and MD 1, the DON indicated that he was assisting with Patient 1’s IV placement and was unsuccessful in getting IV access and MD 1 was aware of Patient 1’s status. During a telephone interview on 10/15/25 at 9:50 a.m. with the Corporate Medical Director (CMD), he stated, “Many steps were missed in the care of this patient [Patient 1] and that sepsis is a critical condition that requires early intervention.” During a phone interview on 10/16/25 at 2:35 p.m., with RN 2, RN 2 stated she was the day HS on 8/26/25 but could not recall the event. She indicated that if a patient became hypotensive, the nurse must notify the MD, transfer the patient to ICU if a bed was available, obtain MD orders for IV access. During a review of the facility’s document titled “Governing Body Bylaws”, dated 1/22/20, the bylaws indicated, “Ensure that adequate resources and systems are allocated for maintaining safety and quality care, treatment and services, and to review and advise management and the Medical Staff on ... program selection and implementation ...Analyze findings and recommendations from the Hospital’s administrative review and evaluation activities, including system or process failures and actions taken to improve safety, both proactively and in response to actual occurrences ...Perform such other duties concerning ... safety and quality of care matters as may be necessary.” During a review of the facility’s document titled “Medical Staff Bylaws,” dated 2023, the bylaws directed, “The Medical Staff’s responsibilities are: To provide quality patient care ... Review and evaluation of the quality of patient care provided through valid and reliable care evaluation procedures ...An organizational structure and mechanism that allow on-going monitoring of patient care practices; ... A continuing education program based at least in part on needs demonstrated through the medical care evaluation program.” During a review of the facility’s policy and procedures (P&P) titled, “Sepsis”, dated 11/15/24, the P&P indicated, “To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality ....This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines ...Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory ...Definitions ...Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...Septic Shock: subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher mortality ...SIRS (Systemic Inflammatory Response Syndrome): Two or more of the following. Temperature >38° Celsius or <36° Celsius, HR >90 bpm [beats per minute]; RR>20/min ...SBP [systolic BP] less than 100 ...A score >2 suggests high risk of poor outcome.” Further review of the facility’s P&P titled, “Sepsis”, dated 11/15/24, the P&P directed, “Positive screen triggers sepsis or septic shock ...Measure lactate level ...Obtain blood cultures before administering antibiotics ...Administer broad spectrum antibiotics ...Begin rapid administration of 30 mL/kg of ...fluid for hypotension ...Apply vasopressors ...Ongoing management within 6 hours ...Reassess hemodynamics [blood pressure], urine output, and tissue perfusion ...Recheck lactate if initial elevated ...De-escalate antibiotics based on culture results and infectious disease consultation ...Initiate supportive measures (oxygen, ventilator ...) ...Transfer to higher level of care (ICU) as indicated.””

“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: 50619 Based on interviews and record review, the facility failed to ensure nursing staff followed its established policies and procedures for four out of 30 sampled patients (Patients 1, 2, 3, and 13) when nursing failed to accurately perform, assess, document, and escalate positive sepsis screenings (a tool used by the facility to identify life-threatening bloodstream infections). Furthermore, the nursing leadership failed to provide adequate nursing oversight when they were unaware nursing staff were not completing the assessment and documentation for septic screening correctly. These failures resulted in inaccurate and incomplete sepsis screenings, which may have precluded nursing staff and medical doctors from recognizing and appropriately responding to changes in patients’ conditions. This lack of timely intervention contributed to Patient 1’s death and placed Patients 2, 3, and 13 at increased risk for serious harm or death. Findings: During a concurrent interview and record review on 10/14/25 at 8:15 a.m. with Licensed Vocational Nurse 4 (LVN 4), of a document titled, “Septic Screening Parameters”, undated, was reviewed. LVN 4 stated one point is given for each screening parameter that pertains to the patient’s condition during the sepsis screening. LVN 4 stated a score of 2 was considered moderate sepsis and a score of 3 was severe sepsis. The following are the “Septic Screening Parameters”: -Temperature greater than 38 degrees Celsius (a unit of temperature measurement, 36.1-37.2 is normal adult body temperature) -Temperature less than 36 degrees Celsius -Heart Rate (HR) greater than 90 beats per minute or significant change from baseline (normal adult HR is 60-100) -Respiratory Rate (RR) for greater than 20 breaths per minute -Blood pressure (BP) decrease of 20 mmHg (millimeters of mercury- a measurement of blood pressure) from baseline without medication changes - Hypotension (low BP) less than 100 systolic (the pressure in the arteries when the heart pumps blood) -Progressive edema (swelling) -Altered level of consciousness (drowsy or difficult to arouse) -Low White Blood Cell count less than 4,000 (cells per microliter) -High White Blood Cell count higher than 12,000 (cells per microliter) -Positive blood cultures (a laboratory test that detects the presence of bacteria in the bloodstream) -NO SYMPTOMS AT THIS TIME (No points assigned if no symptoms). a. During a review of Patient 1’s “History and Physical [(H&P]),” dated 8/8/25, the “H&P” indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), which required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. During Patient 1’s hospital stay, she was able to wean off dialysis and produce her own urine. During a review of the document titled “Patient Progress Notes [note]” dated 8/23/25 at 7 a.m., the note indicated Patient 1’s BP was 94/54, and HR was 112. According to the facility’s sepsis screening parameters, this would result in a sepsis score of two but was documented as having a “negative” septic screen with “no symptoms at this time”. Additionally, there was no evidence that MD was notified of abnormal vital signs or potential sepsis indicators. During a review of the document titled “Patient Progress Notes,” dated 8/24/25 at 9:30 a.m. the note indicated Patient 1 did not have any vital signs documented by nursing staff at or around 9:30 a.m. The respiratory therapist documented an incomplete set of vital signs that did not include blood pressure or temperature, so would not be able to use for a sepsis screening, but Patient 1’s nursing note indicated a negative septic screen with “no symptoms at this time”. During a review of the document titled, “Patient Progress Notes”, dated 8/24/25 at 7:15 p.m., the note indicated Patient 1’s HR was 103 and BP was 92/48. This was indicative of a sepsis score of 2. During a review of the document titled, “Patient Progress Notes,” dated 8/24/25 at 8:30 p.m., the note indicated a negative septic screen, and there were “no symptoms at this time”, and there was no evidence an MD was notified of abnormal vital signs or potential sepsis indicators. During a review of the document titled, “Patient Progress Notes,” dated 8/25/25 at 11:30 a.m., Patient 1’s note indicated there was a negative sepsis screen, there were “no symptoms at this time”, and no vital signs taken on or around 11:30 a.m. The most recent full set of vital signs taken had been taken 4 hours prior to the septic screen. During a review of Patient 1’s document titled, “Patient Progress Notes,” dated 8/25/25 from 8 p.m. through 11:30 p.m., the note indicated there was no septic screen performed for the night shift nurse assessment at 8 p.m., however an on-call (after-hours) MD was notified at 10 p.m. that Patient 1 had low blood pressure and low urine output. The MD responded to encourage oral intake first and then start continuous intravenous (IV- fluid delivered into the vein) if unable to tolerate oral intake. At 11 p.m. oral fluids were offered to Patient 1, who complained of difficulty swallowing, and nurse documented that oral fluids would continue to be offered and encouraged. Per the nurse’s note, continuous IV fluids were started at 75 ml/hr (milliliters per hour- a unit of measure) at 11:30 p.m. per an MD order. During a review of the document titled, “Patient Progress Notes,” dated 8/26/25 from 12 a.m. until 8 a.m., Patient 1’s notes indicated BP was recorded 9 times between midnight and 6 a.m., with all systolic blood pressures ranging from 64 to 84 mmHg. At 6:27 a.m., an incomplete set of vital signs was documented, missing Patient 1’s temperature. Additionally, no vital signs were recorded at or around 7:30 a.m., when a septic screen was documented as negative with “no symptoms” despite the absence of supporting vital sign data. During a continued review of the document titled, “Patient Progress Notes,” dated 8/26/25 at 11:45 a.m., Patient 1’s note indicated that a nurse reported Patient 1’s low blood pressure to MD 1 and there was no evidence that a septic screening was completed at that time, despite the presence of abnormal vital signs. During a review of the document titled, “Patient Progress Notes,” dated 8/26/25 between 10:19 p.m. and 10:50 p.m., the notes indicated Patient 1 was transferred to ICU for closer monitoring and management, was placed on continuous telemetry (heart monitoring), placed on BiPAP (a bilevel positive airway pressure machine to assist with breathing). The note also indicated that Patient 1 became disoriented, had a BP of 79/52, and was receiving IV fluids at a rate of 125 ml/hr. At 10:31 p.m., the note indicated that an incomplete set of vital signs was recorded for Patient 1, including a HR of 98, BP of 79/52 with no temperature documented. At 10:50 p.m., a partial sepsis screening was completed for Patient 1, which reflected positive screening parameter findings for low blood pressure and elevated WBC count which would indicate a score of 2. However, no sepsis score was documented. Additionally, Patient 1’s HR above 90 was not included in the screening and would have increased the score to a 3 (severe sepsis). During a review of the document titled, “Patient Progress Notes,” dated 8/26/25 at 10:51 p.m., the note indicated a temperature was not documented, HR was 102, and BP was 87/44. The sepsis screening parameters showed hypotension, and an elevated WBC were acknowledged, but a sepsis score was not documented to complete the septic screening. Additionally, Patient 1’s HR above 90 was not included in the screening parameters which would have increased the sepsis score toof a 3 with the available vital signs and labs. available. During a review of the document titled, “Patient Progress Notes,” dated 8/26/25 from 8:52 a.m. through 4:18 p.m., Patient 1’s notes indicated that at 8:52 a.m., the Case Manager met with Patient 1 and Patient 1’s family member to discuss discharge planning and that a decision was made for discharge to a skilled nursing facility (SNF). At 2:15 p.m., the Case Manager noted there was a change in Patient 1’s condition and the planned discharge on 8/27/25 was cancelled. At 4:15 p.m., the Case Manager further noted that discharge was held due to change in condition due to “possible sepsis” and discharge was tentatively rescheduled for two days later. During a review of the document titled, “Patient Progress Notes,” dated 8/27/25 between 7:50 a.m. and 11:38 a.m., Patient 1’s notes indicated at 8 a.m., the septic screening parameters selected included: “No symptoms at this time”, hypotension, HR greater than 90, and high WBC greater than 12,000” with a sepsis score of “3 or more”, consistent with severe sepsis. Patient 1’s vital signs taken at 8 a.m. showed a BP of 73/55, no documented HR; a previously documented HR at 7:50 a.m. was 143. No symptoms at this time were documented despite having a sepsis score of 3 or more, indicating severe sepsis. At 8:05 a.m., an MD was notified of inability to obtain a BP. At 8:10 a.m., nursing documented that Patient 1’s BP could not be read from 7:31 a.m. until 9:02 a.m. despite trying multiple different extremities. At 9:43 a.m., Patient 1’s family requested Patient 1 be transferred to a higher level of care hospital. Patient 1 was transferred to a higher level of care hospital at 11:38 a.m. where she passed away less than a day later. During a record review of [Name of higher level of care Hospital] document titled, “Discharge Death Summary,” dated 8/28/25, the “Death Summary” indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (body does not have enough oxygen, leading to low oxygen in the blood), and acute kidney injury on 8/27/25. Patient 1 died on 8/28/25 at 6:17 a.m. The “Death Summary” indicated the cause of death as “septic shock, multiorgan failure, and septic right hip joint (infected hip joint)” with acute kidney injury (a sudden decline in kidney function) as contributing factor to the cause of death. b. During a review of Patient 2’s H&P, dated 10/9/25, the H&P indicated that Patient 2 had a history of hypertension (high blood pressure), encephalopathy (a condition that affects brain function due to lack of oxygen) related to respiratory failure (breathing problems), heart failure (a weak heart), and encephalomalacia (serious brain injury involving loss of brain tissue) from a prior stroke (brain injury caused from lack of blood flow to brain). During a review of Patient 2’s “Review-Septic Screening Parameters, [sepsis screen]” dated 10/9/25 at 8:45 p.m., the sepsis screen indicated that the RR was greater than 20 and the patient had hypotension, indicating a score of 2. During a review of the document titled “Vital Signs Review [vital signs],” dated 10/9/25 at 8:45 p.m., the vital signs indicated that Patient 2’s RR was 28, BP was 82/57, and HR as 145. Per the sepsis screening parameters, sepsis score should have been a 3 and was documented as a 2. During a review of Patient 2’s “Vital Signs Review,” dated 10/10/25 at 7:55 a.m., the vital signs indicated that a temperature was not taken. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/10/25 at 8 a.m., the sepsis screen indicated that HR was greater than 90 and RR was greater than 20 and that the septic screening score was a 2. During a review of Patient 2’s “Vital Signs Review,” dated 10/10/25 at 7:55 a.m., the vital signs indicated that no temperature was taken. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/11/25 at 8 a.m., the sepsis screen indicated that the HR was greater than 90 and had a septic screen of 1 symptom. Without a temperature taken, the sepsis screen was incomplete with the possibility of being inaccurate. During a review of “Vital Signs Review,” dated 10/11/25 at 8:00 a.m., the vital signs indicated that Patient 2’s RR was 31, HR was 130, and there was no temperature documented. This indicated a sepsis score should have been a 2, and not a 1, per the sepsis screening parameters with available vital signs documented. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/11/25 at 8:45 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen was documented as “negative”. During a review of the “Vital Signs Review,” dated 10/11/25 at 8:45 p.m., the vital signs indicated that Patient 2’s RR was 32, HR was 136, and there was no documented temperature. This indicated that the sepsis score should have been a 2, and not a negative sepsis score, per the sepsis screening parameters with available vital signs documented. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/12/25 at 8:30 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen as a score of 2 with the available vital signs documented. During a review of Patient 2’s “Vital Signs Review,” dated 10/12/25 at 8:30 p.m., the vital signs indicated that Patient 2 did not have a temperature documented. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/12/25 at 10:30 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen as a score of 2 with the available vital signs documented. During a review of Patient 2’s “Vital Signs Review,” dated 10/12/25 at 10 p.m., the vital signs indicated that Patient 2 did not have a temperature documented. During a review of Patient 2’s “Patient Progress Notes,” dated 10/13/25 at 7:45 a.m., the notes indicated, “Septic screening parameters: NO SYMPTOMS AT THIS TIME. Septic Screen: Negative.” During a review of “Vital Signs Review,” dated 10/13/25 at 7:45 a.m., the vital signs indicated that the HR for Patient 2 was 131and respiratory rate was 31. Despite two positive septic screen indicators, a negative screen was documented instead of a score of 2. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/13/25 at 3:51 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and hypotension with a sepsis score of 3 with the available vital signs documented. During a review of Patient 2’s “Vital Signs Review,” dated 10/13/25 at 3:50 p.m., the vital signs indicated that Patient 2 did not have a temperature documented. During a review of Patient 2’s “Review-Septic Screening Parameters,” dated 10/14/25 at 8 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and a sepsis score was not documented despite having two positive sepsis screen indictors with available vital signs. During a review of Patient 2’s “Vital Signs Review,” dated 10/14/25 at 8 p.m., the vital signs indicated that Patient 2 did not have a temperature documented, RR of 32, HR of 136, and BP of 88/37 which would indicate a sepsis score of 3. C. During a review of Patient 3’s “H&P,” dated 8/19/25, the H&P indicated that Patient 3 was admitted with a history of diabetes type 2 (high sugar levels in blood) and had a motor vehicle accident with multiple bone fractures, subdural and subarachnoid hemorrhages (brain bleeds), hemorrhagic shock (illness from losing a lot of blood) from splenic laceration, respiratory failure with tracheostomy (breathing tube), bladder rupture with foley (tube from bladder to outside of body to help urine leave body) placement. During a review of Patient 3’s “Review-Septic Screening Parameters,” dated 10/11/25 at 8 a.m., the sepsis screen indicated that there were no sepsis symptoms. During a review of Patient 3’s “Vital Signs Review,” dated 10/11/25 at 8 a.m., the vital signs indicated that Patient 3 did not have a temperature documented, RR of 31, and HR of 130 which would indicate a sepsis score of 2 instead of “no sepsis symptoms” with available vital signs documented. During a review of Patient 3’s “Review-Septic Screening Parameters,” dated 10/11/25 at 8:45 p.m., the sepsis screen indicated that there were no sepsis symptoms. During a review of Patient 3’s “Vital Signs Review,” dated 10/11/25 at 8:40 p.m., the vital signs indicated that Patient 3 did not have a temperature documented, RR of 32, and HR of 130 which would indicate a sepsis score of 2 instead of 0 with available vital signs documented. During a review of Patient 3’s “Review-Septic Screening Parameters,” dated 10/13/25 at 7:45 a.m., the sepsis screen indicated that there were no sepsis symptoms. During a review of Patient 3’s “Vital Signs Review,” dated 10/13/25 around 7:45 a.m., the vital signs indicated that no vital signs were documented at the time of Patient 3’s sepsis screening. The most recent vital signs documented prior to the sepsis screening were taken at 6:30 a.m. and included a RR of 33, and HR of 99, with no temperature recorded. Based on available data, these findings would indicate a sepsis score of 2; however, the screening was documented as having no symptoms. D. During a review of Patient 13’s “H&P” dated 6/15/25, the H&P indicated that Patient 13 was admitted with End Stage Renal Disease (ESRD, chronic kidney failure that prevents toxins from leaving body) requiring hemodialysis (a procedure that filters toxins from the blood), left below the knee amputation, right toe amputations, respiratory failure (breathing problems), fluid overload, anemia (low blood oxygen levels), and sepsis. During a review of Patient 13’s “Review-Septic Screening Parameters,” dated 6/22/25 at 9:32 p.m., the sepsis screen indicated that there were no sepsis symptoms. During a review of Patient 13’s “Vital Signs Review,” dated 6/22/25 around 9:32 p.m., the vital signs indicated that Patient 13 did not have any vital signs taken. The most recent vital signs taken prior to sepsis screen were taken at 6:15 p.m. with a RR of 24, and HR of 93, which would indicate a sepsis score of 2 instead of 0. During an interview on 10/16/25 at 9:36 a.m. with Registered Nurse 9 (RN 9), RN 9 stated that a full sepsis screening included temperature, BP- assessing for hypotension, RR, HR, level of consciousness, labs, and blood cultures. RN 9 stated that without a recorded temperature, the sepsis screen was not considered complete or accurate because it was important to have a full clinical picture, including all vital signs, for the doctor to accurately assess for sepsis. RN 9 stated that the sepsis screen needed to be documented in the flowsheet. During an interview on 10/16/25 at 3:25 p.m. with the Chief Nursing Officer (CNO), the CNO indicated that a positive sepsis screen was two or more and a provider should be notified. The CNO stated that if sepsis screen was not done accurately or fully completed, the provider may not get notified when needed. The CNO stated that a sepsis screen included a full set of vital signs that included temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. The CNO acknowledged there were incomplete and inaccurate sepsis screenings for Patient 1, 2, 3, and 13. The CNO confirmed nursing leadership was unaware of the identified gaps with the sepsis screenings. During a review of the facility’s policy and procedure (P&P) titled,. “Sepsis,” dated 11/15/24, the P&P indicated, “I. Purpose [:] To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality, and length of stay in the Long-Term Acute Care Hospital (LTACH) setting. This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines. II. Policy Statement [:] All [Facility Name] staff shall follow this protocol for patients presenting with or developing signs of infection or systemic inflammatory response. Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory. III. Definitions [:] Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...A score equal to or greater than 2 suggests high risk of poor outcome. 1. All patients shall be screened using the Sepsis Screening Tool: On admission. Every shift (once per 12 hours minimum). With any change in condition (fever, hypotension, tachypnea [faster than normal breathing], altered mentation [change in a person’s brain function that affects thoughts, awareness, and behavior], elevated lactate [a molecule produced in the body when there is a high demand for energy and not enough oxygen]) 2. Positive screen triggers Sepsis Alert and provider notification.” During a review of the facility’s P&P titled, “CHANGE IN PATIENT CONDITION Early Recognition and Intervention,” dated 11/14/24, the P&P indicated, “ ...SIGNIFICANT CHANGE IN CONDITION DESCRIBED: 1. The following could describe a significant change in condition ...Any single finding ...requires Assessment, Documentation, and Notification ...A positive sepsis screen. ASSESSMENT AND BASIC RECOMMENDATIONS: 1 ...It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs in a timely fashion, and to gather other relevant data. 2. Data should be obtained includes but is not limited to: A complete set of vital signs including accurate temp[erature]-rectal or tympanic membrane [a measure of temperature using an tool placed in the ear] ...NOTIFICATION: (use SBAR [A communication tool with a situation, background, assessment, and recommendation format] format to communicate all critical information) ...DOCUMENTATION: 1. The complete assessment should appear on the nursing flowsheet. The SBAR form will be used to document communication about the patient to the MD and will be placed in the progress notes section of the medical record ...” During a review of the facility document titled, “Job Description: Position Title; Licensed Vocational Nurse,” undated, the document indicated, “Job Summary: ...In collaboration with the physician, the LVN assures implementation of the assessment plan, evaluation, and follows up of the plan of care for the patient population ...RESPONSIBILITIES TO THE PATIENT [:] B ...2. Assess safety ...levels for patients ...E. Provides for ...safety in accordance with hospital and nursing policies and procedures ...G. Assures that documents in the medical record are complete, factual, accurate and timely...H. Provides nursing care to meet patient needs. 1. Performs a complete ...assessment of each assigned patient per shift using proper documentation tools. 2. Acts promptly on changes in patient condition, utilizing SBAR method ...””

“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: 50619 Based on interview and record review, the facility failed to ensure medications were administered in accordance with orders for 3 of 30 sampled patients (Patients 2, 8, and 13) when: a. Nursing staff failed to administer the correct dose of oxycodone (an opioid medication used to treat severe pain) according to the physician order to Patient 8 on four occasions over a period of 18 days; b. Nursing staff failed to administer clonazepam (a medication used to treat seizures) to Patient 2 within parameters ordered and clinically indicated to be administered, and they also failed to notify the physician about holding the medication outside of prescribed parameters; and c. Nursing staff failed to administer diltiazem (medication used to treat high blood pressure) to Patient 13 as ordered and clinically indicated, and also failed to notify the physician about holding the medication outside of prescribed parameters. These failures placed Patients 2, 8 and 13 at potential risk of experiencing adverse side effects and/ or worsening symptoms, health conditions, development of new complications, and even death. Findings: a. During a review of Patient 8’s “History and Physical [H&P]”, dated 8/14/25, the “H&P” indicated Patient 8 was admitted with diagnoses that included right hip septic arthritis (bacterial inflammation of the hip joint), acute respiratory failure (occurs when inadequate oxygen passes from the lungs to the blood) and profound physical deconditioning (generalized decline in physical fitness due to a prolonged period of inactivity). During a review of Patient 8’s “Order Details [Orders],” dated 8/14/25, the “Orders” indicated oxycodone IR (immediate release) 5 mg (milligram- a unit of measure), two tablets to equal total dose of 10 mg for severe pain (7-10- a numerical pain scale of 1-10 with 10 indicating the worst pain) and oxycodone HCL IR 5 mg, one tablet to equal total dose of 5 mg for moderate pain (4-6). During a concurrent interview and record review on 10/16/25 at 2:25 p.m. with the Chief Nursing Officer (CNO), Patient 8’s nursing “Progress Notes,” dated 8/16/25 to 9/3/25 were reviewed, alongside Patient 8’s “Order Details,” dated 8/14/25. The “Progress Notes” indicated Patient 8 received four doses of 10 mg of oxycodone for pain levels that were less than severe: 1. On 8/16/25 at 4:31 p.m., Reason: moderate pain (4-6), 2. On 8/23/25 at 10:04 a.m., Reason: mild pain (1-3), 3. On 8/23/25 at 7:27 p.m., Reason: mild pain (1-3), and 4. On 8/24/25 at 5:13 a.m., Reason: mild pain (1-3). The CNO stated the 10 mg of oxycodone was not given according to the physician’s order. The CNO stated it was her expectation for the nurses to give medications according to the doctor’s orders. The CNO stated if higher doses of opioids were given to a patient than what was ordered by the physician, there was potential for patient harm that could occur such as respiratory depression (too slow and shallow breathing that could result in inadequate oxygen levels) and increased sedation (reduced alertness). b. During a review of Patient 2’s “H&P”, dated 10/9/25, the “H&P” indicated Patient 2 had a history of high blood pressure, encephalopathy (a condition that affects brain function due to lack of oxygen) related to respiratory failure, heart failure, and encephalomalacia (serious brain injury involving loss of brain tissue) from a prior stroke (brain injury). During a review of Patient 2’s “Order Chronology [Orders],” dated 10/10/25 at 12:12 p.m., the “Orders” indicated clonazepam 0.5 mg tablet was to be given every 12 hours by mouth. A document titled, “Vital Signs Review,” dated 10/14/25 at 3:30 a.m., indicated the systolic blood pressure (the top number in a blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood) of Patient 2 was 140 mmHg (millimeters of mercury, a unit of measure). During a review of the “MAR [Medication Administration Record],” dated 10/14/25 at 4:07 a.m., the “MAR” indicated clonazepam 0.5 mg was not given due to blood pressure. Instructions indicated to hold clonazepam for systolic blood pressure of less than 100 [mmHg]. During a review of Patient 2’s electronic medical record (EMR), for the date 10/14/25, the EMR revealed no documented evidence the medical doctor was informed of clonazepam being held outside of ordered parameters. During a continued review of the “Vital Signs Review,” dated 10/14/25 at 11:00 p.m., it indicated the systolic blood pressure for Patient 2 was documented as 122 mmHg. During a review of the “MAR,” dated 10/14/25 at 11:18 p.m., the “MAR” indicated that clonazepam 0.5 mg was not given and to hold for systolic blood pressure of less than 100 [mmHg]. During a review of Patient 2’s nursing “Patient Progress Notes,” dated 10/14/25 at 12:12 a.m., the notes indicated scheduled clonazepam was not given due to nursing judgement for blood pressure. There was no evidence of notification made to the medical doctor that the medication was held outside of ordered parameters. c. During a review of Patient 13’s “H&P,” dated 8/13/25, the “H&P” indicated Patient 13 had a fall at home with a traumatic brain injury, intracranial hemorrhage (brain bleed), and right skull fracture with increasing brain swelling, and confusion. During a review of Patient 13’s, “Ordered Medication”, dated 8/13/25, the “Ordered Medication” indicated diltiazem HCL 60 mg IR tablet (Two 30 mg IR tablets to equal a total dose of 60 mg) was ordered to be administered four times per day and to hold if systolic blood pressure less than 100 or if heart rate less than 60 beats per minute (BPM). During a review of Patient 13’s “MAR,” dated 10/13/25 at 2 p.m., it indicated diltiazem HCL 60 mg was held at 2 p.m. and there was no documented rationale indicating why the medication was held. Additionally, Hydralazine (a blood pressure lowering medication) was documented as given for a systolic blood pressure of 115 and a heart rate of 96 at 2:24 p.m. indicating that at the time, vital signs were within parameters to give diltiazem as well. During a review of Patient 13’s nursing “Progress Notes,” dated 10/13/25, the notes revealed there was no entry around 2 p.m. explaining why diltiazem was held or that the doctor was notified of holding diltiazem outside of ordered parameters. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 10/13/25 at 4:25 p.m., LVN 3 confirmed that medications were held outside of ordered parameters, that blood pressures were within limits to give the medication, and that the doctor should have been notified of the medication that was held outside of ordered parameters. During an interview on 10/14/25 at 10:20 a.m. with LVN 4, LVN 4 stated that nurses should notify the doctor if they hold a medication outside of ordered parameters as doctor may want to change dose or medications and should know if medications are not being given as ordered and why. LVN 4 stated that nurses should document why a medication is held in the MAR or nurse’s note. During an interview on 10/16/25 at 1:53 p.m. with the CNO, the CNO stated that the doctor needs to be notified of medications held outside of ordered parameters, nurses need to document the reason they held medications, and recent vital signs documented when parameters indicate needing them. The CNO stated that a patient can be harmed by not administering medications when indicated. During a review of the facility policy titled, “Medication Administration Policy”, dated 2/13/25, the policy indicated, “Registered Nurses, Licensed Vocational Nurses (LVN) ... shall be responsible for the safe and accurate administration and documentation of medications, as is consistent with their scope of practice, professional practice standards and in accordance with applicable laws and regulations ... To ensure patient safety, and decrease the potential for errors, the following procedure shall be followed for each Medication Pass:... Administer medication following the ‘6 Rights of Medication Administration’: Right patient, Right drug, Right dose, Right route, Right time, Right documentation ...” During a review of the facility document titled, “Job Description: ... Licensed Vocational Nurse,” undated, the document indicated, “RESPONSIBILITIES TO THE PATIENT[:] D. Assures that medication is correct and according to the established nursing policies and procedures ...3. Administers medications as ordered ...G. Assures that documents in the medical record are complete, factual, accurate, and timely ...2. Acts promptly on changes in patient condition, utilizing SBAR [a communication framework to notify doctor of concerns] method.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 46237 Based on interview and document review the hospital failed to provide written notice to patients on admission informing them there was no doctor of medicine or doctor of osteopathy present in the hospital at all times or how their medical needs would be met at a time when no physician was present. This failure increased the potential for patients not being fully informed to make decisions regarding their care. Findings: During a concurrent interview and record review on 1/29/25 at 1:40 p.m. with the Chief Operating Officer (COO), the “[hospital name] Rounding Schedule (RS),” dated December 2024 was reviewed. The RS indicated, “noc [night]: 7 p.m.-7 a.m. Telemed [Telemedicine is the use of technology to provide medical care remotely. It can include video conferencing, phone calls, and messaging] On Call” for each day in December. The COO confirmed the hospital had a physician present from 7 a.m. to 7p.m every day and a physician was on call for telemedicine coverage of the hospital from 7 p.m. to 7 a.m. and were not present in the facility. During a concurrent interview and record review on 1/29/25 at 1:40 p.m. with the COO, an undated “CONSENT TO ADMISSION AND TREATMENT, AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF INSURANCE BENEFITS” form was reviewed. The COO confirmed there was nothing included on the form to indicate there was not twenty-four-hour physician presence at the hospital.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 39792 Based on observation, interview and record review the facility failed to obtain a physician order for one out of three sampled patients (Patient 20) for soft mitten (mitts) restraints. Patient 20 was observed on 1/27/25, 1/28/25 and 1/29/25 by surveyor with bulky soft mitten restraints on both hands without a physician’s order. This failure resulted in a lack of appropriate safety monitoring evidenced by missing documentation of nursing assessments; thereby missing potentially important changes in condition to circulation, sensation and motion by not assessing the hands, fingers and any devices inserted into the patient’s skin underneath the bulky soft mittens not observable with the naked eye as frequently as a restraint device would be monitored per the facility’s policy. Findings: During a review of Patient 20’s “History and Physical”, dated 1/8/24, Patient 20 was admitted to the facility on 1/8/25 with a history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to head), tracheostomy (a surgical procedure which creates an opening in the trachea (windpipe) allowing air to enter the lungs), gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach to allow medication or liquid food to be administered) and chronic encephalopathy ( a condition characterized by persistent changes in brain function that can lead to cognitive, behavioral and neurological problems). During a review of Patient 20’s “Non-Violent Restraint Physician Orders”, dated 1/8/25 and 1/9/25 the orders indicated Patient 20 had a signed physician order requiring the use of soft wrist restraints on the left side to ensure safety and support medical healing. . During a review of Patient 20’s “Non-Violent Restraint Physician Orders”, dated 1/10/25, the order indicated Patient 20 had a signed physician order requiring the use of restraints, but the order did not indicate which type of restraint was used on Patient 20. During a review of Patient 20’s “Non-Violent Restraint Physician Orders”, dated 1/11/25, the order indicated, Patient 20 had a signed physician order requiring the use of soft wrists restraints on the left side to ensure safety and support medical healing. During a review of Patient 20’s “Non-Violent Restraint Physician Orders”, dated 1/12/25, the order indicated Patient 20 had a signed physician order requiring the use of soft wrist restraint for the left wrist to ensure safety and support medical healing. The restraint order was expired or discontinued on 1/13/25 at 10:00 a.m. A review of the medical record indicated no further physician order for a restraints. During a review of Patient 20’s “Nursing Daily Assessment”, dated 1/23/25 at 9:45 p.m., the assessment indicated restraints were not in use; however, in the nursing assessment notes section, “soft mittens maintained for safety” was documented. During a review of Patient 20’s “Nursing Daily Assessment”, dated 1/24/25 at 10:00 p.m., the assessment indicated restraints were not in use; however, in the nursing assessment notes section, “soft mittens on for safety” was documented. During a concurrent observation and interview on 1/27/25 at 1:39 p.m., with Unlicensed Staff A at the bedside of Patient 20, Patient 20 was observed with mittens on both hands, which had bulky padding on the palm area and netting on the top of the hand. Unlicensed Staff A stated they were called mittens and Patient 20 had them on because she kept scratching and trying to pull out her feeding tube and getting out of bed. Unlicensed Staff A stated the mittens had just been changed because they were dirty and smelly and Patient 20 had also been given a bath in her bed. Unlicensed Staff A stated she would be responsible to document in Patient 20’s medical record every time she removed the mittens. Patient 20 was observed wearing the mittens on both hands, able to move her arms freely but unable to pick anything up or use her fingers since the fingers were under netting and the palm area was under a large, padded area. Patient 20 was observed lifting her head off the bed and moving her legs freely with Unlicensed Staff A gently reminding Patient 20 to remain in bed. Patient 20 was in a large room with four other patients and Unlicensed Staff A stated she was assigned to stay there continually with the nurse who was also assigned to provide supervision and care to all of the four patients assigned to beds located in that room. During an interview on 1/27/25 at 1:58 p.m. with Licensed Staff B, Licensed Staff B stated, she was Patient 20’s nurse that day and stated Patient 20 was not wearing restraints on her hands, since mittens were not considered restraints. Licensed Staff B stated, if Patient 20’s hands were tied down to the bed, then that would be considered a restraint but since Patient 20 would be able to move her arms it is not considered a restraint and therefore a doctor’s order was not needed. Licensed Staff B stated the reason why Patient 20 would have the mittens on both of her hands would be to prevent her from pulling out her gastric tube or the tube with formula providing nourishment or her IV (intravenous catheter inserted into a vein to provide access to the bloodstream). Licensed Staff B stated, if Patient 20 had restraints, then she would be checked for circulation, sensation and blood flow to her hands every two hours. Surveyor asked Licensed Staff B where the IV was located since there was no visible tubing and Licensed Staff B stated the IV was capped (remained in the vein but no fluid was being infused) and located on the top of the hand under the netting part of the mittens. Licensed Staff B stated she would assess the IV every shift and would assess the hand as well, since Patient 20 would tend to keep her hands crinkled like a fist rather than straight and outstretched. Licensed Staff B stated Patient 20 had a history of traumatic brain injury which made her non-compliant with trying to pull out her lines (feeding tube and IV) and staying in bed. During an interview on 1/27/25 at 2:25 p.m. with Licensed Staff C, Licensed Staff C stated mittens were not considered restraints unless the wrists were tied down then that would be considered a restraint and a physician order would be required. Licensed Staff C stated if mittens were being used alone by themselves then no, that would not be considered a restraint and physician order would not be required. During an interview on 1/27/25 at 2:34 p.m., with Licensed Staff D, Licensed Staff D stated mittens were not considered restraints unless the wrist part of the hand was tied to the bed. During a concurrent interview and record review on 1/28/25 at 10:24 am. with Chief Nursing Officer (CNO), Patient 20’s “Non-Violent Restraint Physician Orders” dated 1/8/25 was reviewed. The paper order sheet indicated the reason for the restraints (Patient 20 was attempting to remove her tracheostomy or other medical devices), the signature of the physician, date and time of the order, the signature of the nurse, the type of restraint (wrists, mittens or side rail or combination) and when the order expired. CNO stated, per the facility policy the restraint orders were reviewed every day at around 10 a.m. and either renewed or not renewed and if not renewed the order would expire and the restraint would be removed. There was an order dated 1/9/25, 1/10/25, 1/11/25 and 1/12/25. The medical record was reviewed and there was no further restraint orders observed with CNO navigating the electronic medical record and the surveyor observing. CNO stated the use of mittens alone does not constitute the use of a restraint. CNO stated if mitten(s) were used in combination with a wrist restraint tied down then that would constitute a restraint and would require a physician’s order. CNO stated the use of mitten(s) would not require a physician order. The progress notes were reviewed with CNO from 1/12/25 and no indication Patient 20 had mittens applied by nursing staff. During a review of “nursing daily assessments” dated 1/23/25 and 1/24/25, under the notes section of the nursing documentation indicated Patient 20 had mittens applied for safety. CNO was asked since mittens were applied as per the documentation but there was no assessment as to Patient 20’s circulation of her fingers and hands as would if there was a restraint order, CNO could not answer the frequency of assessment for Patient 20’s hands. CNO could not explain further the safety mechanism in place for assessing Patient 20’s hands other than every hour the nurses look in at their patients, but they would not take off the mittens and assess the skin underneath the mittens. CNO stated the hourly rounding or looking in at patients would not capture if there was an injury or dislodgement of the IV for instance on Patient 20’s hand which would be obscured under the netting from view. During a concurrent observation and interview on 1/28/25 at 11:38 a.m., with CNO in Patient 20’s room, Patient 20 was observed laying in bed with her mitts applied to both of her hands. Licensed Nurse E, who was taking care Patient 20, reviewed the electronic medical record and confirmed there were no current restraint orders, stating there would not be a restraint order for mittens since mittens were not considered a restraint. During an observation on 1/29/25 at 1:00 p.m. Patient 20 was observed in her bed with mittens on both of hands. During a concurrent observation and interview on 1/29/25 at 4:30 pm with CNO and Chief Operating Officer (COO), the unopened packaged of mitts was observed in an office, CNO stated it did seem like the mitts were bulky and would follow the definition of restraints. COO nodded in agreement. During a review of the facility’s policy and procedure titled, “Restraints Protocol,” dated 11/14/24, indicated, “A. Restraints: Any method (physical restraint or medication) of applying involuntary restriction on a patient’s bodily movement or access to his or her body areas ... any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to ones’ own body ...Mitts unless tied down or pinned down or unless so bulky or applied so tightly patient cannot use or bend their hand.”. Review of the manufacturer’s description of Patient 20’s mittens titled “Posey Finger Control Mitt,” undated, indicated, “Description of Product: Full padded, mesh mitt with finger separators. INTENDED USE: To protect patients assessed to be at risk of disrupting life-saving treatments (e.g. chronic tube pulling) or in danger of injury to themselves or to others by limiting hand movement. Follow your hospital’s restraint policies and procedures that are compliant with USA CMS guidelines and state laws, or other governing agencies outside the USA.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40402 Based on observation, interview and record review, the facility failed to ensure safe and dignified care for one of 35 sampled patients (Patient 9), when: A staff member silenced Patient 9’s pulse oximetry (a test used to measure the oxygen saturation level of the blood) alarm. This failure had the potential for Patient 9 to experience critical changes in his oxygen saturation without staff knowing it. Findings: 1. During a review of Patient 9’s medical record, History and Physical, dated 10/8/24, indicated, Acute respiratory failure due to encephalopathy, (inflammation of brain causing reduced level of consciousness). Patient 9 was admitted to the facility for ventilation (artificial breathing machine) support and was recently being weaned (safely and intermittently taken off ventilator to assess patient’s ability to breath on their own) from the ventilator. Patient 9 had a Full Code status (directive to use all resuscitation efforts if patient’s heart or respirations stopped). During a review of Patient 9’s medical record, a Respiratory Therapy Progress Note, dated 11/18/24, signed by Licensed Staff DD, indicated Patient 9 had diminished breath sounds and was on continuous pulse oximetry monitoring. During a review of Patient 9’s medical record, an MD order, signed by Licensed Staff EE, dated 10/8/24, indicated to keep SP02 (oxygen level) no less than 90%. During an observation on 11/18/24 at 10 a.m., in the ICU (Intensive Care Unit) (unit that is staffed by specially trained medical personnel and has equipment that allows for continuous monitoring and life support), Patient 9’s pulse oximetry alarm was silenced with an oxygen reading level of 88% on the monitor. During an interview on 11/18/24 at 10:04 a.m., in the ICU, Licensed Staff CC was queried as to why the pulse oximetry alarm was silenced on patient 9’s monitor. Licensed Staff CC stated she checked Patient 9’s pulse oximetry adhesive attachment on his finger earlier and found it to be loose and not giving an accurate oxygen reading, so she silenced the alarm. Licensed Staff CC was queried what the risks were to patient safety when a patient in the ICU had their pulse oximetry alarm silenced. Licensed Staff CC stated she knew if the oxygen alarm was silenced, and the patient’s oxygen level dropped, the alarm would not sound and, “We wouldn’t know the patient’s oxygen level was low.” During a review of Patient 9’s medical record, Patient Progress Note for Vital Signs, dated 11/18/24, indicated there was no pulse oximetry reading for 10 a.m. During an interview on 11/18/24 at 10:20 a.m., Director of Nursing O, was queried what the patient safety risks were when Patient 9 had his pulse oximetry alarm silenced by Licensed Staff CC. Director of Nursing O stated he knew the facility policy indicated that no ICU alarm should be silenced without correcting the reason the alarm originally sounded. Poor equipment fitting was not a reason to silence an alarm and leave the bedside. Licensed Staff CC should have her eyes on the patient’s respirations while she was changing out the equipment. If the alarm was silenced and no one was at the bedside, the patient could stop breathing, and we would not know they were in trouble. Poor fitting monitoring equipment does happen, but we expect it to be fixed immediately. During a review of the Job Description for Licensed Staff CC, it indicated, “The ICU Registered Nurse reports to the Director of Nursing. The ICU Registered Nurse is responsible for assessing the needs of each patient on his/her team, planning, and implementing the care to meet those needs, interacting with team member, and reporting to supervisor as appropriate. The ICU Registered Nurse position demonstrates clinical competence when providing care, using technology, administering medications, performing procedures, and managing emergencies, acting as patient advocate in order to monitor and maintain patient rights. Registered Nurse must have the ability to learn function of ALL machines and equipment utilized in a critical care environment.” During a review of the facility’s, “ICU Scope of Services,” revised 11/24/22, indicated, “The ICU provides Intensive Care monitoring for continuous assessment of cardiac condition, respiratory management with continuous oxygen therapy, including ventilator support. Standards of practice: The American Association of Critical Care Nurses and the American Nurse’s Association recognized core curriculum, teaching aids and Standards of Care for Acute and Intensive Care Nursing are used as reference for the development of standards and policies on the Intensive Care Unit.” During a review of the facility’s policy and procedure titled, “Telemetry Monitoring Protocol - ICU,” revised 11/14/24, indicated, “The ICU nurse will assure that the monitor alarms are set and operational at all times.” During a review of the facility’s policy and procedure titled, “Patient Rights,” revised 2/1/23, indicated, “Safety: To provide with care and services at this hospital in a safe and secure environment, and be free from all forms of abuse and neglect.” During a review of the facility’s policy and procedure titled, “Pulse Oximetry,” reviewed on 5/8/23, indicated, “Pulse oximetry has become the most common tool used to determine the gas exchange status of oxygen.....Patients receiving oxygen therapy and/or patients with orders to evaluate oxygen status as indicated.” Pulse Oximetry Probes to be used, ear probe, disposable probe, and finger probe as appropriate. During a review of The American Association of Critical Care Nurse Vol. 38, No. 2, April 2018, titled, “AACN Practice Alert: Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry,” indicated, “Provide proper skin preparation for and placement of electrodes and Pulse Oximetry Probe, check alarm setting at the start of each shift and with any change in the patient’s condition and customize alarm parameter settings for individual patients in accordance with unit or hospital policy.” 41175”

“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: 39792 Based on observation, interview and record review, the facility failed to: 1. follow and implement its policy and procedure on skin care assessment and maintenance for one sampled patient (Patient 18) out of three sampled patients, when a physician order for wound consult was not carried out, when there was missing documentation regarding nursing assessment underneath Patient 18’s foam dressing and there was missing documentation of weekly effectiveness of wound treatment to Patient 18’s sacral area; and, 2. implement its policies and procedures on pressure ulcer prevention and managemement, when one unsampled patient (Patient 72) was not repositioned per protocol. These failures resulted in Patient 18 developing a 7 cm x 4cm wound, increased the potential for the development of pressure injuries to at-risk patients, including Patient 72. Findings: 1. During a review of Patient 18’s, “History and Physical,” dated 7/13/23, indicated Patient 18 had become a quadriplegia (a medical condition that causes partial or total loss of movement and sensation in all four limbs) due to a spinal cord injury causing paralysis or loss of muscle function in all four limbs. Patient 18 also required a tracheostomy (surgical procedure which creates an opening in the neck and into the trachea or windpipe to provide an airway to breathe) and requiring a ventilator (device which helps or replaces a person’s breathing). The plan was for Patient 18 to continue with supportive care and rehabilitation. A review of Patient 18’s, “Physician Order,” dated, 7/14/23, indicated, Wound Consult for Evaluation and Treatment was ordered. Multiple requests to the facility for the completed wound care consult were made on 11/18/24, 11/19/24, 11/20/24, and 11/21/24, but the facility was unable to produce the document. During a review of Patient 18’s, “Admission Four Eyes in Four Hours,” dated 7/14/23, indicated Patient 18 was assessed by nursing to have sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on the right side of the neck. The back sacrum (area between the hipbones and the pelvis) was described as intact blanchable (described as when depressed the area turns white momentarily) redness. During a review of Patient 18’s, “Total Braden Score,” dated 7/14/23 indicated to be at risk for skin breakdown with a score of 12 out of a score of 20. During an concurrent interview and electronic record review on 11/18/24 at 9:15 am with Unlicensed Staff FF, there was a physician order for a wound consult evaluation. When a copy of the completed wound consult was requested, Unlicensed Staff FF was unable to locate the completed consult in the electronic medical record and stated it would be found later. Unlicensed Staff FF could not explain if the consult had taken place and the document was unable to be located or if the consult had not taken place at all. During a concurrent interview and electronic record review on 11/19/24 at 9:55 am, with Licensed Staff GG, Licensed Staff GG observed the wound consult order, dated 7/14/23, and observed a wound care Progress Note, dated 8/11/23, and a Braden Score of 13, dated 8/3/23. Unlicensed Staff GG observed an order for a foam dressing to the sacral area, and Unlicensed Staff GG stated it would be documented in the Medication Administration Record area under Wound Care Reminder. Nursing documentation consisted of date, time and nurses’ initials but no further description. Unlicensed Staff GG was asked if there was a wound care Progress Note dated earlier in the medical record, and he stated he could not find one but there was a Braden Assessment score of 13 on 7/14/23, and that should have triggered a wound consult as part of the policy because it [the score] was so low. A copy of the completed wound consult document from the order was requested on 7/14/23, again as part of the medical record requests. Licensed Staff GG observed the picture taken of Patient 18’s sacral area measuring 7 cm x 4 cm, where an open wound had developed from intact skin upon admission to the date of the picture on 8/6/23, and could not explain how the wound developed. Licensed Staff GG stated the nurses did not stage wounds, only the wound care team would stage a wound, and the point of the foam dressing was to protect the skin. During an interview and concurrent record review on 11/22/24 at 9:02 am, with Director of Nursing O, Patient 18’s medical record was reviewed including the physician order for wound consult, dated 7/14/23. Patient 18’s Admission Four Eyes in Four Hours, dated 7/14/23, was reviewed where it was indicated Patient 18 had sutures and Director of Nursing O stated, based upon the documentation of sutures, Patient 18 should have had a wound consult and could not explain why, when a physician ordered a wound consult, it was not done. Director of Nursing O stated Patient 18 was admitted before he worked for the facility so he could not speak directly to the care, but the wound team did monitor sutures, and the consult should have been done. During an interview and concurrent record review on 11/22/24 at 9:22 am, with Licensed Staff D, Licensed Staff D stated, in reviewing the records, there was no physician order for a special bed, and Patient 18 should have been on a special bed and it was probably why the wound developed. The foam dressing was almost the same size as the wound in the wound picture, dated 8/6/23, and it was very dark and black; meaning the tissue was dead. The wound had been there a long time, and Licensed Staff D stated the wound was also deep and stated the dressing had not been changed every day, and it was hard to assess what was going on underneath the dressing, and the wound team was not following Patient 18 by the lack of wound notes found in the medical record. Licensed Staff D stated a completed wound consult note was not found when researching the record. A review of the facility’s policy and procedure titled, “Skin Care, Assessment and Maintenance of,” dated 11/15/24, indicated, “Skin Assessment shall be performed at least every 12 hours all bedfast patients shall be turned every 2 hours unless contraindicated by physician’s order. Any impairment in skin integrity shall be documented in Nursing Flowsheet and Wound Documentation Form...2. Appropriate skilled treatment modalities shall be determined following a comprehensive functional evaluation that will include special wound data..4. The effectiveness of all wound care treatment will be reassessed on a weekly basis. This reassessment will be performed by a designated nurse, and may include other members of the treatment team as appropriate. The team members will make rounds on all patients and perform weekly head to toe skin assessment. 1. turn and position every two hours.” 38088 2. During an observation on 11/20/24 at 9 a.m., Unsampled Patient 72 was on his back in his bed. During an observation on 11/20/24 at 11 a.m., Unsampled Patient 72 was on his back in his bed. During an observation on 11/20/24 at 2:20 p.m., Unsampled Patient 72 was on his back in his bed. During an interview on 11/20/24 at 2:35 p.m., with Unlicensed Staff B, she stated the patients were supposed to be turned every two hours to prevent skin problems like pressure wounds. During an interview on 11/20/24 at 3:15 p.m., Unlicensed Staff NN stated patients were to be turned every two hours to prevent skin problems and prevent contractures (A joint that cannot move. Occurs when patients are bedridden in the same position without moving). A review of Unsampled Patient 72’s medical record indicated he was a 72 year-old male who was admitted to the facility 11/9/24, with diagnoses that included left-sided paralysis related to a surgery for a brain tumor, Diabetes, vascular disease, vascular disease related skin wounds of the lower extremities with swelling, kidney disease with dialysis, and pressure ulcers. During a record review and interview on 11/20/24 at 4:05 p.m., Licensed Staff Y stated a two hour repositioning form was used to document patient turning performed by staff and wound care nurses. The facility Nursing Supervisor was supposed to audit the form. During a review of a document titled, “2 HOUR REPOSITIONING FORM (12 HOUR (DAY) SHIFT FORM), for Unsampled Patient 72, she stated the documentation on the form indicated it was blank at 6 a.m., 10 a.m., 12 p.m., 2 p.m., and 4 p.m. She stated the form indicated Unsampled Patient 72 was sitting on a chair at 8 a.m. She stated the document was incomplete and turning Unsampled Patient 72 every two hours was not documented. Licensed Staff Y stated Unsampled Patient 72 was very uncooperative with turning and always refused to turn. She stated he was supposed to be up in a chair three times a day for meals. She stated the risk to patients who did not turn every two hours was risk of injury and pressure wounds. On 11/20/24 at 3:40 p.m. and 4:20 p.m., a request to interview the House Supervisor and Chief Nursing Officer was made and never completed by the facility. During a review of a facility Policy and Procedure titled, “SKIN CARE ASSESSMENT AND MAINTENANCE OF,” revised 11/15/24, it indicated, “Turn and position every two hours.” 41175”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 38088 Based on observation, interview and record review, the facility failed to ensure the dietary needs of one sampled patient (Patient 72), when a significant weight gain of 16 pounds in five days was not assessed, communicated, or responded to by facility staff and providers. This failure had the potential for patient harm from unrecognized electrolyte imbalance, Congestive Heart Failure (CHF)(A condition that occurs when the heart cannot pump the amount of blood and plasma in an efficient manner resulting in shortness of breath, fatigue, and heat failure), poor wound healing, malnutrition, and potential for death. Findings: During an interview and observation on 11/18/24 at 11:35 a.m., Patient 72 stated he had throat cancer and had radiation therapy that resulted in a vascular port infection. He stated he was on a liquid diet because the pain and discomfort of swallowing was too bad. He stated he lost of ton of weight before his admission to the facility. Patient 72 was lying in bed and appeared thin and pale. During an interview and record review on 11/18/24 at 410 p.m., Patient 72’s medical record was reviewed with the Director of Nursing. Review of the record indicated Patient 72 was admitted 11/11/24 at 2:41 p.m. He stated the admission weight on 11/11/24, was 124 pounds. He stated Patient 72’s weight on 11/16/24, was 140 pounds. Licensed Staff PP stated Patient 72 had gained 16 pounds since admission. Licensed Staff PP stated he could not find a Dietary Consult order or any documentation that any facility staff had communicated the 16 pound weight gain to either the physician or Registered Dietician. During an interview and record review on 11/19/24 at 9:15 a.m., Licensed Staff U reviewed Patient 72’s medical record and stated a Dietary Consult was ordered 11/12/24. She stated she was unable to find any notification of physician or dietary for Patient 72’s weight gain. She stated no one documented anything in the medical record and staff were supposed to do follow up about a significant 16 pound weight gain to the nurses, physician and dietary. During an interview on 11/20/24 at 2:35 p.m., Unlicensed Staff B stated, when a patient gets weighed the weight is put in the weight binder at the nursing station. She stated the nurses were supposed to check it. She stated, about the patient weight changes: “If it’s a lot we tell them.” During an interview on 11/20/24 at 2:40 p.m., with Licensed Staff OO, she stated, “If a patient has a weight gain or loss, the CNA (Certified Nursing Assistant) is supposed to inform us and then we ask for an RD (Registered Dietician) consult and tell the Physician.” She stated the risk to patients for weight gain was cardiac fluid overload, potential dialysis complications, electrolyte imbalances, malnutrition and poor wound healing. During a record review and interview on 11/22/24 at 9:15 a.m., Licensed Staff U stated the Registered Dietician completed an assessment for Patient 72 on 11/12/24. She stated, on 11/16/24, the Registered Dietician completed a follow up assessment and Patient 72 weighed 142 pounds. She stated the Registered Dietician requested an updated weight and it was documented by staff as 140 pounds which indicated a 16 pound weight gain in five days after admission. Licensed Staff U was unable to find any documentation by staff, Registered Dietician or Physician about the 16 pound weight gain. During an interview and record review on 11/22/24 at 11 am, the Registered Dietician was never notified of a patient weight gain. She stated Patient 72’s medical record did not have any communication about the 16 pound weight gain. She stated the Physician and she should have been notified. She stated a significant weight gain in five days was a risk for Congestive Heart Failure, Electrolyte imbalance, and poor wound healing. She stated she was unsure if the facility had a policy and procedure about reporting weight gain or weight loss. She stated it was a national standard for patient care to monitor patients’ weight gain or loss. During a review of Patient 72’s medical record, a document titled, “INITIAL PHYSICAL ASSESSMENT,” dated 11/11/24, indicated, “Dietary consult ordered: No - Not at this time.” During a review of Patient 72’s medical record, a document titled, “PATIENT PROGRESS NOTES,” dated 11/11/24, at 4:14 p.m., indicated, “Weight 124 lb 12.5 oz 56.6 kg ...Bed Scale.” During a review of Patient 72’s medical record, a document titled, “PATIENT PROGRESS NOTES,” dated 11/13/24 at 10:52 a.m., indicated, “Weight 142 lb 6.4 oz 64.59 kg ... Bed Scale.” During a review of Patient 72’s medical record, a document titled, “NURSING ORDERS,” dated 11/11/24 - 11/15/24 at 5 p.m., indicated, “Performed Nursing Order Monitor for optimal nutrition.” During a review of Patient 72’s medical record, a document tiled, “PHYSICAL ASSESSMENT,” dated 11/13/24 at 9:30 a.m., 11/15/24 at 9:45 a.m., 11/16/24 at 9 a.m., indicated, “Nutrition Adequate.....Dietary consult ordered: No - Not at this time.” During a review of Patient 72’s medical record, a document titled, “PHYSICAL ASSESSMENT,” dated 11/14/24 at 9:15 a.m., 11/17/24 at 7 a.m., indicated “Nutrition: Probably inadequate.....Dietary consult ordered: No - Not at this time.” During a review of Patient 72’s medical record, a document titled, “Problems /Goals,” dated 11/11/24, indicated, “PROBLEM Malnutrition R/T (related to) inadequate calorie & protein intake....PROBLEM Inadequate oral intake RT altered swallow ability....PROBLEM Altered nutrient utilization R/T diabetes or renal disease.....PROBLEM Alteration in skin integrity related to poor nutrition.” During a review Patient 72’s medical record, a document titled, “PATIENT PROGRESS NOTES,” dated 11/13/24, indicated, “Were weights obtained? Yes 142.2 via bed scale.” Another note, dated 11/16/24, indicated, “Were weights obtained? Yes (via floor scale, 140.3 lbs.” During a review of Patient 72’s medical record, a document titled, “Physician Entered Ordered,” dated 11/11/24, indicated, “Nursing Order Problem Description: Head and Neck cancer, dysphasia (Difficulty swallowing), PEG (Percutaneous endoscopic gastrostomy tube)(A soft tube into the stomach from the abdomen, that allows for liquid nutrition and medications to be administered) malnutrition....DIETARY CONSULT Tube feed.” During a review of Patient 72’s medical record, a document titled, “Dietary,” dated 11/12/24, indicated, “Dietitian Assess / Diagnosis: Nutrition Risk : High. Ht: 68 Wt 125 lbs....Dietician Notes C: Goals ... weight maintenance.....F/U (Follow Up) w/n (within) 3-5 days.” During a review of Patient 72’s Medical record, a document titled, “Dietary,” dated 11/16/24, indicated, “Dietitian Assess / Diagnosis: ...Wt: 142 lbs....Reports of wt loss, sever muscle wasting.....Dietitian Notes ...Unsure of wt gain, req updated weight. “ Review of a facility Policy and Procedure titled, “WEIGHT VARIANCE PROGRAM,” revised 11/15/24, indicated, “Obtaining patient weights: ...2. Nursing staff must compare current weight with previous weight. If 3 lb or greater difference is noted (loss or gain), the patient must be re-weighed to check accuracy. 3. 3 lb or greater weight difference must be recorded in the Weight Variance binder. Weight must be recorded in EMR (Electronic Medical Record) by nursing staff. 4. Nursing staff must notify dietitian by sending a diet consult. MD must also be notified. 5. The weight Variance binder is located on Med/Surg nursing unit and is reviewed by the Nursing Supervisor on a daily basis and by the RD (Registered Dietician) on a weekly basis.””

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 38088 Based upon interview and record review, the facility failed to ensure an effective Infection Control Program that reduced the risk of infection when the Infection Preventionist did not meet the qualifications for training and experience. This failure had the potential for patient infections, staff infections and potential for death. Findings: On 11/21/24, at 2:40 p.m., during an interview with Physician AA, he stated he was consulted by phone and monitored staff and patients. He stated he was an Infection Preventionist for the facility, and Licensed Staff BB provided day-to-day Infection Prevention duties. Physician AA stated he had heard that Licensed Staff BB did not have the required training to function as the Infection Preventionist. During an interview on 11/21/24, at 2:40 p.m., Licensed Nurse BB stated he had worked for the facility as the Infection Preventionist for eight months. He was unable to state what professional standards and / or guidelines he used to guide the infection prevention at the facility. Licensed Nurse BB stated he did not have any training or certification in infection prevention. During the interview he stated he, “thought” the hand hygiene compliance rate was 100%. He stated he completed observations and made the determination of compliance. He did not know if the observations included just nursing staff or physicians, or therapists. He stated he did not do observations of housekeeping staff. He did not answer when asked if he did observations of infection control practices in the Dietary Department. Licensed Staff BB stated he did not know if the facility had a Policy and Procedure (P&P) for wearing artificial fingernails. He stated the risk to patients if staff wore artificial fingernails was infection and skin tears. Licensed Staff BB stated he did not monitor contracted linen services for delivery or processing to ensure the service was compliant with national standards for infection prevention in linen services. He stated he monitored housekeeping twice a week and thought they performed at 90%. He was unable to state what that meant. He was unable to say anything about the approval of cleaning and disinfection products chosen by the hospital and if they were approved and Environmental Protection Agency (EPA) compliant. Licensed Staff BB stated staff were monitored for vaccine and immunization status. He stated they were supposed to wear masks in patient care areas. He did not respond to whether staff had to wear masks in non-patient care areas, like the lounges and non-patient corridors. He did not state if he had a list of all staff who had declined vaccinations / immunizations. He did not state how staff with declinations were monitored for compliance with the facility P&P to wear a mask. He did not state what the national guidelines for infection prevention and staff declination of vaccines and immunizations was. A review of Licensed Nurse BB’s employment file did not indicate any infection training education or training documentation. A review of, “§482.42(a) Standard: Infection prevention and control program organization and policies,” indicated, “The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership.””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 41175 Based on observation, interview and record review, the facility failed to implement its infection prevention and control protocols, when: 1. Three flying insects were observed in the Dietary Department; 2. Dietary staff did not test the disinfection buckets (Buckets of disinfection solution used to sanitize food preparation surfaces to avoid food Cross-contamination and reduce the risk of foodborne illnesses), according to manufacturer’s instruction for use (MIFU) and state law; 3. Staff did not disinfect walkie talkies after use in a patient room, with Contact Precautions (Infection control measures used in healthcare settings to prevent the spread of diseases transmitted through direct or indirect contact with an infected patient or their contaminated environment, typically requiring healthcare workers to wear gloves and gowns when entering the patient’s room and interacting with them or their surroundings); 4. Three staff members were observed wearing artificial nails while providing direct patient care; and, 5. Staff who had declined vaccinations and immunizations were not monitored for compliance with facility safety protocols designed to protect the hospital community. These failures had the potential to increase the risk of spread of disease-causing microorganisms among the vulnerable patients, staff, and visitors. Findings: 38088 1. During an observation and interview with Unlicensed Staff LL in the Dietary Services kitchen on 11/18/24, at 9:52 a.m., the door to the dry storage area was propped open. A sign on the door indicated, “This door to remain shut.” At 10:02 a.m., Unlicensed Staff LL wiped the bottom of a wire storage rack with a white disposable cloth. He stated he observed gray / brown matter on the disposable cloth that, “Looked like dirt and dust.” Unlicensed Staff LL stated the shelves were supposed to be dusted and cleaned daily and they were not. He stated the risk to patients was food contamination and foodborne illness.” During an observation and interview in the Dietary / Kitchen Department on 11/18/24, at 11 a.m., the Registered Dietician opened a large door that led to an area which contained a trash dumpster, dirty linens bagged and ready for pickup, a table and chairs and a locked trailer for biohazardous waste pickup. She stated this area was used for staff breaks and all food deliveries. The area was dusty, dirty, and had multiple leaves that gathered under the furniture and in corners. During an observation and interview in the Dietary / Kitchen Department on 11/19/24 at 11:04 a.m., a fly was on the wall in the food prep counter area in front of the office. Unlicensed Staff KK and a Cook were prepping food for patient lunches and did not respond to the fly. There was a wall-mounted piece of equipment designed to lure and capture flying insects. Unlicensed Staff KK stated she saw the fly and stated the insect trap could not catch everything and did not know if it worked. During an observation and interview with the Registered Dietician, in the Dietary / Kitchen Department on 11/19/24 at 12:36 p.m., a fly was in the air and on the wall above the desk located near the tray line. At 12:44 p.m., the Registered Dietician stated she saw a fly on the wall above the food prep counter. She stated there was no screen door or air curtain on the door used by staff to enter and exit and for vendor food delivery. She stated the risk to patients from flying insects in the kitchen was cross-contamination and foodborne illness. During an interview on 11/21/24 at 3:50 p.m., Licensed Staff BB was unable to state what professional standards he followed to manage the facility Infection Control Program. He stated he did not have any training from any professional organization. He stated he performed surveillance on Hand Hygiene. Licensed Staff BB stated he did not perform any observation of the Dietary Services Department. 2. During an observation and interview in the Dietary / Kitchen Department, on 11/19/24 at 8:55 a.m., Unlicensed Staff JJ stated, to test the red disinfection bucket (A bucket of sanitizing solution and water that was used to sanitize food prep surfaces to reduce the risk of foodborne illness), located under the three-basin sink in the food prep area, she would use a strip of HYDRION test paper (A way to measure the concentration of sanitizers, that results in a color match on the test paper to detect when disinfection solution should be replaced and if too much sanitizing solution was used), submerge it in the bucket for, “eleven seconds maybe.” At 9 a.m., she put the HYDRION test paper into the red bucket solution for three seconds. She observed the test paper, and stated it was not the correct reading according to the Manufacturer’s Instructions for Use (MIFU) which was posted on the wall above the sink. She placed the test strip back into the red bucket for three more seconds. She pulled the test tape out of the bucket, and the color had changed to reflect a reading of 200, which she stated was, “The safe zone.” No clock was visible from the three basin sink area, and Unlicensed Staff JJ stated she knew it was the correct amount of time to submerge the test tape because she, “Counts in her head.” She stated she did not look at a clock or watch. During an interview on 11/19/24 at 9:15 a.m., the Registered Dietician stated the HYDRION test paper was supposed to be submerged in the disinfection solution for 30 seconds. She stated, if staff did not test the solution according to MIFU, the risk to patients was the solution would not have enough sanitizer, and there would be risk of foodborne illness from cross-contamination of food prep surfaces. During an observation and interview in the dishwashing area of the Dietary Department on 11/19/24 at 12:08 p.m., Unlicensed Staff S demonstrated how to test the solution in the red bucket located in the dishwashing area. He walked to three-basin sink located in the food prep area, got a three-inch strip of test paper, walked back to the dishwashing area and submerged the paper test strip into the red bucket containing disinfection solution, for eight seconds. He did not have a watch, and no wall-mounted clocks were visible in the dishwashing area. He removed the paper test strip, and it was very pale. Unlicensed Staff S took the red disinfectant bucket with solution to the three-basin sink, emptied it and refilled it with the vendor-supplied solution dispenser. He got a new paper test strip and submerged it in the fresh disinfectant solution for 20 seconds. He removed the test paper, and it was a dark bluish-green. He stated it was good. He stated he counted in his head. 3. During an interview on 11/20/24 at 2:45 p.m., with Licensed Staff II, he stated walkie talkies were used to answer call lights or communicate location if anyone needed help. He stated they were supposed to be turned off in patient rooms. Licensed Staff II stated the walkie talkies were supposed to be cleaned after being inside a patient room with contact precautions (A set of infection control practices used in healthcare settings to prevent the spread of infectious agents that could be transmitted through direct or indirect contact with a patient or their environment, typically requiring healthcare workers to wear gloves and gowns when interacting with the patient and properly cleaning contaminated surfaces). During an observation and interview on 11/20/24 at 3:16 p.m., staff were inside a patient room. On the doorway a sign was posted which indicated, “Contact Precautions.” They wore disposable gowns, and face masks and gloves, while they attended the patient. During patient care, one staff member’s walkie talkie went off very loudly, and she reached with a gloved hand to pick-up her walkie talkie affixed to her scrub pants and pulled it out from underneath the disposable gown. She held it up to her face, spoke with someone, and then returned it to her cargo pants. At the end of patient care she removed her gown and gloves and walked out of the patient room without disinfecting the walkie talkie she carried. Licensed Staff Y stated she was helping a patient in a contact precautions room. She stated the purpose of contact precautions was to protect patients and staff from infections. She stated she forgot to disinfect the walkie talkie after she finished providing care. She stated she was not supposed to use the walkie talkie in any patient room, and she did not follow facility Policy and Procedure for walkie talkie use. She stated the risk to patients and staff was cross-contamination and the spread of infection to other patients and staff. During an interview on 11/21/24 at 3:50 p.m., Licensed Staff BB stated, as the Infection Control Nurse, he monitored staff for putting on and taking off of disposable gowns and gloves in precautions rooms. He stated he monitored the hand hygiene practices and use of walkie talkies in the patient rooms. He stated he did not have any data on walkie talkie use in contact precautions rooms and there were no issues. 4. During an observation and interview on 11/20/24 at 9:45 a.m., Licensed Staff V had artificial nails. She stated she liked her fingernails and, “I know I am not supposed to wear artificial nails, but I use gloves anytime I provide direct patient care during dialysis.” She stated she did not know what the facility Policy and Procedure for artificial nails was. She was unable to state what infection control standards were used for infection prevention. During an interview and observation at the nursing desk, on 11/20/24 at 10:25 a.m., Licensed Staff Y had artificial nails. She stated she did not know the facility Policy and Procedure for wearing fake fingernails. She stated the risk to patients was infection. During an observation and interview on 11/19/24 at 11:46 a.m., Licensed Staff Q was wearing artificial nails. She stated she liked her nails. She stated she thought the facility Policy and Procedure for artificial nails was she was not supposed to wear them because of infection control concerns. She stated she did not follow the facility Policy and Procedure. During an observation and interview on 11/19/24 at 11:50 a.m., Unlicensed Staff R was carrying a patient breakfast tray out of a patient room. She stated she had artificial nails and did not know the Policy and Procedure. She stated she thought they were not supposed to wear them for infection control concerns. During an interview on 11/20/24 at 3:50 p.m., Licensed Staff BB stated as the Infection Control Nurse he monitored staff hand hygiene and reported all his findings. He stated he thought the hand hygiene monitoring was at 100%. He did not respond when asked what exactly he was monitoring. He stated he did not know if the facility had a Policy and Procedure for the wearing of artificial nails. He stated the risk to patients if staff wore fake fingernails was skin tears and infection. When asked what professional standards he used to guide the Infection Control Program he was silent. He stated he did not have any training. 5. During an interview on 11/20/24 at 9:30 a.m., Unlicensed Staff W stated she worked in employee health and was responsible for completing requirement documentation for each employee. She stated employees were checked for Tuberculosis testing, Vaccinations, titers (A test to determine if someone had antibodies for a disease) for MMPR (Measles, Mumps, Pertussis and Rubella) (Contagious illnesses), varicella (Chicken Pox), influenzas and Covid immunizations, upon hire. She stated if an employee refused vaccination or immunizations, they would have to sign a waiver and wear a mask. She did not know if staff who had refused vaccinations or immunizations had to wear masks in the break room or non-patient care areas. She stated she had no direction from infection prevention on staff declinations and did not know what the facility Policy and Procedure was. She stated she did not know who had declined vaccination or immunizations but could maybe find it. Unlicensed Staff W stated she did not know who monitored staff who declined vaccinations or immunizations. During an interview on 11/21/24 at 3:50 p.m., Unlicensed Staff BB stated, as the Infection Prevention Nurse, he did monitor staff practices. He stated staff could decline Covid, influenza and other vaccinations. He stated they had to wear a mask in patient care areas. He did not respond when asked if staff who had declined vaccinations were allowed to be in non-patient care areas without a mask. He did not answer if he monitored staff who had declinations, to determine if they were compliant with mask wearing. He did not answer if he had the names of staff who had declinations for vaccines and immunizations. He stated he did not know what the Centers for Disease Control recommended for staff who declined vaccinations or immunizations. A review of the facility Policy and Procedure titled, “Infection Prevention & Control,” revised 9/9/22, indicated the facility, “Shall ensure that this organization develops, implements and maintains an active, organization wide program for the prevention, control and investigation of infections and communicable disease to reduce the risks of ....infections in patient, visitor and healthcare workers .... [Facility Name] Hospital’s Infection Prevention and Control program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices.....All hospital staff shall participate and support the Infection Prevention and Control Program through compliance with infection prevention and control practices, policies and procedures .....The infection Preventionists(s) and the Infection prevention and Control Committee shall be responsible for identifying, investigating, reporting, preventing and controlling infections and communicable diseases through the following activities: Maintenance of a sanitary hospital environment.....Active Surveillance: ...Conducting surveillance (reliable sampling or other mechanism) on a hospital wide basis in order to identify infectious risks or communicable disease problems at any particular location or department. Conducting surveillance activities in accordance with infection control surveillance practices utilized by the CDC’s National Healthcare Safety Net (NHSN) and shall include infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions.” A review of the facility Policy and Procedure titled, “Dietary Services Kitchen Sanitation and Cleanliness,” reviewed 5/10/24, indicated, “The kitchen shall be maintained in food repair, clean, sanitary, and free of pests.....Dietary staff will follow a cleaning schedule and be trained to properly keep the kitchen clean. Staff will inspect the kitchen for any signs of pests and report any findings to the Dietary Manager.....All kitchens and kitchen areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects.” Review of a facility Policy and Procedure titled, “Dietary Services Multi-Quat Sanitizer,” revised 5/10/24, indicated Multi-Quat Sanitizer must be tested for ppm (Parts per million) levels per manufacturer’s instructions. PROCEDURE: ...Test ppm level by using a HYDRION QT-40 test strip. Hold strip in water for 10 seconds. Use the strip to compare to the color guide to determine PPM levels.” Review of HYDRION QT - 10 product information titled, “Hydrion QT-10 Quaternary Test Paper,” indicated, “A simple, reliable means to measure the concentration of Quaternary Sanitizers, with color matches at 0-100-200-300-400 ppm (parts per million), the test paper measures concentrations between 0-400 ppm, detecting exhaustion of solutions that should be replaced as well as helping to avoid using excessive amounts of sanitizing agents.....Federal, State and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer....In California, the required quat level for manual sanitization is 200 parts per million (ppm) of quaternary ammonium (quat) for at least one minute. This is outlined in the California Health and Safety Code, HSC § 114099.6. To verify the quat level, you use a test strip. Here’s how: Stir the sanitizer and water solution. Dip the test strip paper into the diluted quat solution. Compare the color of the test strip to the color chart after 10 seconds. The test strip should read 200 ppm.” Multiple requests for manufacturer’s instructions for use and the requirement for test levels for prevention of foodborne illness were made and not received by the end of survey. Review of a facility Policy and Procedure titled, “Infection Prevention & Control Hand Hygiene,” revised 9/9/22, indicated, “PURPOSE: To provide guidelines for the use of hand hygiene as the single most effective action in the prevention of transmission of infection. Hand hygiene includes washing with soap and water or use of alcohol based hand rub, and the care of staff’s hands and fingernails.....Artificial nails, nail tips, wraps, or acrylic overlay or polish are prohibited for healthcare worker who provides patient care.” Review of a facility Policy and Procedure titled, “Human Resources Dress Code,” reviewed 12/12/23, indicated, “PERSONAL GROOMING All direct patient care providers must follow CDC (Centers for Disease Control) recommendations for rings, fingernails and facial hair.... Artificial nail enhancements are prohibited. This includes, but is not limited to, artificial nails, tips, wraps, acrylics, gels and any additional items applied to the nail surface.” Review of a facility Policy and Procedure titled, “Administration Communications Walkie Talkie,” effective 2/3/23, did not indicate use in patient rooms or use in isolation rooms. Review of a facility Policy and Procedure titled, “Infection Prevention & Control Precautions: Standard, Airborne, Droplet, Contact, Enteric, Sars-COV-2,” revised 9/8/22,” indicated, “Compliance with Standard and transmission specific precautions is required of all [Facility Name] physicians, healthcare disciplines, ancillary staff and volunteers who have contact with patients or body substances.....Handle used patient care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfers of microorganisms to other patients and environments.” Review of a facility Policy and Procedure titled, “Employee Health Vaccination Declination,” revised 2/3/24, indicated, “Employees who decline a required vaccination must follow the steps outlined below and may be subject to additional safety protocols to protect the hospital community. Procedure for Vaccine Declination 1. Submission of Vaccine Declination Form: Employees who choose to decline a recommended or required vaccine must complete the Vaccine Declination Form. 2. Mandatory Counseling: Individuals declining vaccination must undergo counseling with an [Facility Name] employee health representative to discuss: The benefits of Vaccination. Risks associated with declining the vaccine. Infection prevention and control measures.....Failure to follow this policy, including providing false information or non-compliance with alternative safety measure, may result in disciplinary action up to and including termination of employment.” Review of a document titled, “CDC The National Healthcare Safety Network (NHSN) Manual 2025 Healthcare Personnel Vaccination Module Protocol: Influenza Vaccination Summary Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases Atlanta, GA, USA,” indicated, “Healthcare facilities should provide influenza vaccine to HCP using approaches that have demonstrated effectiveness in increasing vaccination coverage. [1, 2] Healthcare administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. [2; 9-12] Influenza vaccination rates (including ward-, unit-, and specialty-specific coverage rates) among HCP within facilities should be regularly measured and reported to facility administrators and staff [2, 12].””

“LEADERSHIP RESPONSIBILITIES CFR(s): Standard: Leadership responsibilities (1) The governing body must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 38088 Based on interview and administrative document review, the Governing Body (GB) failed to exercise oversight and administrative control over the facility’s total operation when it failed to ensure; 1. Patient rights to receive care in a safe setting for two patients (Patient 1 and Patient 9), when safety alarms were turned off in the Intensive Care Unit and the movement of patient equipment in patient rooms occurred without assessment for adequate space. 2. Patient rights for confidentiality of medical information, when one patient’s (Patient 36) medical record was displayed and unattended in the hallway. 3. Facility Policy and Procedures were followed by staff, when; wound care was performed and documented for one patient (Patient 36), and a weight gain of 16 pounds by one patient (Patient 72) was not documented, assessed or followed up by nursing, dietary and other providers. 4. The Infection Control Nurse had the qualifications to effectively monitor patient and staff health. 5. The Infection Control program assessed and monitored the Policy and Procedures and portocols for the use of Personal Protective Equipment (Masks, gowns, gloves for use in contact precaution rooms), disinfection of dietary surfaces and walkie talkies used by staff in contact precaution rooms, monitoring of staff who declined required vaccines and immunizations and staff who wore artificical nails in patient care areas. Findings: (Cross Reference A144, A147, A398, A692, A748, A 749) During a document review on 11/18/24 at 9 a.m., the facility Chief Nursing Officer and Chief Operating Officer were requested to provide a copy of the Governing Body Minutes for review. They were not received by the end of the day. During a document review on 11/19/24 at 2:15 p.m., the Corporate Consultant was requested to provide copies of the Governing Body agendas, minutes, and board membership for review. They were not received by the end of the day. During a document review on 11/19/24, the facility provided documents titled AD HOC MEDICAL STAFF MEDICAL EXECUTIVE/ GOVERNING BODY MEETING,” dated 1/19/24 - 11/30/24. Review indicated no attendance, agenda, standing items, actions and follow-up discussion was documented. The Corporate Consultant was requested to provide copies of the Governing Body agendas, minutes, and board membership for review. They were not received by the end of the day. During an interview and document review on 11/22/24 at 4 p.m., via phone and in person attendance, the Governing Body members were asked to detail how they prepared the facility for survey readiness, and stated they heard about grievances and reviewed pharmacy data submitted to them. The Governing Body was asked what was the facility Policy and Procedure for approval of medical staff. Physician QQ unable to address. Licensed Staff RR stated the Governing Body reviewed audits to ensure compliance with all Condition of Participation with the Centers for Medical Services. None of the Governing Body members were able to speak to what audits were conducted, what monitoring was performed, or how the facility performed. They stated a Provider was approved for priveldges and credentials at the facility, and the Infection Prevention Nurse was approved on 3/2024. The Governing Body was requested to provide documentation of the minutes where audits were reviewed, Providers were approved, the Infection Control Nurse was approved, what infection control data was reviewed, and any follow-up on anything that was presented to the Governing Body in 2024. No documents were provided for Governing Board Membership, Governing Body By-Laws or Policies and Procedures, Governing Body Minutes, review of audits and follow-up, or Infection Prevention Program status by the end of the meeting. Requests for Governing Body Membership, Policy and Procedures, By-Laws, Documentation of meetings that showed evidence of attendance, agenda, discussion, action and follow-up were made repeatedly throughout the survey and were not provided by the end of survey.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 39792 Based on interview and record review, the facility failed to provide timely Speech Therapy services for five (Patient 29, 28, 51, 34 and 33) out of 11 sampled patients. These failures resulted in delay in care and missed crucial timely rehabilitation therapy. Findings: 1. During a review of Resident 29’s, “History and Physical,” dated 8/23/24, indicated Patient 29 was admitted to the facility on 8/23/24, for rehabilitation care. A review of Patient 29’s, “Physician Orders,” dated 9/10/24, indicated a swallow evaluation had been ordered for Patient 29. Patient 29 had opportunities to be evaluated by Speech Therapy but was unable to work with Therapist due to copious amount of secretions on 9/23, 9/24 and 9/26/24. A review of Patient 29’s Speech Therapy Notes, dated 9/10/24, indicated to require continued treatment for swallowing dysfunction to be seen three to five times a week for eight weeks. Patient 29 was evaluated by Speech Therapy on 9/13/24. Patient 29 was seen by Speech Therapy on 9/16, 9/18 and 9/19/24. The week of 9/29/24 to 10/5/24, there were no documented encounters where Speech Therapy had interacted with Patient 29, meaning completed therapy encounters or attempted therapy encounters with Patient 29. The week of 10/6/24 to 10/12/24, there was one documented encounter, dated 10/6/24, where Patient 29 was asleep prior to the encounter and remained sleepy throughout the session, and there were no other attempted therapy encounters. The week of 10/13/24 to 10/19/24, there was one documented encounter, dated 10/13/24, where Patient 29 was indicated to have large amount of secretions during the session, and there were no other attempted therapy encounters. During a concurrent interview and record review on 11/21/24 at 9:48 am., with Licensed Staff HH, the facility’s October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24 -10/5/24, where Patient 29 was observed to have scheduled a therapy session (three to five times a week), the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 29 or numbers/x were observed to indicate an attempt to evaluate Patient 29 was made. Licensed Staff HH stated it was not good that Patient 29 did not have any Speech Therapy services for a week, meaning Patient 29 missed a minimum of three opportunities to have Speech Therapy. Licensed Staff HH stated the Speech Therapist had to leave because of a family emergency, and it was important but there was only one Speech Therapist for the department. The second week of the schedule was reviewed, and Unlicensed Staff HH thought Patient 29 did have therapy on Sunday 10/6/24, when a Speech Therapist from another facility helped out but agreed that Patient 29 would have only had one session compared to three opportunities (the schedule did not indicate any other attempts at therapy were made). Week three of the schedule, dated 10/13/24-10/1924, where Patient 29 was observed to have one scheduled Speech Therapy session on 10/13/24, and no further opportunities were observed during the week. Licensed HH totaled the amount of opportunities for the three weeks Patient 29 had therapy, two times (10/6/24 and 10/13/24) out of nine minimal and 15 maximal opportunities. Licensed HH stated that would have the effect of delaying the overall goal of therapy but could not explain how. 2. During a review of Patient 28’s, “History and Physical,” dated 9/20/24, indicated Patient 28 was admitted to the facility on 9/20/24, for wound care, dialysis and rehabilitation. A review of Patient 28’s, “Physician Order,” dated 9/22/24, indicated a swallow evaluation was ordered. A review of Patient 28’s, “Speech Therapy Treatment Encounter Notes,” dated 9/24/24, indicated Patient 28 was seen at the bedside, on 9/26/24. Patient 28 was not seen due to medical instability. There was no Speech Therapy note found for the week of 9/29- 10/5/24. Patient 28 was seen by Speech Therapy on 10/6/24 and 10/13/24. The facility did not provide the initial speech evaluation as requested on 11/21/24. During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility’s October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24-10/5/24, where Patient 18 was observed to have scheduled a Speech Therapy session (three to five times a week) showed no documentation for any of the corresponding days, meaning initials would have indicated a Therapist had seen Patient 28 or a number/x would have indicated an attempt was made to provide therapy to Patient 28. There was no indication a Therapist provided therapy or an attempt to provide therapy was made since the boxes for the week were all blank. Licensed Staff HH stated the boxes were blank because the Therapist was on vacation, and there was only one Speech Therapist in the department at the time. The second week of the schedule, dated 10/6/24-10/12/24, Patient 28 was observed to have one speech therapy session on 10/6/24. Licensed Staff HH stated the Therapist was from another facility and was helping out and agreed that Patient 28 had one session that week and no further documentation about other attempts of therapy (all other boxes were blank). The third week of the schedule, dated 10/13/24-10/19/24, was reviewed where Patient 28 had one Speech Therapy session on 10/13/24, and no further documentation about other attempts of therapy (all other boxes were blank). Licensed Staff HH stated, per the schedule, Patient 28 had not been receiving his scheduled therapy sessions and again stressed the department had one Speech Therapist. Licensed Staff HH stated it was not ideal for a patient to miss therapy sessions and he could not further explain why the facility did not provide Speech Therapy sessions as ordered. 3. During a review of Patient 51’s, “History and Physical,” dated 10/7/23, indicated Patient 51 was admitted to the facility for abdominal wound management on 10/7/24, and had been on a dysphagia (mechanical soft diet to make it easier for people having difficultly swallowing to reduce the risk of food or liquid going into the airway instead of the throat). During a review of Patient 51’s, “Physician Orders,” dated 10/7/24, indicated a swallow evaluation had been ordered for Patient 51. During a review of Patient 51’s, “Speech Therapy Initial Evaluation,” dated 10/13/24, indicated Patient 51 was evaluated by a Speech Therapist who recommended remaining on the least restrictive diet (soft, bite size diet) and referred back to Speech Therapy when Patient 51’s alertness had improved. “Speech Therapy Initial Evaluation,” dated 10/25/24, indicated Patient 51 had graduated with trial of a regular diet and thin liquids so his diet order was upgraded, and no further speech services were recommended. During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility’s October patient schedule for Speech Therapy, was reviewed. The second week of the schedule, dated 10/6/24-10/12/24, where Patient 51 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 51 nor numbers/x were observed to indicate an attempt to evaluate Patient 51 was made. Licensed Staff HH stated the only Speech Therapist for the department was on vacation. The third week of the schedule, dated 10/13/24-10/19/24, Patient 51 was observed to have his speech evaluation completed on 10/13/24, and Unlicensed Staff HH stated it usually did not take that long, but the Speech Therapist was on vacation. Unlicensed Staff HH stated waiting a week would delay therapy but could not expand further. 4. During a review of Patient 34’s, “History and Physical,” dated 10/6/24, indicated Patient 34 was admitted to the facility on 10/6/24, for wound management, tracheostomy (surgical procedure which creates an opening in the neck and into the trachea or windpipe to provide an airway to breathe) management and ventilation (device which helps or replaces a person’s breathing) management and rehabilitation. A review of Patient 34’s, “Physician Orders,” dated 10/6/24, indicated a swallow evaluation was ordered. A review of Patient 34’s, “Speech Therapy Initial Evaluation,” dated 10/13/24, indicated Patient 34 was evaluated and recommended to continue speech therapy one to five times a week but Patient 34 was not a candidate for oral trial due to weak shallow breaths. During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility’s October patient schedule for Speech Therapy, was reviewed. The second week of the schedule, dated 10/6/24-10/12/24, where Patient 34 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 34 or numbers/x were observed to indicate an attempt to evaluate Patient 34 was made. Licensed Staff HH stated the only Speech Therapist for the department was on vacation, and that was probably why Patient 34 was not evaluated that week. The third week, dated 10/13/24-10/19/24, was reviewed, and Patient 34 was observed to have his speech evaluation completed on 10/13/24. Unlicensed Staff HH stated it usually did not take a full week to have an evaluation but thought it was due to the only Therapist for the department being on vacation. Licensed Staff HH stated he was not sure of the exact time frame but it could take a few days to complete a swallow evaluation. 5. During a review of Patient 33’s, “History and Physical,” dated 9/27/24, indicated Patient 33 was admitted for ventilator management and rehabilitation. Records were requested on 11/22/24, for Physician Orders for a swallow screen but the facility did not provide any Physician Orders. A review of Patient 33’s, “Speech Therapy Initial Evaluation,” dated 10/6/24, indicated Patient 33 was evaluated and deemed not appropriate for an oral trial at this time and, due to lack of cognition, no further trials were indicated. During a concurrent interview and record review on 11/21/24 at 9:48 am, with Licensed Staff HH, the facility’s October patient schedule for Speech Therapy, was reviewed. The first week of the schedule, dated 9/29/24- 10/5/24, where Patient 33 was observed to have a scheduled Speech Therapy evaluation, the boxes corresponding for each date were blank; meaning no initials or Therapist had evaluated Patient 33 nor numbers/x were observed to indicate an attempt to evaluate Patient 33 was made. The second week of the schedule, dated 10/6/24-10/12/24, Patient 33 was observed to have a scheduled Speech Therapy evaluation, dated 10/6/24. Licensed Staff HH stated he was not sure when Patient 33 had been admitted but stated he thought the evaluation was delayed a week due to the single Speech Therapist being on vacation and the evaluation took place on 10/6/24, because a Speech Therapist from another facility helped out. During an interview on 11/22/24 at 9:53 am, with Licensed Staff MM, Licensed Staff MM stated she had been the only Speech Therapist in the building for some months now. Licensed Staff MM stated the hours were Monday through Friday so if there was a time to take off during the week, the time could be made up on the weekend. The new admission speech evaluations usually took a day or two but not much more than that, and the case load was not that bad. Licensed Staff MM stated there was a family emergency, and she had to take some time off so maybe some of the Speech Therapy evaluations were delayed; it was not planned, and she was not aware of what took place when she was gone. During a review of the facility’s Policy and Procedure titled, “Rehabilitation Therapy,” dated 9/18, indicated, “Speech Language Pathologists shall respond to MD orders for Speech Language pathology ...Patients will be evaluated, and a plan of care established to remediate goals. Documentation will be timely, shall be completely in CPSI by days end and meet all outside payer source guidelines ...Treatment including skills remediation, family and caregiver training and equipment recommendation to optimize patient function status.””