San Joaquin Valley Rehabilitation Hosp

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47205 Based on interview and record review, the hospital failed to ensure Licensed Nurses (LNs) developed and kept current a Nursing Care Plan (NCP- a process through which the nurse identifies, documents, and keeps track of a patient’s state or condition, needs, and risks) for one of 20 sampled patients (Pt 3), when a NCP for Pt 3 had not been created, updated, or changed to reflect the active use of a one-to-one sitter (1:1 sitter- a staff member-often a nursing assistant, aide, or specialized observer-assigned to monitor a single high-risk patient continuously, staying within eyesight to ensure safety) in accordance with hospital policies (P&Ps) and professional standards. This failure resulted in LNs providing care without an assessment and development of a patient specific NCP to guide the LN in the management of Pt 3’s care needs and had the potential to result in Pt 3’s care needs to go unmet and/or possibly an unnecessary extended time under continuous physical monitoring. Findings: During a concurrent interview and record review on 3/6/26 at 10:11 a.m. with the Chief Nursing Officer, Pt 3’s “Electronic Medical Record (EMR- is a digital version of the paper charts that healthcare providers traditionally used to document patient care),” undated was reviewed. The DON stated he document titled, “History and Physical (H&P- a comprehensive, formal document in healthcare that records a patient’s medical history, current health status, and a detailed physical exam),” indicated, Pt 3 was a 76-year-old with the chief complaint of “Right [RT] femur [upper long bone of leg] fracture [broken bone] status post [is a medical term meaning “after” or “following” a specific, significant event, procedure, or intervention] OIRF [Open Reduction and Internal Fixation is a two-part surgical procedure used to treat severe bone fractures].” During a concurrent interview and record review on 3/6/26 at 10:15 a.m. with the CNO, Pt 3’s “EMR,” undated was reviewed. The EMR indicated, Pt 3’s Past Medical History (PMH) included “...Hypertension [high blood pressure], Diabetes [a chronic metabolic disorder characterized by high blood sugar resulting from the body’s inability to produce enough insulin (a hormone) or use it effectively], CHF- [Congestive Heart Failure- when the heart muscle cannot pump blood efficiently enough to meet the body’s needs], Dementia [a loss of thinking, remembering, and reasoning skills]. ..” The CNO stated the EMR indicated Pt 3 was admitted to the hospital on 12/13/25 with a treatment plan to engage in “...at least 3 hours of combined PT/OT [Physical Therapy and Occupational Therapy are essential rehabilitative health professions that improve patient quality of life] and 24-hour skilled rehabilitation nursing under the supervision of a physician with training and experience in physical medicine and rehabilitation...” The EMR indicated nursing staff had initiated other NCP’s. The CNO stated she could not locate a NCP for Pt 3’s need for a 1:1 sitter for patient safety. The CNO stated her expectation was that if Pt 3 needed a 1:1 sitter for his safety, the LN should have initiated a NCP to ensure Pt 3’s needs were met. During a review of the hospital’s P&P titled, “One on One (1:1) Supervision,” dated 10/25, the P&P indicated, “ ... POLICY: One to one level of care is provided, upon the order of a physician, to patients assessed to have impaired judgment with potential for injury, suicidal ideations or elopement. ...PROCEDURE: ... 4.0 The nursing care plan will reflect one-to-one supervision and the behavior necessitating 1:1 level of care. It will also reflect the interventions to decrease the use of 1:1 supervision...” During a review of the hospital’s P&P titled, “Care Planning,” dated 10/25, the P&P indicated, “ ...POLICY: 1. Care, treatment and services are planned to ensure that they are individualized to the patient’s needs. The Hospital shall provide an individualized, interdisciplinary plan of care for all patients that are appropriate to the patient’s needs, strengths, results of diagnostic testing, limitations and goals. ...3. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable. ...5. The plan of care is maintained and updated based upon ongoing patient assessments and the patient’s response to care, treatment and services. ...PROCEDURE: 2. The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family. ... 3. ...The plan of care will be continually evaluated based on the patient’s clinical condition, results of diagnostic tests, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the patient’s changing condition. ...6. The plan of care shall be updated, with revisions reflecting the reassessment of needs of the patient. ...” During a review of a professional reference titled, “Nursing Process,” dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/, the reference indicated, “ ...Planning ...The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP (Evidence-based Practice- recommendations for nursing care that are based on scientific evidence) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: 1. Specific; 2. Measurable or Meaningful; 3. Attainable or Action-Oriented; 4. Realistic or Results-Oriented; 5. Timely or Time-Oriented ...””

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 42321 Based on observation, interview and record review, the Condition of Participation (COP) for Compliance with Federal, State, and Local laws and regulations related to the health and safety of patients was determined to be NOT MET when: 1.The hospital did not report an adverse event: the death of Patient (Pt) 1 who fell and died on 1/19/25. 2.The hospital did not report an unusual occurrence: the nonfunctional boilers that caused the hospital to be without warm and hot water for a period of four days. The cumulative effect of these systemic failures resulted in the hospital’s substantial noncompliance with federal, state and local laws. Findings: 1.During a concurrent interview and record review on 11/6/25, at 11:25 a.m., with Chief Nursing Officer (CNO), Pt 1’s Electronic Medical Records (EMR) for his admission starting 1/17/25 was reviewed. Pt 1’s face sheet (document that contains personal information, name, date of birth, address, contact person, etc.) indicated Pt 1 was a 75 year old (yo) male admitted on 1/17/25 at 3:53 p.m., arrived at the hospital at 9:30 p.m. Pt 1’s History and Physical (H&P) dated 1/18/25 at 8:52 pm indicated Pt 1 was being admitted for “ ... debility and self-care deficits secondary to severe back pain T11-S1 (Lower back bones) spinal fusion (surgical procedure by fusing bones together to create one solid piece) decompression limiting of mobility and self-care ... fusion by [name of surgeon] on 1/14/25 postoperatively the patient has had difficulty with pain management somewhat so it interferes with his ability to achieve basic mobility and self-care especially with turning transfers his pain level go from a resting level of 5-6 at best with medication on board to 9-10 out of 10 and he is requiring mod assist for transfers min assist sit to stand with physical therapy and mod to max assist for lower body dressing ... he is having bloating of the abdomen there is some loss of appetite he is uncomfortable no sharp pains in the abdomen send only slight bowel production since surgery ... Very large gentleman with in mild state of distress appears aggravated uncomfortable ... Abdomen: Moderately distended tympanitic throughout with mild-moderate tenderness of moderately deep palpation ... bowel sounds are hypoactive no rebound tenderness ... Treatment plan recreations 1. Admit to acute rehab for comprehensive spinal rehabilitation program involvement by physical Occupational therapy 3 hours daily punctuated treatment progressive up time strengthening lower extremities gradual progression of mobility and self-care. 2. Pain management. 3. Nursing to manage constipation with a bowel program ... 13. Patient expected to require 2-week period of inpatient rehabilitation ... in order to return home with his wife with use of adaptive equipment. Close monitoring necessary to prevent complications ... accommodations from postoperative ileus (a temporary condition where the bowels stop functioning normally after surgery, causing symptoms like abdominal pain, bloating, nausea, vomiting, and the inability to pass gas). [Medical Doctor (MD 1)]” During an interview on 11/6/25, at 2:33 p.m., with the Environmental Services Resp (EVS 1), EVS 1 stated she worked on 1/19/25 and was present when Pt 1 fell from his bed to the floor. EVS 1 stated, “I was doing th EVS daily cleaning and when I go in the room, I announce myself and was getting the trash. I said hello, he [Pt 1] did not respond back, he was sitting on the edge of the bed. I asked him if he [Pt 1] needed anything. He wasn’t looking at me but past me. He looked flat looking past me. I said sir do not move. I called to [name of the unit clerk] the unit clerk that this guy needs something. Then I saw him go down and went straight to the right side and hit the front of his temple head and then turned onto his back. That’s when I pressed the rapid response button. I didn’t see him move after that. All I saw fluid coming out of his mouth, body fluid. They [nursing staff] came in and checked for pulse and trying to do cpr (cardiopulmonary resuscitation, is an emergency procedure that involves chest compressions and rescue breaths to keep blood circulating during a cardiac arrest) ... code blue button” was pushed, “I think when he hit the floor he was already gone. No bleeding from his head. He was in B bed; he was in the corner of the bed close to the bathroom. It was lunch time. I thought he was going to try and get up.” During an interview on 11/6/25, at 4:31 p.m., with Nurse Supervisor (NS 1), NS 1 stated she worked as a floor nurse on 1/19/25. NS 1 stated, “I wasn’t supposed to work that day, I was working the same hallway. The patient [Pt 1] had fallen on the floor; we were trying to feel a pulse turned into a code blue immediately. I was not the first one who initiated. I think it was [name of 2 other nurses] rotating off, he had gastric fluid (a mix of water, mucus, hydrochloric acid, and digestive enzymes that are secreted by the stomach to aid in digestion), 911 called, they were there in 5-10 minutes. We tried to get an IV (intravenous- in a vein) line. The [paramedics] put in IO (intraosseous- in the bone- line to give medications) 1-2 rounds of epinephrine (medication used to improve blood flow and perfusion pressure to the vital organs), until they finally pronounced him. The wife was there all day and had just left for lunch. We called her back ... We had to move the roommate he was traumatized. The nursing supervisor would be the one to report to California Department of Public Health [NS 2].” NS 1 stated when a patient dies, we normally notify the Medical Doctor (MD), the Administrator on Call (AOC), she believes NS 2 contacted the CNO as well. NS 1 stated, “We had a hiccup normally when paramedics come, they take the patient with them and continue care. We were unfamiliar with if he [Pt 1] needed to be a coroner’s case. I would defer to CNO or policy. [MD 1] was there that day ... [MD 1 stated] he was just talking to him he was just as surprised, he was the one that called time of death. I believe he [MD 1] was thinking it was a PE (pulmonary embolism- a blockage in one of the arteries in the lungs), he [Pt 1] did have a lot of comorbidities (medical conditions). [MD 1] left it to us to call coroner’s office. I believe it was [NS 2] who called.” During a concurrent interview and record review on 11/7/25, at 2:16 p.m., with NS 2, Pt 1’s “Record of Death” form dated 1/19/25 was reviewed. NS 2 stated that she had been the one to fill the Record of Death form for Pt 1. NS 2 stated, “RRT (rapid response when a patient it down) was called, we ran to the room, patient was already down on the floor. I don’t remember who was first, not breathing called code blue, unresponsive, greenish bile like substance out of mouth and nose, cpr was already started. We tried to put an IV we could not, paramedics were called, heart monitor on, cpr until paramedics came, they were able to establish an IO access, they took over the cpr. No he never had a pulse on manual checks or on the machine.” NS 2 stated, “[MD 2] was here he spoke with the family the wife was just there before lunch tray came out. We thought it was a simple fall, he [Pt 1] was still a max total assist. After he was pronounced. Paramedics called the coroner’s office. They never told me if it was going to be a coroner’s case or not. NS 2 stated she is not sure why she marked “yes” that Pt 1’s death was a reportable event, she stated as for the Coroner’s Case box she marked “yes” because she thought they called the coroner’s office. NS 1 stated, “this is the first time I had to fill in this form [referring to the Record of Death].” NS 1 stated she did not know that she should call and report this death to the California Department of Public Health. During an interview on 11/6/25, at 11:14 a.m., with the CNO, the CNO stated she was informed about Pt 1’s death on 1/19/25. CNO stated she was called by NS 2 after Pt 1’s death and was informed that the Paramedics told her to call the Coroner’s, then “she came back and told me the Paramedics called the coroner”. The CNO stated she felt Pt 1’s death was not a coroner’s case because she had called the police department nonemergent line and they told her if the death was not through foul play, then to contact the mortuary where the family wanted the patient to go. The CNO stated, “any code blue is unusual, I looked up what is a reportable case, and I know a death from a fall would be reportable but based on what caused the fall was the medical event [for Pt 1 and] it didn’t feel like it was a reportable event.” The CNO agreed that a death in a rehabilitation hospital is an unusual occurrence, she noted that in the last 10 years she has worked here the hospital has sent out maybe 10 patients that had coded. The CNO stated she remembers discussing if Pt 1’s death was reportable with the Regional Director of Quality (RDQ) and the Chief Executive Officer (CEO) and “I wasn’t under the impression it was something we had to report”. The CNO stated she believed the Paramedics made the call to the coroners and that she has attempted to get ahold of American Ambulance, but they have not gotten back to her, there is no documentation in Pt 1’s records of the names of the Paramedics or who actually called the coroner’s office. During an interview on 11/13/25, at 10:11 a.m., with Medical Doctor (MD) 1, MD 1 stated Pt 1 was admitted on 1/17/25, he was in a lot of pain, it was immobilizing to him, it was mostly back pain, his bilateral leg pain and numbness was better after his surgery, and he had a bloated belly. MD 1 stated on 1/19/25 Pt 1 had been working with Physical Therapy (PT), and he was sitting on the edge of the bed with a blood pressure of 90/60, we had him take some deep breaths and listened to his lungs and heart not having any chest pain or shortness of breath but was in a fair amount of pain. MD 1 stated Pt 1 was able to do sit to stand exercises with no orthostatic (drop in blood pressure when standing) vital sign issues. MD 1 stated Pt 1 had a medium bowel movement but was still very bloated, with a distended abdomen. MD 1 stated he was notified of an RRT and code blue on Pt 1 and by the time he got to the room staff had already started CPR and Pt 1 was asystole (the complete cessation of the heart’s electrical and mechanical activity) on the monitor. MD 1 stated Pt 1 expelled quite a bit of clear green bile and was being suctioned, face mask on for oxygen, within 10 minutes EMS had arrived and took over compressions, the whole time Pt 1 did not respond in any way. MD 1 stated he called time of death and believed Pt 1 either died of a PE, DVT (deep vein thrombosis- blood clot), ileus, aspiration pneumonia (infection in the lungs caused by bile from his abdomen going into his lungs) but that Pt 1 had a lot of comorbidities. MD 1 stated he did not call the coroner’s office, but he did speak with Pt 1’s spouse. MD 1 stated he believed the police came and talked with Pt 1’s spouse and helped make the decision if it was a coroner’s case but he was not involved in making that decision. During an interview on 11/13/25, at 3:02 p.m., with the Chief Executive Officer (CEO), the CEO stated Pt 1’s death was reviewed and the facility felt it was not a reportable event, so it did not get reported. During a review of the facility’s policy titled, “Risk Management Plan,” last review date 12/2024, the Risk Management Plan indicated, “ ... Definitions ... Sentinel Event: An unexpected event or occurrence involving death or serious physical or psychological injury, either permanent or temporary ... Unusual Occurrence Reporting: An unusual occurrence is defined as an unusual occurrence involving a patient, visitor, or employee, which may transpire in or on the premises of the facility or within the course and scope of the facility’s operations. The occurrence is considered unusual if it was unintended, undesirable and/or unexpected ... RESPONSIBILITY Overall responsibility for the risk management process lies with the Governing Body. The Director of Quality & Risk Management (DQM) manages the daily operation in the hospital, reporting to the Hospital Chief Executive Officer (CEO) ... Unusual Occurrences Process ... Reportable unusual occurrences shall be reported to the local health officer by the DQM, or designee, according to state statues ... Examples of unusual occurrences to be reported include but not limited to those events related to: ... Falls ... Unexpected deaths ... Any unusual occurrence ... Confidentiality and External Reporting ... The CEO or designee, after consultation with the Corporate VP of Risk Management and/or Hospital Legal Counsel, may report the sentinel event to the Joint Commission and other applicable regulating bodies within five days of the determination the occurrence is reportable ...”. During a review of a professional reference titled, “Health and Safety Code - HSC DIVISION 2. LICENSING PROVISIONS [1200 - 1796.70] (Division 2 enacted by Stats. 1939, Ch. 60.) CHAPTER 2. Health Facilities [1250 - 1339.59] (Chapter 2 repealed and added by Stats. 1973, Ch. 1202) ARTICLE 3. Regulations [1275 - 1289.5] (Article 3 added by Stats. 1973, Ch. 1202.) 1279.1. (a) A health facility licensed pursuant to subdivision (a), (b), or (f) of Section 1250 shall report an adverse event to the department no later than five days after the adverse event has been detected, or, if that event is an ongoing urgent or emergent threat to the welfare, health, or safety of patients, personnel, or visitors, not later than 24 hours after the adverse event has been detected. Disclosure of individually identifiable patient information shall be consistent with applicable law. (b) For purposes of this section, “adverse event” includes any of the following: ... (5) Environmental events, including the following: ... (D) A patient death associated with a fall while being cared for in a health facility ...”. Retrieved from: https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1279.1.&lawCode=HSC 2.On 11/4/25 California Department of Public Health received three anonymous complaints that the hospital had “no hot water since 10/30/25”. During concurrent observations and interviews in the kitchen on 11/5/25, at 2:25 p.m., with Dietary Aid (DA) 2 and the Director of Nutritional Services (DNS), the hot water was turned on and checked in multiple faucets and was working. The DA 2 stated “yes” the facility was having issues with hot water starting Thursday (10/30/25) of last week, and on Friday (10/31/25) she was having to boil water to wash the dishes, and other staff were brought in to help. DA 2 stated when she came back to work on Tuesday (11/4/25) the hot water had been fixed. The DNS stated the hot water issue did not affect the dishwasher and sanitizing process because the dishwasher had its own water heater. During an interview on 11/5/25, at 2:54 p.m., with Lead Cook (CK) 1, CK 1 stated on Thursday 10/30/25 around 9 a.m. the hot water stopped. CK 1 stated, “we started boiling pots of water to fill the sink to clean the dishes.” CK 1 stated the hot water being out did not affect the dishwasher because it is a low temperature sanitizer and has its own water heater. During an interview on 11/5/25, at 3:52 p.m., with Licensed Vocational Nurse (LVN) 2 and LVN 3, LVN 2 and LVN 3 stated there was no hot water over the weekend (11/1/25 and 11/2/25), the facility told them they were having issues with the boilers, and this was explained to the patients. LVN 2 and LVN 3 stated they had no complaints from the patients, and the hot water is currently working. During an interview on 11/5/25, at 4:46 p.m. with the Regional Director of Plant Operations (RDPO), the RDPO stated he has worked for the hospital for the last 7 months and he was informed on Thursday 10/30/25 that the facility was having issues with hot water around noon. The RDPO stated he tried to see if there was anything he could do to fix the issue but ultimately called a vendor and they were able to come onsite that day but to get the boiler fixed the motor needed to be shipped in. The RDPO stated at first, they said it would be in by Friday but that did not work out, and the vendor finally came on Tuesday 11/4/25 and fixed the boilers around 3 p.m. The RDPO stated on 11/4/25 after the boilers were fixed, he made sure to visit each of the patient rooms to make sure the hot water was working. The RDPO stated he did not contact California Department of Health Care Access and Information (HCAI-the state agency that ensures hospital buildings in California are safe) when the hot water went out. During an interview on 11/6/25, at 10 a.m., with the Chief Executive Officer (CEO), the CEO stated the boilers started having issues a long time ago, back in April was the first issue when the boiler was not working appropriately. The CEO stated at that time we got a quote and ultimately had everything we needed to fix it, so we did, and the hot water was still good at that time. The CEO stated on Thursday 10/30/25 in the late afternoon the Regional Quality Director (RQD) said she started getting reports that the hot water was not working in certain areas and at that time they began reaching out to vendors to get a quote to fix the issue. The CEO stated the facility Regional Director of Plant Operations (RDPO) was working on getting the issue fixed, and the CNO was staffing up to help with bed baths and explaining the situation to the staff and the patients. The CEO stated that he did report the issue to his Vice President and leadership. The CEO stated we thought everything was being done appropriately so we did not feel that it needed to be reported to California Department of Public Health (CDPH). During an interview on 11/6/25, at 11:14 a.m., with the CNO, the CNO stated she was told the facility was having hot water issues on Thursday 10/30/25 and as of Friday 10/31/25 the whole building was having issues with no hot water. The CNO stated our DPO was on the phone right away with a vendor that was able to come the same day and diagnose the issue, but they did not have the part, and it was not local and would need to be shipped in. The CNO stated they were informed that the part could be in by Saturday (11/1/25), but this did not happen because the company was closed. The CNO stated the DPO drove out to Hayward to pick up the part just to find out it was not actually there. The CNO stated the part arrived on Tuesday and the vendor came and fixed the boiler. The CNO stated the staff and her went to speak with each patient and apologize for the inconvenience of not having hot water, and for the most part it was received very well. The CNO stated to make bed baths more comfortable we made sure the water was at room temperature and got okay from patients to give them bed baths. The CNO stated we also brought on more staff to help with the patients’ bed baths. The CNO stated we did use the tea maker to heat up water, there were no burns, and she bought thermometers to check the water’s temperature. The CNO stated she was on call all weekend and informed staff she was happy to speak with any patient or family that had issues with the no hot water. During a review of the facility’s policy titled, “Risk Management Plan,” last review date 12/2024, the Risk Management Plan indicated, “Introduction: [Name of Hospital] is committed to continuously analyzing its environment and its care delivery practices to ensure both remain safe and of excellent quality. Continuous analysis occurs, in part, by the hospital’s unusual occurrences reporting, response procedures, and strategies for prevention of such events. Every effort will be made to minimize loss in this hospital. These include but are not limited to: patient injury, loss of belongings, property damage. This hospital is committed to ensuring a culture of safety and service excellence ... Definitions Patient Safety Event: an event, incident, or condition that could have resulted or did result in harm to a patient ... Unusual Occurrence Reporting: An unusual occurrence is defined as an unusual occurrence involving a patient, visitor, or employee, which may transpire in or on the premises of the facility or within the course and scope of the facility’s operations. The occurrence is considered unusual if it was unintended, undesirable and/or unexpected ... RESPONSIBILITY Overall responsibility for the risk management process lies with the Governing Body. The Director of Quality & Risk Management (DQM) manages the daily operation in the hospital, reporting to the Hospital Chief Executive Officer (CEO) ... Unusual Occurrences Process ... Reportable unusual occurrences shall be reported to the local health officer by the DQM, or designee, according to state statues ... Examples of unusual occurrences to be reported include but not limited to those events related to: ... Equipment related events ... Any unusual occurrence ... Confidentiality and External Reporting ... The CEO or designee, after consultation with the Corporate VP of Risk Management and/or Hospital Legal Counsel, may report the sentinel event to the Joint Commission and other applicable regulating bodies within five days of the determination the occurrence is reportable ...”. During a review of a professional reference titled, “Cal. Code Regs. Tit. 22, § 70972 - Adverse Event Reporting Requirements” (no date) State Regulations indicated, “(a) Pursuant to Health and Safety Code sections 1279.1 and 1279.3, adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines: (1) Adverse events that are ongoing urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected ... (3) All other adverse events shall be reported to the Department no later than five (5) calendar days after the adverse event is detected. (b) When reporting adverse events, the hospital shall provide to the Department the following information: (1) Name and address of the hospital. (2) Location and service area where the adverse event occurred. (3) Date and time the adverse event occurred and was detected, if known. (4) Name of each individual affected by the adverse event and any patients, personnel, and visitors involved or a witness to the adverse event, if known. (5) Description of the circumstances surrounding the adverse event, including the nature and extent of injury or harm. (6) If an individual affected by the adverse event is a patient, the date the patient, or the party responsible for the patient, was informed of the adverse event. This date shall not be later than the date the hospital reported the adverse event to the Department. (7) Name, title, area code, and telephone number of a hospital representative for the Department to contact for additional information. (8) Hospital’s immediate corrective or mitigating action in response to the adverse event. (9) Any additional information as it becomes available regarding the adverse event ...” Retrieved from: https://www.law.cornell.edu/regulations/california/22-CCR-70972 During a review of a professional reference titled, “Policy Intent Notice (PIN) 72”, dated 6/15/22, the PIN 72 indicated, “ ... Emergency Work Authorization ... HCAI will consider and may issue an Emergency Authorization to Proceed (EAP) with emergency work prior to plan approval and building permit based on emergency conditions and necessity ... Where an emergency situation arises, the facility shall take the following action: I. Immediate Action ... The facility may take the necessary emergency actions to abate and make safe the emergency condition that poses an imminent danger to life, injury, or property damage. Such emergency actions may proceed prior to contacting HCAI and the HCAI Regional Compliance Officer (RCO) must be contacted immediately thereafter ... Beyond Emergency actions to abate the emergency conditions and make safe the emergency conditions, Emergency repairs, restoration, or replacement of an element of the building, structure, utility system, or equipment shall be authorized by HCAI prior to proceeding with work ...”. During a review of a professional reference titled, California Code of Regulations, Title 22. Social Security Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies Chapter 1. General Acute Care Hospitals ... Records and Reporting ... § 70746. Disruption of Services (a) Each hospital shall develop a written plan to be used when a discontinuance or disruption of services occurs. (b) The administrator shall be responsible for informing the Department, via telephone, immediately upon being notified of the intent of the discontinuance or disruption of services or upon the threat of a walkout of a substantial number of employees, or earthquake, fire, power outage or other calamity that causes damage to the facility or threatens the safety or welfare of patients or clients ...”. Retrieved from: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/AFL-20-08-Attachment-02.pdf”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42321 Based on observation, interview, and record review, the hospital failed to have an effective governing body (GB) that is legally responsible for the conduct of hospital when: 1. Resources and oversight were not provided to ensure the hospital followed Federal, State and Local laws and regulations when: 1) The hospital did not report an adverse event: the death of Patient (Pt) 1 who fell and died on 1/19/25. (Refer to A-0021, finding 1). 2) The hospital did not report an unusual occurrence: the boilers issues that cause the hospital to be without warm and hot water for a period of four days. (Refer to A021, finding 2) 2.The GB did not ensure the facility had an effective quality assurance and performance improvement program (QAPI) that monitored high risk, high volume, problem prone areas when the Kitchen was not being monitored by the infection preventionist and the Director of Nutritional services for infection control issues. (Refer to A747, A772, A283) 3. The hospital did not provide the appropriate resources and oversight to ensure an active infection prevention and control program which adhered to nationally recognized infection prevention and control guidelines for the surveillance, prevention and control of hospital acquired infections (infection one gets while receiving treatment in a health care facility) and other infectious diseases. (Refer to A747 and A750) 4.The hospital failed to have a well-organized and nursing service when: 1) Licensed Nurses (LNs) failed to follow the hospital’s P&P titled, “Skin Integrity and Pressure Injury Prevention” for one of 20 sampled patients, Patient (Pt) 3, when a Wound Nurse made recommendations for Pt 3 to receive pressure reduction surfaces, and positioning interventions while in her wheelchair on 11/27/24 and these interventions were never implemented. On 12/9/24, a pressure injury (PI - localized damage to the skin and/or underlying tissue) was discovered and the pressure injury was not reported to Pt 3’s physician as required by hospital policy. (Refer to A-0398, finding 1); 2) LNs did not follow the hospital’s P&P titled, “Administration of Medications”, “Change in Condition”, and “Pain Assessment and Management” for six of 20 patients (Pt 4, Pt 8, Pt 9, Pt 10, Pt 11, and Pt 15). LNs failed to assess, reassess, or treat reported pain in accordance with hospital P&P. (Refer to A398, Finding 2) 5. Resources and oversight were not provided to ensure the physical environment was maintained in a sanitary and safe environment throughout the hospital when: 1) The floors, walls, ceilings, cabinets, and doors were visibly damaged in the Outpatient Physical Therapy Department, Medical Surgical Unit, and Kitchen. (Refer to A-0701, Finding 1). 2) Preventative maintenance (PMs) was not implemented at the hospital for the kitchen ice machine, boilers, and Heating, Ventilation, and Air Conditioning (HVAC) systems. (Refer to A701, Finding 2) The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality healthcare in a safe and professional manner.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42321 Based on observations, interviews, and record reviews, the hospital failed to identify opportunities for improvement in a high-risk, high-volume, problem-prone area when the kitchen environment was observed to be dirty, grimy and not maintained in accordance with professional standards of practice, Food Code and hospital policies and procedures. The Infection Preventionist was aware of the need to track and monitor the kitchen environment and no rounds were done. The QAPI committee was aware of the need for Infection Control to report to QAPI for all areas of the hospital and no tracking and monitoring reports were submitted for review related to the condition of the kitchen environment. (Refer to A-0283) These failures resulted in avoidable serious infection control concerns in the kitchen environment and did not have the benefit of a QAPI improvement project in order to address the concerns. This placed all patients and visitor of harm related to possible cross-contamination and transmission of infections. The cumulative effect of these systemic problems resulted in the facility’s inability to comply with requirements for Quality Assessment and Performance Improvement and placed all patients at risk of not receiving care in a safe setting.”

“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: 42321 Based on interview and record review, the hospital failed to have an organized nursing service when: 1.Licensed Nurses (LNs) failed to follow the hospital’s P&P titled, “Skin Integrity and Pressure Injury Prevention” for one of 20 sampled patients, Patient (Pt) 3, when physician-ordered Wound Nurse recommended Pt 3 receive pressure reduction surfaces, and positioning interventions while in her wheelchair on 11/27/24 and these interventions were not implemented until after 12/9/24. On 12/9/24, a pressure injury (PI - localized damage to the skin and/or underlying tissue) was discovered and the pressure injury was not reported to Pt 3’s physician as required by hospital policy. (Refer to A-0398, Finding 1) These failures resulted in an avoidable unstageable (the full extent of tissue damage including the depth, is hidden by dead tissue, often yellow, tan, or black/brown.) PI to Pt 3’s coccyx (tailbone) and had the potential to cause Pt 3 unnecessary pain, a worsening in condition, a longer hospital admission, and to place Pt 3 at risk for infection leading to sepsis (a serious blood infection). 2. LNs did not follow the hospital’s P&P titled, “Administration of Medications” dated 12/2022, “Change in Condition”dated 10/2016, and “Pain Assessment and Management” dated 6/2024 for six of 20 patients (Pt 4, Pt 8, Pt 9, Pt 10, Pt 11, and Pt 15). LNs failed to assess, reassess, or treat reported pain in accordance with hospital P&P. (Refer to A-0398, Finding 2) These failures placed patients at risk of receiving inadequate pain management, oversedation (excessive sleepiness) and had the potential for LNs to not recognize changes in condition promptly. The cumulative effects of these systemic problems resulted in the hospital’s inability to provide quality health care in a safe setting.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42321 Based on observations, interviews, and record review, the hospital failed to ensure that the Condition of Participation for Physical Environment were met when they failed to maintain a sanitary and safe environment throughout the hospital as evidenced by: 1. The floors, walls, ceilings, cabinets, and doors were visibly damaged in the Outpatient Physical Therapy Department, Medical Surgical Unit, and Kitchen. (Refer to A-0701, Finding 1) 2. Preventative maintenance (PMs, for performing regular and scheduled upkeep on equipment) were not implemented at the hospital for the kitchen ice machine, boilers, and Heating, Ventilation, and Air Conditioning (HVAC) systems. (Refer to A-0701, Finding 2) The cumulative effect of these systemic failures resulted in the hospital’s inability to provide quality healthcare in a safe and sanitary environment for patients, visitors, and staff.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 42321 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when: 1. In the Outpatient Physical Therapy (PT) Gym, one of two Clean Utility Rooms was visibly dirty, with chipped, and cracked cement flooring. The linoleum flooring throughout the PT Gym was also scratched and gouged, with dirt and grime accumulating along the walls, and not maintained in accordance with hospital policies and procedures (P&P) and professional standards of practice. (Refer to A0750, Finding 1) 2. In the Outpatient PT Department’s Indoor Pool area, the painted metal door frames were bubbling, peeling, and flaking, exposing dusty red material and sharp metal paint edges. The stainless-steel base plate on the men’s bathroom door had reddish streaks and visibly dirty. The water drainage grate surrounding the PT Department’s indoor pool was brown from dirt, debris, and grime. The two patient showers were dirty with cracked grout (a filler between tiles), and one had two shower chairs stained gray, and not maintained in accordance with hospital P&P and professional standards of practice. (Refer to A0750, Finding 2) 3. a. Hospital staff purposely placed and stored food storage containers on the floor in the café storage room. Hospital staff stored food for the café alongside staff uniforms and placed food on the floor of the dry pantry. These practices are not in accordance with hospital policy and procedure (P&P), and professional standards of practice. (Refer to A0750, Finding 3a) 3. b. The walk-in refrigerator had chipped paint floors and the walk-in freezer had chipped and cracked concrete floors, and in the kitchen a large, uneven L-shaped crack under a handwashing sink was covered by a rubber mat, and items were not maintained in accordance with hospital P&P and professional standards of practice. (Refer to A0750, Finding 3b) 3. c. Kitchen staff did not clean grease and grime buildup on the walls, leading to peeling paint in some areas of the food preparation area. A hanging fan with greasy and dusty blades directed air towards the food preparation area. Staff did not clean several ceiling tiles, causing them to become discolored due to grease accumulation, and three out of five exhaust fan vents, and surrounding tiles were coated in brown dust. The hospital left the floors in the food preparation areas dirty and in poor condition, with an accumulation of trash, food residues, grease, and black grime, and not in accordance with hospital P&P or professional standards of practice. (Refer to A0750, Finding 3c) 3. d. The ice machine was visibly dirty with brown debris inside the ice bin along the white covering. White flakes had accumulated on the ice deflector (a component that directs ice flow to prevent spillage and improve efficiency) and was not maintained in accordance with manufacturer recommendations, hospital P&P, and professional standards of practice. (Refer to A0750, Finding 3d) 3. e. Hospital Staff stored open bags of frozen café food with loose French fries at the bottom of a chest freezer, which measured approximately 33.5 inches in size. A 1-inch layer of frost covered the top, sides, bottom, and back of the freezer, and was not maintained in accordance with manufacturer recommendations and professional standards of practice. (Refer to A0750, Finding 3e) 3. f. Hospital kitchen staff used cutting boards that were worn, had deep scratches, and stains, making it difficult to clean and sanitize properly. Dark stains were visible inside many of the cuts and gouges on the white cutting boards, and were not maintained in accordance with professional standards of practice. (Refer to A0750, Finding 3f) 4. Hospital staff failed to maintain two of two ice and water dispensers on the Medical Surgical (MS) Unit, which were visibly soiled with white flaky buildup in the dispensing chutes, and not in accordance with manufacture recommendations, hospital P&P, or professional standards of practice. (Refer to A0750, Finding 4) 5. In the multipurpose room, ceiling tiles had brown circular staining, the linoleum flooring had deep scratches and gouges, paint was peeling, and a brown bumpy dirt substance around the bottom of the windowsills had pushed out the caulking by approximately 2 inches in several areas around the room, and the area was not maintained in accordance with hospital policy, and professional standards of practice. (Refer to A0750, Finding 5) 6. Staff stored two pressure reduction mattress foam rolls and one respiratory therapy supplies on the floor in three of six clean storage rooms in the Medical Surgical Department, which was not in accordance with hospital P&P and professional standards of practice. (Refer to A0750, Finding 6) 7. Staff stored clean patient pillows (D1) and boxes of electrocardiogram (ECG- disposable, adhesive medical devices used to monitor the heart’s electrical activity) electrodes (D2) in the cabinets of two dirty utility rooms on the MS Unit, which was not in accordance with professional standards of practice. (Refer to A0750, Finding 7) 8. The Infection Preventionist was not aware of the hospital-wide infection problems, did not have a systemic approach to track and monitor infection control practices and did not make rounds in all areas of the hospital, including the kitchen. (Refer to A0772) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality care in a safe and sanitary environment and placed patients and staff at risk of cross contamination.”

“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: 42321 Based on interview and record review, the hospital failed to ensure 11 of 20 sampled patients (Pt) (Pt 2, Pt 6, Pt 7, Pt 8, Pt 9, Pt 10, Pt 11, Pt 12, Pt 13, Pt 15, and Pt 16), advanced directives (AD-Legal document that states a person’s wishes for medical care if they are unable to communicate their preferences) were known and documented during the admission process. This failure resulted in Pt 2, Pt 6, Pt 7, Pt 8, Pt 9, Pt 10, Pt 11, Pt 12, Pt 13, Pt 15, and Pt 16’s rights and wishes to go unidentified in the event of an emergency. Findings: During a concurrent interview and record review on 11/6/25 at 2:51 p.m. with the Chief Nursing Officer (CNO), the CNO opened Pt 2’s “Electronic Medical Record (EMR).” The document titled, “H&P,” dated 3/6/25 was reviewed, the H&P indicated Pt 2 was a 69-year-old with the chief complaint of gait impairment (abnormalities in how a person walks) and decline in transfers and self-care, after back surgery. The CNO stated Pt 2 was admitted to the hospital on 3/6/25 at 8:05 p.m. with a treatment plan consisting of at least 3 hours of combined physical therapy (PT- a healthcare profession focused on restoring, maintaining, and improving movement, function, and overall quality of life for individuals with injuries, illnesses, or other conditions)/occupational therapy (OT- teaching new techniques, recommending adaptive equipment, or modifying their environment to increase independence and improve quality of life) and 24-hour skilled rehabilitation nursing (round the clock care by trained medical professionals to help patients recover from illness, injury, or surgery). The document titled, “ADVANCED DIRECTIVE (AD) AND PATIENT SELF-DETERMINATION,” dated 3/7/25, the “AD” indicated it was blank and only had Pt 2’s initials. The CNO stated the “AD” form should be filled in for each patient but at this time she was unsure why it was blank with Pt 2’s initials and not Pt 2’s signature. The CNO stated it was important to know what the patient’s wishes were while they were hospitalized to ensure their wishes were followed in the event the patient was unable to verbalize their wishes. During a concurrent interview and record review on 11/7/25 at 12:12 p.m. with Nurse Supervisor (NS) 2, NS 2 opened Pt 6’s “EMR,” for review. The document titled, “H&P,” dated 11/3/25, indicted Pt 6 was an 89-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to failure to thrive (syndrome characterized by an overall decline in physical and functional ability) and heart failure. NS 2 stated Pt 6 was admitted to the hospital on 11/3/25 at 6:40 p.m. with a treatment plan of least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 11/4/25, the “AD” indicated it was blank and only had Pt 6’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 6’s form was left blank. NS 2 stated it was important to know what the patient’s wishes were. During a concurrent interview and record review on 11/7/25 at 1:50 p.m. with NS 2, NS 2 opened Pt 7’s “EMR,” for review. The document titled, “H&P,” dated 10/31/25, indicted Pt 7 was an 86-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to Medical debility (a state of general weakness and frailty, characterized by a loss of physical and/or cognitive abilities) secondary to complicated urinary tract infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract and multiply). NS 2 stated Pt 7 was admitted to the hospital on 10/31/25 at 7:50 p.m. with a treatment plan of least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/31/25, indicated, Pt 7’s “AD” was blank and only had Pt 7’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 7’s form was left blank. During a concurrent interview and record review on 11/7/25 at 2:11 p.m. with NS 2, NS 2 opened Pt 8’s “EMR,” for review. The document titled “H&P,” dated 11/1/25, indicated Pt 8 was a 90-year-old with the chief complaint of weakness and self-care deficits due to a left total hip replacement. This was followed by complications of gastrointestinal bleed (GI- bleeding anywhere in stomach, intestines, swallowing tube, rectum or anus) and pulmonary embolism (blockage in a lung artery [blood tubes with oxygenated blood]). NS 2 stated Pt 8 was admitted to the hospital on 10/31/25 at 8:30 a.m. with a treatment plan to engage in 3 hours daily therapy spread out as tolerated with physical therapy for restoration of strength and mobility and OT for restoring activities of daily living and self-care helping to contribute to appetite and return to normal self-independence. The document titled, “AD,” dated 11/4/25, indicated, Pt 8’s “AD” was blank and only had Pt 8’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 8’s form was left blank, but the form should have been completed. During a concurrent interview and record review on 11/7/25 at 2:51 p.m. with the CNO, the CNO opened Pt 13’s “EMR”. The document titled, “H&P,” dated 10/24/25, indicated Pt 13 was a 76-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a nontraumatic spinal cord injury secondary to back surgery. The CNO stated Pt 13 was admitted to the hospital on 10/24/25 at 3:05 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/27/25, the “AD” indicated it was blank and only had Pt 13’s initials. The CNO stated the AD form should be filled in for each patient but at this time she was unsure why it was blank with only Pt 13’s initials and not Pt 13’s signature. The CNO stated it was important to know what the patient’s wishes were. During a concurrent interview and record review on 11/12/25 at 10:49 a.m. with the CNO, the CNO opened Pt 15’s “EMR.” The document titled, “H&P,” dated 10/15/25, indicated Pt 15 was a 74-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a right femur fracture (break in the upper leg bone) status post right hip surgery. The CNO stated Pt 15 was admitted to the hospital on 10/15/25 at 7 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/16/25, the “AD” indicated it was blank and only had Pt 15’s initials. The CNO stated the “AD” form should be filled in for each patient but at this time she was unsure why it was blank with Pt 15’s initials and not Pt 15’s signature. The CNO stated it was important to know what the patient’s wishes are. During a concurrent interview and record review on 11/12/25 at 12:12 p.m. with the CNO, the CNO opened Pt 16’s “EMR.” The document titled, “H&P,” dated 10/17/25, indicated Pt 16 was a 65-year-old with chief complaint of gait impairment and decline in transfers and self-care, due to myopathy (a disease of the muscles, causing symptoms like weakness, stiffness, and cramps) secondary to a heart attack status post cardiac cath with percutaneous intervention (a minimally invasive medical procedure that uses a catheter to access and treat a blood vessel from the inside, without open surgery). The CNO stated Pt 16 was admitted to the hospital on 10/17/25 at 7:50 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/24/25, the AD indicated it was blank and only had Pt 16’s initials. The CNO stated the “AD” form should be filled in for each patient but at this time she was unsure why it was blank with Pt 16’s initials and not Pt 16’s signature. The CNO stated it was important to know what the patient’s wishes were. During a concurrent interview and record review on 11/12/25 at 2:30 p.m. with NS 2, NS 2 opened Pt 10’s “EMR,” for review. The document titled, “H&P,” dated 6/23/25, the H&P indicated Pt 10 was a 69-year-old with a chief complaint of gait impairment and decline in transfers and self-care, due to right sided below-knee amputation (surgical removal of body part) on 6/18/2025. NS 2 stated Pt 10 was admitted to the hospital on 6/23/25 at 6:47 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated, 6/28/25, indicated, Pt 10’s “AD” was blank and only had Pt 10’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 10’s form was left blank, but it should have been completed completely. During a concurrent interview and record review on 11/12/25 at 2:52 p.m. with NS 2, NS 2 opened Pt 9’s “EMR,” for review. The document titled, “H&P,” dated 10/22/25, indicated Pt 9 was a 75-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a spinal cord injury secondary to lumbar stenosis (narrowing of the spinal canal in the lower back), and a spinal fusion (permanently joins two or more vertebrae in the spine to eliminate movement) back surgery. NS 2 stated Pt 9 was admitted to the hospital on 10/22/25 at 2:40 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/4/25, indicated, Pt 9’s “AD” was blank and only had Pt 9’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 9’s form was left blank, but it should have been completed completely. During a concurrent interview and record review on 11/12/25 at 3:12 p.m. with NS 2, NS 2 opened Pt 11’s “EMR”. The document titled, “H&P,” dated 9/16/25, indicated Pt 11 was a 77-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a left total knee replacement (a surgical procedure to replace the damaged surfaces of the left knee joint with an artificial joint made of metal and plastic). NS 2 stated Pt 11 was admitted to the hospital on 9/16/25 at 7:15 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 9/21/25, indicated Pt 11’s “AD” was blank and only had Pt 11’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 11’s form was left blank, when it should have been completely filled out. During a concurrent interview and record review on 11/12/25 at 3:30 p.m. with NS 2, NS 2 opened Pt 12’s “EMR.” The document titled, “H&P,” dated 10/26/25, indicated Pt 12 was a 63-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to Myasthenia gravis crisis (a chronic autoimmune neuromuscular disease, characterized by severe muscle weakness, particularly in the muscles that control breathing) secondary to septic shock (blood infection that caused organ damage) due to acute pyelonephritis (kidney infection). NS 2 stated Pt 12 was admitted to the hospital on 10/25/25 at 8:50 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “AD,” dated 10/27/25, indicated Pt 12’s “AD” was blank and only had Pt 12’s initials. NS 2 stated the “AD” form should be completed, and all boxes filled in for each patient, but she did not know why Pt 12’s form was left blank. During an interview on 11/7/25 at 12:24 p.m. with the Admissions Manager (AM), the AM stated her department staff were responsible for helping patients’ complete admission paperwork, including the advance directive and patient self-determination form. The AM stated staff were supposed to talk to the patient and their family to find out if an advance directive was already in place or if the patient wanted information about it. The AM stated based on this discussion, staff could provide information about advanced directives if requested and additionally, staff were expected to ask the patient who should make medical decisions if they are unable to do so and document the answer on the form. The AM stated her expectations was for the form to be fully completed. The AM stated the importance of the form because if patients were signing the AD form without proper information, they might not understand what they were agreeing to. During a review of the hospital’s document titled, “ADVANCED DIRECTIVE (AD) AND PATIENT SELF-DETERMINATION,” undated, the “AD” indicated, “All patients have the right to participate in their own health care decisions, make Advance Directives or to execute powers of attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes in the event the patient is unable to make decisions, or is unable to communicate decisions. These wishes must be put into writing and must be discussed with your medical doctor. The Patient Self-Determination Act (Omnibus Budget Reconciliation Act of 1990) directs that every patient be informed of their right to make known to the hospital, staff and physicians the type(s) of treatment desired in the event that they are later unable, due to medical condition, to make these wishes known. 1. Have you signed any of the following concerning your medical treatment: ? Living Will (Not legally recognized Advance Directive in the State of Massachusetts.) ? Durable Power of Attorney for Healthcare ? Advance Healthcare Directive ? Physician Directive / Statement of Self-Determination ? Declaration Under the California Natural Death Act 2. Where is the original document located? 3. Have you been legally divorced or separated since instituting a proxy in which you named your spouse as an agent? ? Yes ? No 4. Copy of original document provided for the medical record? ? Yes ? No 5. Copy of the original document will be provided by: Name: Telephone Number: 6. Name, telephone number, and relationship of person authorized to make healthcare decisions on my behalf if I am unable to do so: Name: Telephone Number: Relationship: 7. Case Manager / Patient Care Coordinator notified of advance Directive Status: Name: Date: 8. If I request, I will receive information on the development of an Advance Directive. ? Yes, I would like information. ? No, I would not like information. Facility Staff Person to Provide Information: 9. I have executed a Do Not Resuscitate order: ? Yes ? No Patient has been advised to discuss their treatment desires in relation to DNR with their physician: ? Yes ? No If yes, Admission Staff to forward information to Nursing Staff and my physician. 10.I have executed authorization for Organ Donation: ? Yes ? No I have been given written materials and verbal explanations about my right to accept or refuse medical treatment (Colorado: “Your Right to Make Health Care Decisions”, California: brochure prepared by the California Consortium on Patient Self-Determination). I understand that the terms of any Advance Direction that I have executed will be followed by the health care facility and my caregivers to the extent permitted by law. I understand that I am not required to have an Advance Directive in order to receive medical treatment at this health care facility. Signature of Patient or Patient Representative Printed Name of Patient or Patient Representative Signature of Witness Printed Name of Witness ...”. During a review of the hospital’s policy titled, “Admission Process,” dated 10/6/25, the policy indicated, “POLICY: It is the policy of [name of hospital’s corporate organization] to ensure patient admissions are based upon documented consent, clinical appropriateness, accurate billing and payment information and timely completion. [name of hospital’s corporate organization] admission procedures are designed to collect admission and registration data for all patients treated by the hospital to help ensure that: 1. The appropriate legal representative is identified 2. Consent for admissions is obtained ... The essential elements in the admissions process include: ... 7. Providing a complete admissions documentation package to the patient and/or legal representative and obtain the necessary signatures ... IV. Patient Admissions ... C. Completing Admission Forms: ... 4. Ensure Advance Directive information follow-up items are noted and tracked for completion by the Case Management Department ... V. Admission Documents ... C. Admissions or designee is required to present the following forms to the patient/legal representative. The required Inpatient Admissions Forms are: ... 3. Advance Directive and Patient Self-Determination- Forms a. These forms are utilized to ensure the patient has necessary information and assistance to execute an advanced directive if desired. b. Follow-up action is required to obtain copies of any advance directives identified ...”.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 42321 Based on observations, interviews, and record reviews, the hospital failed to identify opportunities for improvement in a high-risk, high-volume, problem-prone area when the kitchen environment was observed to be dirty, grimy and not maintained in accordance with professional standards of practice, Food Code and hospital policies and procedures. The Infection Preventionist was aware of the need to track and monitor the kitchen environment and no rounds were done. The QAPI committee was aware of the need for Infection Control to report to QAPI for all areas of the hospital and no tracking and monitoring reports were submitted for review related to the condition of the kitchen environment. These failures resulted in avoidable serious infection control concerns in the kitchen environment and did not have the benefit of a QAPI improvement project in order to address the concerns. This placed all patients and visitor of harm related to possible cross-contamination and transmission of infections. Findings: During a concurrent observations and interviews on 11/5/25, at 2:20 p.m. with the Manager of Nutrition Services (MNS), Nursing Supervisor (NS 1), and the Director of Nutrition Services (DNS), while in the kitchen a food storage room was seen to have staff uniforms, food and food packaged items, along with boxes on the floor. The MNS stated products used for food should not be on the floor, and clothing should not be stored with patient food. The hospital’s kitchen had the following issues seen: walk-in refrigerator floor had chipped paint, walk-in freezer floor cracked and chipped cement; near the dishwashing section large uneven L-shaped crack on the floor with two rubber mats holding it together; hand washing station sink had paint and chipped stucco behind the damaged sink; the walls, ceiling exhaust vent were covered in dust and grime, and the floors had trash, food remnants, and grease; the hanging fan in the food prep area was dirty and blowing air over cooking areas. The DNS admitted that there was no deep cleaning schedule for the ceilings and that cleaning would require shutting down the kitchen. The walls behind stored pans had grease and dust, peeling paint was observed, and floor drains contained trash and food bits. The ice machine had brown debris along the inside white plastic casing in the bin. A small chest freezer had an open bag of chicken patties sitting at the top and fries spilled on the bottom. The freezer had approximately one inch of frost on the sides of the freezer walls and approximately ½ inches of frost on the lid. The freezer did not have a thermometer or a temperature log. Eight cutting boards were scratched, scored, and stained black, indicating inability to clean and sanitize them thoroughly. During an interview on 11/13/25 at 9:13 a.m. with the Infection Preventionist (ICPC), the ICPC stated she held multiple roles besides Infection control including Nurse Educator. The ICPC stated she had worked at the hospital for 1.5 years, and this hospital was her first infection control role. The ICPC stated she had a two-week orientation, and a one-day orientation with a corporate lead. The ICPC stated she does participate in the Environment of Care (EOC) rounds but had not done any rounds in the kitchen. ICPC stated she did not take any infection control classes about food safety but understood the importance due to the risks of food borne illnesses. The ICPC stated no one educated her about the kitchen and where to start. The ICPC stated her focus for infection prevention had been hospital acquired infections (HAI)’s, hand hygiene, and ensuring high touch areas were cleaned correctly. When asked if she noticed a need for other projects she stated, “I honestly don’t know”. During an interview on 11/14/25, at 10:45 a.m., with the Chief Nursing Officer (CNO), the CNO stated that the hospital should have no infection control issues, that the facility is inspected and cleaned daily. The CNO stated the hospital had contracted with an outside company [name provided] for the maintenance and quality metrics of the kitchen and about two years ago this contract was cancelled, and we brought the care of the kitchen in house. The CNO stated the facility hired the Director of Nutrition Services (DNS) to replace the outside company. The CNO stated she expected the DNS and her manager to round in the kitchen and make sure things are in “top-notch condition”. During an interview on 11/17/25 at 11 a.m. with the Regional Quality Director, the RQD stated she was responsible for the Quality Assurance and Performance Improvement (QAPI) Program at this hospital and prior to being the RQD she was the Infection Preventionist (IP) for the hospital. The RDQ stated the current IP took over the role of IP about 1.5 years ago. The RQD stated, “The Kitchen is a fall out. I had planned to take the IP through the kitchen but every time we got to that part something came up, and we never made it”. During a review of the hospital’s document titled, “[name of hospital] 2025 PERFORMANCE IMPROVEMENT PLAN (PIP)”, dated 2025, the PIP indicated, “SCOPE OF CARE ... [name of hospital] provides the highest quality comprehensive acute rehabilitation services to inpatients regardless of sex, race, color, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, educational background, economic status, or the source of payment for care. These services are provided in a caring and supportive environment in a cost-effective manner. The primary services are Acute Rehabilitation Services ... Specializes in treating patients with medical rehabilitation needs along with often complex medical conditions requiring a longer length of stay, usually about 20-30 days, than is typically provided by traditional acute care hospitals. Provides acute inpatient services that support the patient moving from one level of care to another according to his/her needs. Provides services 24 hours a day, 365 days per year for inpatients, and Monday through Friday hours available for Outpatient Services ... The hospital staff leadership is committed to providing an environment which encourages performance assessment and improvement of patient care and services, as well as governance, managerial, clinical and support functions ... The systems and processes for improvement are prioritized by the hospital’s leadership so that appropriate planning takes place and resources are allocated. OBJECTIVES ... To ensure that one level of the highest quality of patient care is maintained and delivered in a safe, effective and cost-responsible manner. To provide collaboration and communication throughout the hospital. To sustain an integrated and coordinated data measurement system. To promote the use of benchmarks and reference databases for comparison. To demonstrate improvement both systematically and collaboratively in processes which have been established as priorities. To identify continuing education needs for both the medical and hospital staff. To fulfill regulatory requirements in order to achieve and maintain licensure requirements by the State of California, accreditation by the Joint Commission and CARF, and fulfill requirements of the Medicare Conditions of Participation. To provide an annual assessment of the Performance Improvement Program’s effectiveness. AUTHORITY AND ACCOUNTABILITY The Governing Board has the ultimate authority and responsibility for performance improvement. The Governing Board delegates to the hospital leadership the authority to: Establish a hospital-wide Patient Safety and Quality Assessment and Performance Improvement (QAPI) Committee to oversee the program. Assess and prioritize the performance improvement activities. Require mechanisms for, and reports of, the monitoring and evaluation of patient care services. Provide resources and support systems for performance improvement functions related to services and safety. Assure that one level of care is provided for all patients ... QAPI’s responsibilities include but are not limited to: Establishing a planned and systematic approach to performance improvement. Identifying and monitoring the hospital-wide performance measures. Promoting a hospital culture that values commitment to continuous improvement in safety, quality care and services to patients, families, visitors, community, medical and hospital staffs. Implementing operational activities that are consistent with the Strategic Plan and the Mission, Vision and Values of the hospital and [name of corporation over hospital]. Providing education on performance improvement approaches. Prioritizing performance improvement projects. Reviewing and approving performance improvement team projects. Monitoring the progress of quality control activities and of designated project teams. Evaluating the effectiveness of action taken to improve a process. Managing the flow of information to ensure follow up. Reporting performance improvement activities to the Governing Board ... Planning will provide for collaboration across disciplines and departments to identify and prioritize important opportunities for improvement. These identified areas will reflect high risk, high volume, the possible impact to the organization & patients, and any problem prone issues ... Each department manager/director is responsible for identifying quality indicators, collecting and analyzing data, developing and implementing changes to improve services ... Dietary (Monthly): Tray line accuracy. Tray line items within acceptable range during cooking and mid-tray line ... Infection Prevention (Monthly): Staff hand hygiene compliance. Staff PPE compliance. Healthcare acquired infection rate ... PRIORITIZATION: The QAPI committee will utilize the following criteria for prioritizing performance improvement initiatives: Patient Safety and impact on patient care. Infection Prevention. Patient Satisfaction ... High cost, high volume, high risk, problem prone processes ... The program may be modified or amended at any time to maintain compliance with regulatory standards and regulations and to improve the effectiveness of the delivery of care, treatment and services.””

“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: 42321 Based on interview and record review, the hospital failed to ensure Licensed Nurses (LNs) adhered to the hospital’s policies and procedures (P&P)for seven of 20 patients (Pt 3, Pt 4, Pt 8, Pt 9, Pt 10, Pt 11, and Pt 15) when: 1.LNs failed to follow the hospital’s P&P titled, “Skin Integrity and Pressure Injury Prevention” for one of 20 sampled patients, Patient (Pt) 3, when a physician-ordered Wound Nurse consult recommended Pt 3 receive pressure reduction surfaces, and positioning interventions while in her wheelchair on 11/27/24 and the interventions were not implemented until after 12/9/24. On 12/9/24, a pressure injury (PI - localized damage to the skin and/or underlying tissue) was identified and the pressure injury was not reported to Pt 3’s physician as required by hospital policy. These failures resulted in an avoidable unstageable (the full extent of tissue damage including the depth, is hidden by dead tissue, often yellow, tan, or black/brown.) PI to Pt 3’s coccyx (tailbone) and had the potential to cause Pt 3 unnecessary pain, a worsening in condition, a longer hospital admission, and to place Pt 3 at risk for infection leading to sepsis (a serious blood infection). 2. LNs did not follow the hospital’s P&P titled, “Administration of Medications”, “Change in Condition”, and “Pain Assessment and Management” for six of 20 patients (Pt 4, Pt 8, Pt 9, Pt 10, Pt 11, and Pt 15). LNs failed to assess, reassess, or treat reported pain in accordance with hospital P&P. These failures placed patients at risk of receiving inadequate pain management, oversedation (excessive sleepiness) and had the potential for LNs to not recognize changes in condition promptly. Findings: 1. During a concurrent interview and record review on 11/6/25 at 3:28 p.m. with Nursing Supervisor (NS)1 and the Regional Director of Quality (RDQ), NS 1 opened Pt 3’s “electronic medical record (EMR),” for review. The document titled, “History and Physical (H&P- an assessment from physician including medical history and exam),” dated 11/22/24, indicated, Pt 3 was admitted into the rehabilitation hospital for “Gait (walking) impairment and decline in transfers (bed to chair or walking) and self-care”, after a surgical procedure on her spinal cord and nerves in the neck on 11/16/24. NS 1 stated Pt 3 had a past medical history of stroke (blood flow to the brain is interrupted) with left side weakness, a recent kidney transplant and systemic lupus erythematosus (a chronic autoimmune disease where the immune system attacks the body’s healthy cells and tissues causing inflammation and damage). The H&P indicated Pt 3 had quadriparesis (muscle weakness in all four limbs). During a concurrent interview and record review on 11/7/25 at 11:45 a.m. with Nursing Supervisor (NS) 2 and the RDQ, NS 2 opened Pt 3’s “electronic medical record (EMR),” “undated” for review. The documents titled, “Nursing Assessment Skin (NAS),” and “Braden Scale (a tool used to identify the risk of a pressure injury for a patient, scored from 6 to 23, with a low score indicating a higher risk),” dated 11/22/24 were reviewed. The “NAS” indicated Pt 3 had no PI upon admission to the hospital, and a “Braden Score” of 16 (mild pressure injury risk). NS 2 stated Pt 3’s physician entered a routine (regular) order for a wound care consultation on 11/23/24, due to a Braden score of 16, and the risk of PI due to a surgical incision of the neck. The document titled “Wound Care Note (WCN)”, dated 11/27/24, indicated a treatment plan to inspect skin every shift, if in bed, position should be changed every two hours, if in chair change position every hour. Pillows or wedges should be used to keep knees or ankles from touching each other, Float (raise) heels while in bed. NS 2 stated nursing staff did not document any turning or repositioning until 12/9/24 at 12:35 p.m. The document titled, “NAS” dated 11/29/24, indicated redness to the right buttock. During a concurrent interview and record review on 11/7/25 at 11:50 a.m. with Nursing Supervisor (NS) 2 and the Regional Director of Quality (RDQ), NS 2 opened Pt 3’s “electronic medical record (EMR),” for review. The “Physician Order (PO),” for Egg Crate (a foam pad with a textured surface similar to an egg carton, dated 11/29/24 at 7 p.m. was reviewed. NS2 stated the egg crate was a pressure reduction mattress, for the bed. The document titled, “Registered Nurse (RN) Shift Wound Assessment,” dated 12/9/24, indicated, “open wound noted to coccyx, pictures taken and wound care consult done for further assessment... Not Present on Admission.” The “WCN,” dated 12/9/24, indicated a full-thickness pressure injury of the coccyx, unable to stage due to adherent white slough (creamy-white dead tissue that accumulates in a wound), scant serous (clear, watery) drainage, no odor. Wound edge unable to visualize due to slough. NS 2 stated Pt 3’s “EMR” did not indicate nursing staff contacted the physician to report Pt 3’s PI, and they should have. The RDQ stated, after a root cause analysis (RCA- a process to investigate an adverse event or near-miss to understand what happened, why it happened, and how to prevent it from happening again) was performed and the RCA investigation determined Pt 3’s wound formed because Pt 3 preferred to be in her wheelchair during the day and there were no pressure reduction surfaces in her chair, leading to prolonged pressure to her tailbone. During a concurrent interview and record review on 11/12/25 at 10:35 a.m. with RN 2, Pt 3’s “EMR”, was reviewed. RN 2 reviewed his documentation from the night of 12/8/24 and the morning of 12/9/24, confirming he was Pt 3’s primary nurse when the PI was discovered. RN 2 identified the PI on Pt 3’s coccyx during a skin assessment, informed his supervisor, requested a Wound Nurse consultation, and reported it to the next shift. RN 2 cleaned and dressed (bandaged) the wound, educated Pt 3 about the PI, but could not find his documentation regarding physician notification, which he should have recorded. RN 2 stated he must have forgotten to document reporting to the physician. During a review of Pt 3’s document titled, “Case Manager Note”, dated 12/10/24, the note indicated, “Cm [Case Manager] was informed pt has Stage... Decubitus [which are sores that develop from pressure on the skin] & needs home health. Referral sent to [name of Home Health agency] by fax.” During a review of Pt 3’s document titled, “Notes”, dated 12/11/24, notes indicated, “Nursing reviewed discharge paperwork and discharge medications with [name of Pt 3] ... home with family ... Skin checked with [Wound RN]. Dressing changed and no bleeding and no s/s of infection. Time of discharge 1200 ...”. After review there was no other description of Pt 3’s wound provided on discharge. During an interview on 11/14/25 with the Chief Nursing Officer (CNO), the CNO stated, patients should have an egg crate for the bed and the chair for pressure reduction. The CNO stated the physician should be notified when a patient had a pressure injury, to receive orders for treatment. During a review of the hospital’s P&P titled, “Skin Integrity and Pressure Injury Prevention,” dated 10/25, the P&P indicated, “ ... Response to presence of new or worsened Pressure Injury ... The nurse will notify the [medical doctor] and obtain a physician order or initiate a protocol for treatment. Care plan interventions will be individualized based on the level of risk determined by the total Braden and sub-scale scores as well as additional risk factors ...Care Plan Based on Pressure Injury Assessment /Braden Scale ...Mobility, Activity or sensory perception ...Pressure Relief ... Turn/reposition schedule ...Pressure redistribution device -bed/chair ...Braden Scale 1. Uses 6 (six) subscales to measure patients risk of developing pressure injuries. a) Sensory Perception - ability to respond meaningfully to pressure related discomfort b) Moisture - degree to which skin is exposed to moisture. c) Activity (i.e., ability to ambulate) - Degree of physical activity d) Mobility (i.e., ability to turn in bed) - ability to change and control body position e) Nutrition - Usual food intake pattern f) Friction and shear - friction occurs when the patient’s skin moves against a support surface, whereas shear occurs when skin and adjacent bony surface slide across one another. 2. Numerical values must be selected for each sub-scale based upon the patient’s condition. These numerical values are then totaled to determine the patients Braden Score a) Total scores range from 6-23. b) A score of 18 or less indicates at-risk status. c) Lower Braden scores indicate higher levels of risk for pressure ulcer development. d) Evidenced based clinical guidance (WOCN 2015) recommends utilization of Mobility (2-1) and Moisture (2-1) subscales to further identify persons at risk of pressure injury ...”. During a review of the professional reference titled, “Preventing pressure injuries in individuals with impaired mobility: Best practices and future directions,” dated 8/7/25, indicated, “ ... Pressure injuries, also known as decubitus ulcers or bedsores, are a major source of preventable morbidity (illness) among individuals with impaired mobility, particularly those recovering from spinal cord injury, stroke, or traumatic brain injury. These wounds not only prolong hospital stays and increase healthcare costs but also significantly impair rehabilitation outcomes and quality of life. ...Pressure injuries remain a significant yet preventable complication among patients with limited mobility. As the healthcare system continues to shift toward value-based, patient centered care, pressure injury prevention must be reframed as an interdisciplinary priority involving nursing, physicians, nutritionists, wound care teams, and caregivers. Evidence based interventions such as regular repositioning, pressure-relieving devices, nutritional optimization, and skin care protocols are critical, but their success hinges on consistent implementation, individualized risk assessment, and proactive care transitions ...”. 2. During a concurrent interview and record review on 11/6/25 at 11:55 a.m. with NS 1, NS 1 opened Pt 4’s “EMR”, for review. The document titled “H&P”, dated 12/31/24, indicated, Pt 4’s chief complaint was gait impairment and decline of transfers and self-care. The “H&P” indicated Pt 4 was an 82-year-old patient with an admitting diagnosis of critical illness myopathy (a condition of generalized muscle weakness) due to gallstones (hardened deposits built up in the pear-shaped organ under the liver that concentrates bile to help digestion) with cholecystoduodenal fistula (abnormal connection between gallbladder and first part of the small intestine). Pt 4 underwent gallbladder removal surgery with lower stomach removal and a surgical procedure to reconnect the digestive tract after the stomach was removed on 12/18/24. NS 1 stated Pt 4 was admitted to the hospital on 12/30/24 at 8 p.m. with a treatment plan of at least 3 hours of combined Physical Therapy (PT-physical interventions to promote health and restore function) and Occupational Therapy (OT-helping people perform daily activities, known as “occupations,” which can include self-care, work, and leisure) and 24-hour skilled rehabilitation nursing. During a concurrent interview and record review on 11/6/25 at 12:10 p.m., with NS 1, NS 1 opened Pt 4’s “EMR”, for review. The document titled “Nursing Admission Assessment (NAA)”, dated 12/30/24 indicated Pt 4’s reported pain goal was 3 out of 10. NS 1 stated her expectation was for nursing staff to treat Pt 4’s reported pain and reassess pain after treatment to meet the pain goal. The document titled “Medication Administration Record (MAR)”, dated, 12/31/24 at 3:57 p.m. indicated Pt 4 had a pain score of nine (severe) out of 10 (worst) and nursing staff administered a 5 milligram (mg - a unit of measurement) oxycodone (a strong pain medication) tablet. NS 1 stated nursing staff reassessed Pt 4 at 4:50 p.m. and Pt 4’s pain was six (moderate). NS 1 stated nursing staff did not document in the “EMR” the physician was contacted to report the ineffectiveness of the pain medication, and they should have. NS 1 stated the next “MAR” entry was on 12/31/24 at 9:09 p.m., with a pain level of 9 out of 10. NS 1 stated nursing staff should have contacted the physician to report the pain medication was not effective for Pt 4, and to request an alternative. During a review of the Pt 4’s document titled, “Physician Medication Order (PMO)”, dated 12/30/24, the “PMO” indicated, “ ... oxycodone HCL [hydrochloride-a salt form]5 mg, give 5 mg (1 tablet(s)) by mouth Every Four Hours PRN [as needed] PAIN 1-10 Indication [reason]: PAIN 1-10 ...” During a concurrent interview and record review on 11/7/25 at 2:11 p.m. with NS 2, NS 2 opened Pt 8’s “EMR”, for review. The document titled “H&P,” dated 11/1/25, indicated Pt 8 was a 90-year-old with the chief complaint of weakness and self-care deficits due to a left total hip replacement. This was followed by complications of gastrointestinal bleed (GI- bleeding anywhere in stomach, intestines, swallowing tube, rectum or anus) and pulmonary embolism (blockage in a lung artery [blood tubes with oxygenated blood]). NS 2 stated Pt 8 was admitted to the hospital on 10/31/25 at 8:30 a.m. with a treatment plan to engage in 3 hours daily therapy spread out as tolerated with physical therapy for restoration of strength and mobility. OT for restoring activities of daily living and self-care helping to contribute to appetite and return to normal self-independence. During a concurrent interview and record review on 11/7/25 at 2:20 p.m. with NS 2, NS 2 opened Pt 8’s “EMR”, for review. The document titled, “NAA”, dated 10/31/25, indicated Pt 8 reported a pain goal of zero out of 10, and had no pain at admission. The document titled, “Vital Signs”, dated 11/1/25 to 11/7/25 indicated, on 11/2/25 a pain score of 8 (severe) out of 10. NS 2 stated no medications were administered to Pt 8. NS 2 stated the pain score was entered by a Physical Therapist (PT). During a review of the document titled, “MAR”, dated 11/6/25 at 8:49 a.m., the “MAR” indicated Pt 8 was administered 650 mg acetaminophen (a mild pain medication) by mouth for a pain score of one. NS 2 stated nurses reassessed Pt 8’s pain at 9:49 a.m. as zero. An entry on the “VS” document from 11/6/25 at 1:01 p.m. indicated a pain score of 5 (moderate). NS 2 stated no pain medications were administered, and the score was entered by a PT. NS 2 stated the “Physical Therapist Note”, dated 11/6/25, indicated Pt 8’s nurse was given report that Pt 8 was in pain at the end of the session. NS 2 stated no nursing assessments were completed at the time of the PT note to indicate Pt 8’s pain was assessed. NS 2 stated the next pain score documented was on 11/7/25 at 8:02 a.m. NS 2 stated her expectation was for nursing staff to assess the patients for pain and treat accordingly. During a review of the Pt 8’s document titled, “Physician Medication Order (PMO)”, dated 10/31/25, the “PMO” indicated, acetaminophen 325 mg two tablets by mouth every four hours as needed for fever, headache, and pain levels from one to 10. During a concurrent interview and record review on 11/12/25 at 2:30 p.m. with NS 2, NS 2 opened Pt 10’s “EMR”, for review. The document titled, “H&P”, dated 6/23/25, indicated Pt 10 was a 69-year-old with a chief complaint of gait impairment and decline in transfers and self-care, due to right sided below-knee amputation (surgical removal of body part) on 6/18/2025. NS 2 stated Pt 10 was admitted to the hospital on 6/23/25 at 6:47 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “NAA”, dated 6/23/25, indicated Pt 10 reported a pain goal of four out of 10, and reported 10 out of 10 pains at admission. The document titled “MAR”, dated 6/23/25 to 6/24/25, indicated that on 6/23/25 at 9:54 p.m., Pt 10 reported a pain score of 10 and was administered one 10 mg tablet of oxycodone (a strong pain medicine) by mouth. The “MAR” noted a reassessment at 10:45 p.m. with a value of 5. The “MAR” indicated on 6/24/25 at 3:18 p.m. Pt 10 reported a pain score of 7 and was administered one 10 mg of oxycodone. NS 2 stated nursing staff did not document a reassessment for the medication administration, and they should have. NS 2 stated reassessments were important to make sure the pain medications and treatment were effective for the patient to meet their stated pain goals. During a review of the Pt 10’s document titled, “Physician Medication Order (PMO)”, dated 6/23/25, the “PMO” indicated, “ ... oxycodone HCL [hydrochloride-a salt form] 10 mg, give 10 mg (1 tablet(s)) by mouth Every Three Hours PRN [as needed] LOOK ALIKE SOUND ALIKE Indication [reason] ...” During a concurrent interview and record review on 11/12/25 at 2:52 p.m. with NS 2, NS 2 opened Pt 9’s “EMR”, “undated”, for review. The document titled, “H&P”, dated 10/22/25, indicated Pt 9 was a 75-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a spinal cord injury secondary to lumbar stenosis (narrowing of the spinal canal in the lower back), and a spinal fusion (permanently joins two or more vertebrae in the spine to eliminate movement) back surgery. NS 2 stated Pt 9 was admitted to the hospital on 10/22/25 at 2:40 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. During a concurrent interview and record review on 11/12/25 at 3:02 p.m. with NS 2, NS 2 opened Pt 9’s “EMR”, for review. The document titled, “NAA” dated 10/22/25, indicated Pt 9 reported a pain goal of zero out of 10, and had no pain at admission. The document titled, “MAR”, dated 11/6/25, indicated Pt 9 reported back pain of seven (severe) out of 10 at 2:53 p.m., and was administered 1 tablet of oxycodone HCL/Acetaminophen 5/325 mg (a strong pain medication) by mouth. The “MAR” indicated nursing staff reassessed Pt 9 at 3:33 p.m. with a score of 5. NS 2 stated Pt 9’s “EMR” did not have any documentation indicating nursing staff contacted the physician to report ineffective pain medications, and nursing staff did not assess Pt 9’s pain again until 11/7/25 at 10:11 a.m. NS 2 stated nursing staff should contact the physician if the pain medications are ineffective and should continue to reassess patients pain if the patient wanted to wait before taking other medications. NS 2 stated nursing staff should document the refusals and physician notifications. During a review of Pt 9’s “EMR” document titled, “Physician Medication Order (PMO)”, dated 11/6/25, the “PMO” indicated, “ ...Oxycodone HCL/Acetaminophen 5/325MG [5 mg of oxycodone (strong pain medication)/ 325 mg acetaminophen (mild pain medication)] Give 1 tablet(s) by mouth Every Four Hours PRN [as needed] MAX APAP [acetaminophen] 3GM [gram -a unit of measurement]/24HR [hours] Indication Pain 7-10 ...” During a review of Pt 9’s “EMR” document titled, “Physician Medication Order (PMO)”, dated 10/24/25, the “PMO” indicated, ...Acetaminophen [Brand Name] 325 MG, Give 650 mg (2 tablet(s)) by mouth Every Four Hours PRN fever, headache and pain 1-6 Indication: fever ...” During a concurrent interview and record review on 11/12/25 at 3:12 p.m. with NS 2, NS 2 opened Pt 11’s “EMR”. The document titled, “H&P”, dated 9/16/25, indicated Pt 11 was a 77-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a left total knee replacement. NS 2 stated Pt 11 was admitted to the hospital on 9/16/25 at 7:15 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “NAA” dated 9/16/25, indicated Pt 11 reported a pain goal of zero out of 10, and had no pain at admission. The document titled, “MAR”, dated 9/17/25, indicated Pt 11 reported a pain score of 9 at 3:37 a.m., and was administered one tablet of 5/325 oxycodone HCL/acetaminophen by mouth. The “MAR” indicated nursing staff reassessed Pt 11 at 4:30 a.m. with a score of 8. NS 2 stated Pt 11’s “EMR” did not have nursing documentation indicating Pt 11’s physician was notified the pain medication was ineffective, and they should have. During a review of Pt 11’s “EMR” document titled, “Physician Medication Order (PMO)”, dated 9/16/25, the “PMO” indicated, “ ...Oxycodone HCL/Acetaminophen 5/325MG [5 mg of oxycodone (strong pain medication)/ 325 mg acetaminophen (mild pain medication)] Give 1 tablet(s) by mouth Every Four Hours PRN [as needed]MAX APAP [acetaminophen] 3GM [gram -a unit of measurement]/24HR [hours] Indication: pain (1-10) ...” During a concurrent interview and record review on 11/12/25, at 10:49 a.m., with the CNO, the CNO opened Pt 15’s “EMR”. The document titled, “H&P”, dated 10/15/25, indicated Pt 15 was a 74-year-old with the chief complaint of gait impairment and decline in transfers and self-care, due to a right femur fracture status post right hip surgery. The CNO stated Pt 15 was admitted to the hospital on 10/15/25 at 7 p.m. with a treatment plan consisting of at least 3 hours of combined PT/OT and 24-hour skilled rehabilitation nursing. The document titled, “Administration History (AH)” dated 10/15/25-11/7/25, the AH indicated Pt 15 reported a pain score of 8 at 9:45 a.m. on 10/17/25 and was administered one tablet of 10/325 Hydrocodone-acetaminophen by mouth. The “AH” indicated nursing staff reassessed Pt 15 at 12:25 p.m. on 10/17/25 with a score of 6. The “AH” indicated Pt 15 reported a pain score of 6 at 6:29 p.m. on 10/26/25 and was administered one tablet of 10/325 Oxycodone/Acetaminophen by mouth. The “AH” indicated nursing staff reassessed Pt 15 at 10:29 p.m. on 10/26/25 with a score of 5. The CNO stated pain should have been reassessed within 30-60 minutes after giving pain medication and it was more than 2-4 hours for Pt 15’s pain to be reassessed each time. The CNO stated it is important to reassess patients pain to make sure the medication is helping, the patient is not having side effects and to make sure that if the pain is not resolving to reach out to the provider and get a different order. During a review of Pt 15’s “Pharmacy Orders”, dated 10/15/25, the “PO” indicated, “ ... HYDROcodone-acetaminophen 10-325MG ... 10MG-325MG, Give 1 tablet(s) by mouth Every Four Hours PRN MAX APAP 3GM/24HR Indication: Pain 1-10 ...”. During a review of Pt 15’s “PO”, dated 10/23/25, the “PO” indicated, “ ... Oxycodone/Acetaminophen 10/325MG ... Give 1 tablet(s) by mouth Every Four Hours PRN MAX APAP 3GM/24HR, FOR PAIN 1-6 Indication: pain 1-6 ...”. During an interview on 11/14/25 at 10:50 a.m. with the CNO, the CNO stated, her expectation was for nursing staff to administer pain medications if a patient had a pain level requiring intervention. The CNO stated nursing staff should reassess the patient within 30-60 minutes and, if pain persists, contact the physician for a breakthrough (sudden and brief flare-up of pain) medication. The CNO stated nursing staff must not leave patients in pain and should document all assessments and calls to the physician for pain medication. During a review of the hospital’s P&P titled, “Administration of Medications”, dated 12/22, indicated, “ ...If a medication dose is held or refused by the patient, document “Patient Refused”, or the reason the dose was missed, as appropriate. ...If administering prn [as needed] pain medications, document pre and post medication administration pain scale score. Pain reassessment will occur within 1 hour of administration. Follow-up documentation includes a reassessment of the numeric pain intensity scale. ...Document response to all PRN medications ...” During a review of the hospital’s P&P titled, “Pain Assessment and Management”, dated 6/24, indicated, “ ...Management of a patient’s pain includes individualized assessment, intervention, and evaluation of pain and pain relief. A patient’s self-report of pain will be accepted as the most reliable indicator of pain. ...Patients are assessed for pain at the Hospital on admission and then reassessed at least every shift. Determining the location of pain. Determining the intensity [strength] of pain. Determining the duration of pain. Determining the onset of pain. Determining aggravating [makes worse] and alleviating [makes it better] factors. Utilization of the Pain Rating Scale. Patients that are administered pain medications will be reassessed within 1 hour of administration. Follow-up documentation includes a reassessment of the numeric pain intensity scale. ...1-3 mild pain 4-6 moderate pain 7-10 severe pain Documentation in the EMAR [electronic medication administration record] on effectiveness must be completed using same scale used for pain assessment within 1 hour. Nursing may administer pain medications lower than what is ordered for the patient level of pain, if requested by the patient and documented in the EMAR ...” During a review of the hospital’s P&P titled, “Change in Condition”, dated 10/16, indicated, “ ...The following could describe a significant change in patient condition. This list is not meant to exclude other possibilities, but rather to describe the most common causes for significant changes in condition. Any single finding does describe a significant change in condition and requires Assessment, Documentation and Notification. ... Acute onset of pain: Change in patient’s baseline pain pattern, i.e. - no relief from previous effective interventions or escalation in the rating of the pain on the scale ...” During a professional reference review titled, “Pain management in hospitals: patients’ satisfaction and related barriers,” dated 9/25/18, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207353/) indicated, “ ... Suboptimal [not the best possible level] pain control has been frequently reported in healthcare settings and documented to negatively impact patients’ health. Patients’ perception regarding pain management may influence their satisfaction regarding treatment ...”. During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional]”, dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “...Uncontrolled pain worsens patient outcomes. ...Uncontrolled acute pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life. ... Acute pain management in hospitalized patients should therefore be a clinician and institutional [facility] priority as a key driver of patient outcomes ...”.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 42321 Based on observation, interview and record review, the hospital failed to maintain a safe and clean physical environment when: 1. The floors, walls, ceilings, cabinets, and doors were visibly damaged in the Outpatient Physical Therapy Department, Medical Surgical Unit, and Kitchen. 2. Preventative maintenance (PMs, for performing regular and scheduled upkeep on equipment) were not implemented at the hospital for the kitchen ice machine, boilers, and Heating, Ventilation, and Air Conditioning (HVAC) systems. These failures placed all patients, staff, and visitors in the hospital at risk of injury and infection. Findings: 1. During a concurrent observation and interview on 11/5/25 at 1:49 p.m., with Nurse Supervisor (NS) 1, and the Physical Therapy Outpatient Coordinator (PTOC), in the Outpatient Gym Clean Utility Room number 182, the Outpatient Gym and the Outpatient Pool area were observed. Room 182 had cracks and chunks missing out of the cement floor. The flooring throughout the gym had gouges (deep hole) in the linoleum (type of flooring), and paint flaking off the tan walls with white visible underneath. The PTOC stated the floors should be smooth to prevent falls. NS 1 stated the floors and walls should be smooth for proper cleaning. Through a door on the west side of the PT Department was a large indoor pool. Multiple metal doors were around the pool leading to different rooms or storage areas, and the door frames had paint chipping, bubbling and peeling off revealing dusty reddish material. The men’s bathroom had the same reddish material in large streaks across the stainless-steel panel at the bottom of the door. NS 1 stated the reddish material was “rust”. The patient showers in the pool area were made with small ceramic (made of clay and hardened by heat) tiles and had missing grout (a paste for filling crevices like gaps between wall or floor tiles) on the floor between some of the tiles, the PTOC stated patients used the shower to rinse off before and after using the pool for physical therapy and did not use shoes in the shower. During a concurrent observation and interview on 11/5/25 at 2:20 p.m. with NS 1, the Manager of Nutrition Services (MNS), and the Director of Nutrition Services (DNS) the hospital Kitchen including storage areas were observed. A cleaning closet with a floor sink had walls that were chipped and cracked with drywall visible, the drywall had a black substance. The (DNS) stated the black substance was grime and should not be there. The DNS stated the wall should not be chipped with the inner wall exposed next to a water source. The walk-in refrigerator floor had chipped paint. The walk-in freezer floor was cracked and chipped. The DNS stated the floors should be smooth and in good repair to allow for cleaning and prevent bacteria (germs) from growing. A large crack was on the floor by the low heat dishwasher; a rubber mat was on top of the crack. The DNS stated a pipe had broken and the hospital opened the floor for repair. The DNS stated the hospital had a company coming to repair the floor within a few weeks. A handwashing sink on the north side of the kitchen had cracked and discolored caulking (waterproof filler and sealant) around the top of the sink attaching the sink to the wall. The DNS stated the caulking should not be cracked because there was no way to clean around the sink. Paint was peeling over the area where the cutting boards were stored. The DNS stated the paint should not be peeling, walls should be smooth for cleaning. During a concurrent observation and interview on 11/5/25 at 3:20 p.m. with NS 1 in the 2 North Medical Surgical (MS) Multipurpose Room, the linoleum flooring was gouged (groove, hole or indentation) and cracked, with pieces of the plastic baseboard missing. The walls had black scuffs, deep scratches, and peeling paint, ceiling tiles had brown stains, and the window had areas where the caulking at the floor was pushed inward two inches by a flaky bumpy brown substance. The rooftop had two drains with weeds and water pooling. NS 1 stated the floors, walls, and ceiling tiles were infection control issues due to bacteria and was unsure about the substance around the window, which appeared to be pushing the seal away from the window. During a concurrent observation and interview on 11/5/25 at 4:13 p.m. with NS 1 on the second floor MS Unit, outside Dirty Utility Room 2259, a plastic handrail was broken and dangling off the wall. NS 1 stated the handrail should not be broken because handrails were used to help patients keep their balance when walking or standing. During a concurrent observation and interview on 11/5/25 at 4:38 p.m. with NS 1 in the Nutrition Room / Clean Storage Room number 2262, it was noted that a door separated the nutrition room from the clean storage room. In the Nutrition Room under the ice and water dispenser, the wood was observed to be damaged and crumbling where the water lines went from the sink to the dispenser. The floors were noted to be chipped and cracked in the clean storage area. NS 1 stated that the wood should not be damaged, and the cabinet should not be dirty, and the floors should not be cracked to ensure safety and cleanliness and to prevent infection. During an interview on 11/7/25 at 3:17 p.m. with the Regional Director of Plant Operations, the RDPO stated his role was to oversee anything that had to do with the building’s maintenance. The RDPO stated he toured the hospital during environment of care rounds where walkthroughs were completed to find safety issues or areas that needed repair. The RDPO stated the purpose of these rounds was to protect patients as well as anyone in the building. The RDPO stated he was responsible for maintaining the building and he had two maintenance employees under him. The RDPO stated the flooring in the Clean Utility Rooms throughout the hospital should be without cracks and chips, because they were a trip hazard and infection control issue. The RDPO stated grout should not be broken in showers, due to infection control. The RDPO stated ceiling tiles should not be stained, and caulking should be without cracks. The RDPO stated the area around the pool was wet and the metal areas around the pool required maintenance. The RDPO stated he needed to “keep an eye on it” to address the paint peeling because when metal rusts patients can get sick if punctured by rusty materials. The RDPO stated there were no maintenance logs to indicate where or when the preventative maintenance was done, and there should be. During a review of the hospital document titled, “Proposal”, dated 7/14/25, the proposal indicated a floor repair was proposed to remove the broken flooring and replace a new section of flooring with a moisture sealant. The email document was sent to the Chief Executive Officer (CEO) on 7/14/25 at 4:08 p.m. with high importance. The email document sent from the Regional Director of Plant Operations (RDPO) to the CEO indicated “ ...Please see attached kitchen floor repair proposal. Please let me know when approved so I can coordinate the repair work with the contractor ...” During a review of the hospital document titled, “Deadline Extension”, dated 11/4/25 at 1:05 p.m. the email document indicated the city’s Code Enforcement Unit inspected the kitchen floor crack and gave the hospital an initial deadline of 11/17/25 to have the flooring repair completed and be ready for reinspection. The hospital requested an extension on 11/4/25 and the city granted the request with a new deadline of 12/5/25 and re-inspection set for 12/8/25. During an interview on 11/7/25 at 4:50 p.m. with NS 1, NS 1 was tearful when asked about the physical environment. NS 1 stated the hospital needed to do upgrades to the floors, and upkeep the walls, and has been told by senior leadership there is no money. During an interview on 11/13/25 at 3:30 p.m. with the CEO and the Chief Clinical Officer (CCO) the CCO stated a requisition was in place to have the floor in the kitchen replaced. When asked why a proposal was sent in July of 2025 and the floor had not been replaced as of November 2025, the CEO stated he made the decision to hold off on the repair for financial reasons. The CEO stated he did not believe anyone had fallen from the crack, but the crack was an infection control issue. The CEO stated he did not consider the floor repair an emergent issue but an urgent issue and would be fixed at the beginning of December. During an interview on 11/14/25 at 10:55 a.m. with the Chief Nursing Officer (CNO), the CNO stated her expectation was when staff saw an issue with the physical environment such as peeling paint, chips in the floor, a new crack, or a piece of equipment not working properly the expectation was to put in a work order and take the piece of equipment out of service. The CNO stated her expectation was for the physical environment to be safe and clean for patients, visitors and staff. During a review of the hospital’s P&P titled, “Safety Surveys - Environmental Rounds”, dated 1/15/19, indicated, “ ...The environmental safety rounds team shall consist of persons from the following departments: Environmental Services Facilities Maintenance Department Director of designee (responsible for the area being surveyed) Infection Control ... The structural and physical integrity of the hospital buildings, exteriors and grounds will be checked as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. Special emphasis will be placed on locating any defects (loose brick, roofing, broken walkways, trip hazards) which may pose a danger to patients, visitors, employees and other personnel. Any defect located which constitutes a hazard will be appropriately identified and repaired in a timely manner. The interior of all buildings will be inspected as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. These inspections will be carried out in order to locate any physical or mechanical defects in the building or equipment which may pose a hazard to any person. If employees notice a defect or unsafe situation, they should report it to their department head and/or the Director of Plant Operations, or complete a Maintenance work order request ...” During a review of the hospital’s P&P titled, “Preventative Maintenance Program”, dated 1/15/19, indicated, “ ...The Plant Operations personnel of the Hospital will perform all preventative maintenance within our facility that is not covered by Biomedical or service contracts. The supervision of said program shall be the responsibility of the Director of Plant Operations ... [name of program] preventive maintenance/work order web based program is the corporate preferred means to manage and document equipment maintenance activities. Maintenance personnel will follow manufacturer’s recommended procedures and maintenance schedules on all equipment. Hard copies of maintenance activities/logs in lieu of [name of program] will be stored in the Maintenance/ Engineering Department ...”. According to an article in Health Facilities Management, dated August 16, 2019, titled, “The Role of Maintenance in Infection Prevention,” retrieved from https://www.hfmmagazine.com/articles/3728-how-maintenance-can-help-or-hurt-infection-prevention, the article indicated, “ ... Because of their random nature, miscellaneous HAI (Hospital Acquired Infection) concerns can sometimes be the hardest to spot. Some things to look for include: ... Evidence of water damage. Water damage that is not quickly repaired can result in mold. ...Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern. ...Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable and also is an infection prevention concern. ...Damaged plastic laminate, upholstery, doors and similar items. Plastic laminate casework is frequently damaged, resulting in a surface that cannot be cleaned properly. ...Damaged materials must be repaired or replaced to provide a cleanable surface ...”. 2. During a concurrent interview and record review on 11/5/25 at 2:33 p.m. with the DNS, the ice machine in the kitchen was noted to have brown debris along the inside white plastic casing in the bin and on the ice deflector (a component that directs ice flow to prevent spillage and improve efficiency) where the ice drops into the holding bin, under the door. The DNS stated kitchen staff were responsible for cleaning the outside of the ice machine and maintenance staff were responsible for cleaning the inside. The DNS did not recall the last time the inside was cleaned. The DNS stated the Preventative maintenance (PMs) was provided by an outside company. The DNS stated the ice machine should be clean without debris to prevent infection. During an interview on 11/7/25 with the RDPO, the RDPO stated he did not have a maintenance log or cleaning log for the kitchen ice machines, but the hospital used an outside vendor for preventative maintenance. The RDPO stated the ice machines should not have brown debris on them due to the risk of spreading infections. The RDPO stated he was unable to find the invoice for the last work completed by the contracted vendor. During a review of a hospital document titled, “Planned Service Agreement (PSA)”, dated 9/12/16, the “PSA” indicated, the vendor would provide preventative maintenance services for three ice machines. The “PSA” indicated the agreement took effect on 10/1/16 and continued until 9/30/19. During an interview on 11/5/25, at 4:46 p.m. with the RDPO, the RDPO stated he has worked for this facility for the last seven months and he was informed on Thursday 10/30/25 that the facility was having issues with hot water around noon. The RDPO stated he tried to see if there was anything he could do to fix the issue but ultimately called a vendor and they were able to come onsite that same day. The RDPO stated the boiler required a new motor that needed to be shipped in. The RDPO stated at first, they said it would be in by Friday but that did not work out, and the vendor finally came on Tuesday 11/4/25 and fixed the boilers around 3 p.m. In a separate interview on 11/14/25, at 11:27 a.m., with the RDPO, the RDPO stated no PMs have been done on the boilers or the HVAC system since he has been here and the prior person in his position did not keep records of when the last PMs were done. The RDPO stated when an equipment needs PMs a work order comes up, and he will reach out to the vendors to get a quote. Once a quote is received and submitted an approval is then needed to have the PMs done. The RDPO stated he has not had approval for any of the PMs to be done. The RDPO stated PMs are important to make sure equipment is working appropriately and does not breakdown. The RDPO stated it can be a patient safety issue if the HVAC and or the boiler go down, and we want our equipment to be 100 percent. During an interview on 11/14/25 with the CNO, the CNO stated her expectation was the cleaning and maintenance should be completed as often as the manufacturer instructions dictate. The CNO stated she believed there was a company that came in to do the preventative maintenance on the kitchen’s ice machine. The CNO stated it is important to do preventive maintenance to make sure equipment is functioning “top notch” and less likely to break and interrupt good patient care. During a review of hospital document titled, “EOC (Environmental of Care) Capital Projects” not dated, the EOC Capital Projects indicated, “Project/Start Date ... Start Date: 4/3/25 Boiler 1- Replace Circulation Pump Status/Updates/Setbacks 4/14/25 - Proposal from [name of company] submitted for review and approval; 5/8/25 - Proposal from [name of company] submitted for review and approval; 9/25/25 - No approval as of today; 10/10/25 - No approval as of today. Project Completion Date (none). Project/Start Date ... Start Date: 4/2/25 HVAC Preventative Maintenance Status/Updates/Setbacks 4/9/25 - Received proposal to implement HVAC PM. Work put on hold. 9/24/25 - Received updated proposal. Will submit for review and approval. 10/10/25 - Proposal approved. Vendor will place PM work on hold until account balance is paid in full and 50 % deposit for PM work is received. Project Completion Date (none) ...”. During an interview on 11/13/25, at 3:02 p.m., with the CEO, the “EOC Capital Projects” document was reviewed. The CEO stated the hospital has companies that do the PMs on the boilers and the HVAC. The CEO stated we [hospital administration] discussed a proposal for the boiler circulation pump back in 4/14/25 and as of 10/1/25 it still was not approved because it was an expensive project and at the time it was not affecting the hot water. The CEO stated, “if we could pay for everything and get it done, we would but not everything is worth getting it done right away and some projects can wait”. The CEO stated once the hot water went out, we got a vendor in to fix it right away. The CEO stated if it is something that puts patients’ safety at risk then it is a priority and will get done right away. The CEO stated, “We do make the decisions based on cost”. During a review of the hospital’s P&P titled, “Preventative Maintenance Program”, dated 1/15/19, indicated, “ ...The Plant Operations personnel of the Hospital will perform all preventative maintenance within our facility that is not covered by Biomedical or service contracts. The supervision of said program shall be the responsibility of the Director of Plant Operations ... [name of program] preventive maintenance/work order web based program is the corporate preferred means to manage and document equipment maintenance activities. Maintenance personnel will follow manufacturer’s recommended procedures and maintenance schedules on all equipment. Hard copies of maintenance activities/logs in lieu of [name of program] will be stored in the Maintenance/ Engineering Department ...”. During a review of the hospital document titled “Instruction for Use (IFU) S Model Ice Machines”, dated 12/19, the IFU indicated, “ ...You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Maintenance procedures are not covered by the warranty. Descale and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. [Name of Company] Ice Machine Cleaner and Sanitizer are the only products approved for use in [Name of Company] ice machines. ... CLEANING/SANITIZING PROCEDURE This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized. All ice produced during the cleaning and sanitizing procedures must be discarded. Removes mineral deposits from areas or surfaces that are in direct contact with water. REMEDIAL CLEANING PROCEDURE Perform this procedure if you have some or all of these symptoms. ... Your water has a high concentration of minerals. The ice machine has not been on a regular maintenance schedule. DETAILED DESCALING/SANITIZING PROCEDURE This procedure must be performed at least once every six months. The ice machine and bin must be disassembled, descaled and sanitized. All ice produced during the descaling and sanitizing procedures must be discarded ...”. During a review of the hospital document titled, “IFU Boilers DynaFlame Series”, not dated, the IFU indicated, “ ... PART 10 MAINTENANCE CAUTION It is important that all gas appliances to be serviced by a Camus® trained service technician. It is in your own interest and that of safety to ensure that all local codes, and all the “NOTES” and “WARNINGS” in this manual are complied with. To service or adjust this appliance, it is imperative that the Camus® trained service technician utilize a combustion analyzer to read CO2, CO and flue pressure according to Camus® Hydronics recommendation ... Frequency Performed by Service [Titles] Monthly Owner/Operator Check vent and air intake system, Check relief valve, Check condensate system. Semi-Annually Owner/Operator Test low water cutoff, Check flow switch operation, Test air proving switch, Check boiler piping (gas and water) for leaks, Check condensate media and replenish. Annually Owner/Operator Ensure scheduled service is conducted at least annually. Shut boiler down at end of season. Daily/Periodically Owner/Operator Check boiler area for any abnormalities and leaks, Check pressure/temperature gauges. Annually Service Technician Examine venting system and draft reading, Inspect and test relief valve operation, Check wiring and connections, Inspect and flush condensate system, Replenish condensate media as needed, Check for leaks (water, gas), Test all safety controls (LWCO, IAS), Inspect/clean heat exchanger and burner, Verify water quality and take sample, Check flame signal (flame rod, UV scanner), Check flame characteristics (stable, uniform), Inspect igniter and check amp draw (3.0A) minimum, Replace burner gaskets, Check control settings and parameters, Set combustion and verify CO2 and CO ...”. During a review of the hospital document titled, “IFU HVAC 102.20-NOM1”, not dated, the IFU indicated, “ ... GENERAL This manual has been prepared as a guide for installing, operating and maintaining YORK Solution Air Handling Units. Johnson Controls has produced a quality product that is adaptable to almost any comfort or industrial application. However, proper installation, operation and maintenance must be followed to realize the full capacity and life of the units ... A planned program of regularly scheduled maintenance will return dividends by averting possible costly and unexpected periods of down time. It is the responsibility of the owner to provide the necessary maintenance for the air handling equipment and components ... MAINTENANCE RECOMMENDATIONS FOR SOLUTION AIR HANDLER ... PROCEDURE MONTHLY QUARTERLY YEARLY OTHER Clean exterior of air handler cabinet. As Needed. Inspect doors, handles, latches and hinges for proper operation. Yearly. Inspect door gaskets for damage and proper seal. Yearly. Inspect panels for damage. Yearly. Inspect air hoods and air louvers for damage and debris. 6 months. Inspect bird screens for damage and debris. 6 months. Inspect bird screens for damage, dirt and debris. 6 months. Clean fan segment and fan assembly (supply, return, exhaust). Yearly. Check fan housing, wheel, shaft, frame, inlet vanes and bearings for damage, wear, loose parts, dirt and debris. Yearly. Check fan base, vibration isolators and thrust restraints for damage, wear, loose parts, dirt and debris. Yearly. Check flex connector for damage and wear. Yearly. Check the cleanliness of the filters and replace or clean as required. Monthly. See IOM Tables. Check filter frames (filter tracks) for residual contaminates and clean as necessary. Quarterly. Verify filter gauge and/or switch function properly. Monthly. Check drive kit for damage, loose parts, wear, dirt, alignment and belt tension. Quarterly. Check belt tension. Quarterly. Lubricate fan bearings. (Ball Bearing-Table 4-2, Roller Bearing-Table 4-3, Split Pillow Block-Table 4-4) See IOM Tables. Check condition of extended lubrication lines when present. Quarterly. Clean variable inlet vanes. Yearly. Check adjustable fan motor base and mounting hardware for loose parts. Yearly. Check adjustable fan motor base for damage. Yearly. Check fan motor for leaky bearing seals. Yearly. Check fan for motor damage. Yearly. Clean dampers. Quarterly. Check for dirt, dust & debris in air vents on fan motor housing. Yearly. Clean dehumidification coils. Yearly. Clean condensate drain pan, trap, drain line and adjacent wetted surfaces. Yearly. Check, clean and calibrate controls. 6 months. Check Energy Recovery Wheel, clean media, adjust seals, replace belt. As Needed ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 42321 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when: 1. In the Outpatient Physical Therapy (PT) Gym, one of two Clean Utility Rooms was visibly dirty, with chipped, and cracked cement flooring. The linoleum flooring throughout the PT Gym was also scratched and gouged, with dirt and grime accumulating along the walls, and not maintained in accordance with hospital policies and procedures (P&P) and professional standards of practice. 2. In the Outpatient PT Department’s Indoor Pool area, the painted metal door frames were bubbling, peeling, and flaking, exposing dusty red material and sharp metal paint edges. The stainless-steel base plate on the men’s bathroom door had reddish streaks and visibly dirty. The water drainage grate surrounding the PT Department’s indoor pool was brown from dirt, debris, and grime. The two patient showers were dirty with cracked grout (a filler between tiles), and one had two shower chairs stained gray, and not maintained in accordance with hospital P&P and professional standards of practice. 3. a. Hospital staff purposely placed and stored food storage containers on the floor in the café storage room. Hospital staff stored food for the café alongside staff uniforms and placed food on the floor of the dry pantry. These practices are not in accordance with hospital policy and procedure (P&P), and professional standards of practice. 3. b. The walk-in refrigerator had chipped paint floors and the walk-in freezer had chipped and cracked concrete floors, and in the kitchen a large, uneven L-shaped crack under a handwashing sink was covered by a rubber mat, and items were not maintained in accordance with hospital P&P and professional standards of practice. 3. c. Kitchen staff did not clean grease and grime buildup on the walls, leading to peeling paint in some areas of the food preparation area. A hanging fan with greasy and dusty blades directed air towards the food preparation area. Staff did not clean several ceiling tiles, causing them to become discolored due to grease accumulation, and three out of five exhaust fan vents, and surrounding tiles were coated in brown dust. The hospital left the floors in the food preparation areas dirty and in poor condition, with an accumulation of trash, food residues, grease, and black grime, and not in accordance with hospital P&P or professional standards of practice. 3. d. The ice machine was visibly dirty with brown debris inside the ice bin along the white covering. White flakes had accumulated on the ice deflector (a component that directs ice flow to prevent spillage and improve efficiency) and was not maintained in accordance with manufacturer recommendations, hospital P&P, and professional standards of practice. 3. e. Hospital Staff stored open bags of frozen café food with loose French fries at the bottom of a chest freezer, which measured approximately 33.5 inches in size. A 1-inch layer of frost covered the top, sides, bottom, and back of the freezer, and was not maintained in accordance with manufacturer recommendations and professional standards of practice. 3. f. Hospital kitchen staff used cutting boards that were worn, had deep scratches, and stains, making it difficult to clean and sanitize properly. Dark stains were visible inside many of the cuts and gouges on the white cutting boards, and were not maintained in accordance with professional standards of practice. 4. Hospital staff failed to maintain two of two ice and water dispensers on the Medical Surgical (MS) Unit, which were visibly soiled with white flaky buildup in the dispensing chutes, and not in accordance with manufacture recommendations, hospital P&P, or professional standards of practice. 5. In the multipurpose room, ceiling tiles had brown circular staining, the linoleum flooring had deep scratches and gouges, paint was peeling, and a brown bumpy dirt substance around the bottom of the windowsills had pushed out the caulking by approximately 2 inches in several areas around the room, and the area was not maintained in accordance with hospital policy, and professional standards of practice. 6. Staff stored two pressure reduction mattress foam rolls and one respiratory therapy supplies on the floor in three of six clean storage rooms in the Medical Surgical Department, which was not in accordance with hospital P&P and professional standards of practice. 7. Staff stored clean patient pillows (D1) and boxes of electrocardiogram (ECG- disposable, adhesive medical devices used to monitor the heart’s electrical activity) electrodes (D2) in the cabinets of two dirty utility rooms on the MS Unit, which was not in accordance with professional standards of practice. As a result of these failures all patients, visitors and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: 1. During a concurrent observation and interview on 11/5/25 at 1:49 p.m., with Nurse Supervisor (NS) 1, and the Physical Therapy Outpatient Coordinator (PTOC), in the Outpatient PT Gym Clean Utility Room number 182, the Outpatient Gym, and the Outpatient Pool area were observed. Room 182 had cracks and chunks missing out of the cement floor. The flooring throughout the gym had gouges in the linoleum, and paint flaking off the tan walls with white visible underneath. The PTOC stated the floors should be smooth to prevent falls. NS 1 stated the floors and walls should be smooth for proper cleaning. During an interview on 11/13/25 at 9:13 a.m., with the Infection Control and Prevention Coordinator (ICPC), the ICPC stated she had been in the role for 1.5 years, but Infection Control was not her only role. The ICPC stated she had not toured multiple areas in the hospital on her rounds and had not toured all the areas in the Outpatient PT department, but she should have. The ICPC stated the flooring in the Outpatient PT Gym should be smooth and in good condition for cleaning, because bacteria may stick to non-smooth surfaces. During an interview on 11/7/25 at 3:17 p.m. with the Regional Director of Plant Operations (RDPO), the RDPO stated his role was to oversee anything that had to do with the building’s upkeep and maintenance. The RDPO stated he toured the hospital during environment of care rounds where walkthroughs were completed to find safety issues or issues that needed repair, to protect patients as well as anyone in the building. The RDPO stated he was responsible for maintaining the building and he had two maintenance employees under him. The RDPO stated the flooring in the Clean Utility Rooms, and the linoleum throughout the hospital should be without cracks and chips, because they were a trip hazard and Infection control issue. During a review of the hospital’s P&P titled, “Safety Surveys - Environmental Rounds”, dated 1/15/19, indicated, “ ...The structural and physical integrity of the hospital buildings, exteriors and grounds will be checked as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. Special emphasis will be placed on locating any defects (loose brick, roofing, broken walkways, trip hazards) which may pose a danger to patients, visitors, employees and other personnel. Any defect located which constitutes a hazard will be appropriately identified and repaired in a timely manner. The interior of all buildings will be inspected as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. These inspections will be carried out in order to locate any physical or mechanical defects in the building or equipment which may pose a hazard to any person ...” According to an article in Health Facilities Management, dated August 16, 2019, titled, “The Role of Maintenance in Infection Prevention,” retrieved from https://www.hfmmagazine.com/articles/3728-how-maintenance-can-help-or-hurt-infection-prevention, the article indicated, “ ... Because of their random nature, miscellaneous HAI (Hospital Acquired Infection) concerns can sometimes be the hardest to spot. Some things to look for include: ... Evidence of water damage. Water damage that is not quickly repaired can result in mold. ...Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern. ...Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable and also is an infection prevention concern. ...Damaged plastic laminate, upholstery, doors and similar items. Plastic laminate casework is frequently damaged, resulting in a surface that cannot be cleaned properly. ...Damaged materials must be repaired or replaced to provide a cleanable surface ...”. 2. During a concurrent observation and interview on 11/5/25 at 2:02 p.m., with NS 1 and the PTOC, in the PT Gym indoor pool area, the indoor pool was observed through a door on the west side of the PT Department. Several patients were getting therapy with Physical Therapy (PT) providers in the pool. Several metal doors surrounded the pool, leading to different rooms or storage areas, with door frames showing paint chipping, bubbling, and peeling, revealing a dusty reddish material. The men’s bathroom displayed the same reddish material in large streaks across the stainless-steel panel at the bottom of the door. NS 1 identified the reddish material as “rust”. The white plastic grate where the water drained back into the pool around the sides, was a dingy grayish brown color with debris. During a concurrent observation and interview on 11/5/25 at 2:07 p.m. with NS 1 and the PTOC, in the PT Gym indoor pool area, the showers in the pool area were visibly dirty and grout was missing from between the grout (a paste-like material to fill gaps) of the small tiles. Two stained shower chairs were sitting against the shower wall, and the PTOC stated they should be cleaned between patient use and not stained. The PTOC stated that patients used the shower to rinse off before and after using the pool for physical therapy and did not wear shoes in the shower. NS 1 stated the red material could poke the patients and lead to an infection, and the showers should be cleaned before and after the patients use them to prevent infection. During an interview on 11/7/25 at 3:22 p.m. the RDPO stated grout should not be broken in showers, due to infection control. The RDPO stated the area around the pool was wet and the metal areas around the pool required maintenance to “keep an eye on it” to address the paint peeling because when metal rusts people can get sick if punctured by rusty materials. The RDPO stated the staff did maintenance and cleaning to the drain around the pool every two to three months, but he did not have documentation. The RDPO stated he would create a log going forward. The RDPO stated there were no maintenance logs to indicate where or when the preventative maintenance was done, and there should be. During an interview on 11/13/25 at 9:20 a.m., with the ICPC, the ICPC stated showers should be cleaned between patient uses. The ICPC stated the area around the pool needed to remove the exposed metal and paint to prevent a possible injury from staff or patient that could lead to an infection. The ICPC stated the dirt, and grime should be cleaned off the white pool grate because patients touch it with their hands and feet. During an interview on 11/14/25 at 10:55 a.m. with the Chief Nursing Officer (CNO), the CNO stated her expectation was when staff saw an issue with the physical environment such as peeling paint, chips in the floor, a new crack, or a piece of equipment not working properly to put in a work order and take the piece of equipment out of service. The CNO stated her expectation was for the physical environment to be safe and clean for patients, visitors and staff. During a review of the hospital’s P&P titled, “Safety Surveys - Environmental Rounds”, dated 1/15/19, indicated, “ ...The environmental safety rounds team shall consist of persons from the following departments: Environmental Services Facilities Maintenance Department Director of designee (responsible for the area being surveyed) Infection Control ... The structural and physical integrity of the hospital buildings, exteriors and grounds will be checked as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. Special emphasis will be placed on locating any defects (loose brick, roofing, broken walkways, trip hazards) which may pose a danger to patients, visitors, employees and other personnel. Any defect located which constitutes a hazard will be appropriately identified and repaired in a timely manner. The interior of all buildings will be inspected as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. These inspections will be carried out in order to locate any physical or mechanical defects in the building or equipment which may pose a hazard to any person ...” During a review of the hospital’s P&P titled, “Preventative Maintenance Program”, dated 1/15/19, indicated, “ ...The Plant Operations personnel of the Hospital will perform all preventative maintenance within our facility that is not covered by Biomedical or service contracts. The supervision of said program shall be the responsibility of the Director of Plant Operations ... [name of program] preventive maintenance/work order web based program is the corporate preferred means to manage and document equipment maintenance activities. Maintenance personnel will follow manufacturer’s recommended procedures and maintenance schedules on all equipment. Hard copies of maintenance activities/logs in lieu of [name of program] will be stored in the Maintenance/ Engineering Department ...”. 3 a. During a concurrent observation and interview on 11/5/25 at 2:20 p.m. with the Manager of Nutrition Services (MNS), NS 1, and the Director of Nutrition Services (DNS), a food storage room labeled “café storage” had food storage and staff uniforms stored in it in a disorganized manner. The door to enter was from the west, and staff uniforms were hanging across the north wall, food and food packaging items, were on metal shelves on the east, and south walls. Empty metal hangers and a box of disposable food containers were on the floor in front of the east wall metal shelf. The MNS stated the packaging was used to package customer and patient foods in the café. The MNS stated products used for food should not be on the floor, and clothing should not be stored with patient food. During an interview on 11/13/25 at 9:20 a.m. with the ICPC, the ICPC stated she had not toured the Kitchen since she started in the Infection Prevention Role 1.5 years ago. The ICPC stated no food or food supplies should be stored on the floor, due to the risk of spreading or causing infection. The ICPC stated no clothes should be stored with the food. During an interview on 11/17/25 at 10:49 a.m. with the CNO, the CNO stated patient supplies should not be on the floor and cross-contamination could be possible. During a review of the hospital’s P&P titled, “Physical Plant and Equipment-Department Security”, dated 1/23, indicated, “ ...Food and Nutrition Services handles foods and equipment in a manner consistent with accepted food services sanitation practices designed to prevent food borne illness spoilage and contamination. b. Nonperishable foods and supplies are stored in clean, ventilated, dry rooms free from wastewater backflow, and on shelving that assures supplies are stored at least 6 inches above floor. During a review of the professional reference titled, “2022 FDA Food Code, Section 3-305.11 Food Storage”, dated 2022, indicated “ ...Food shall be protected from contamination by storing food: 1) in a clean, dry location; where it is not exposed to splash, dust, or other contamination; and 3) at least 15 cm (6 inches) above the floor...”. During a review of the professional reference titled, “2022 FDA Food Code, Section 3-305.12 Food Storage, Prohibited Areas”, dated 2022, indicated, “ ...FOOD may not be stored: (A) In locker rooms; (B) In toilet rooms; (C)In dressing rooms...”. 3. b. During a concurrent observation and interview on 11/5/25 at 2:30 p.m. with the MNS and DNS in the hospital’s kitchen, the following issues were noted. The walk-in refrigerator floor had chipped paint, while the walk-in freezer floor had cracked and chipped cement. Near a handwashing sink on the East side of the kitchen, there was a large uneven L-shaped crack on the floor covered by two rubber mats. The DNS explained that a pipe broke a few months ago, causing the hospital to open the floor for repairs. The DNS mentioned that a company was scheduled to repair the floor within a few weeks. The DNS emphasized that floors should be smooth and in good condition to facilitate cleaning and prevent bacterial growth. During an interview on 11/7/25 at 3:25 p.m. with the RDPO, the RDPO stated a pipe had an issue in the kitchen and they had to repair the pipe, so the floor had to be opened. The RDPO stated after the pipe repair then the floor needed to be repaired, and it was not something his team could do. He spoke to the CEO and got a quote for the flooring in July of 2025. The requisition was approved, and the company would be onsite to complete the repair in the first week of December. The RDPO stated the crack in the floor was an infection control issue. During a review of the hospital document titled, “Proposal”, dated 7/14/25, indicated a floor repair was proposed to remove the broken flooring and replace a new section of flooring with a moisture sealant. The email document was sent to the Chief Executive Officer (CEO) on 7/14/25 at 4:08 p.m. with high importance. The email document sent from the Regional Director of Plant Operations (RDPO) to the CEO indicated “ ...Please see attached kitchen floor repair proposal. Please let me know when approved so I can coordinate the repair work with the contractor ...”. During a review of the hospital document titled, “Deadline Extension”, dated 11/4/25 at 1:05 p.m. the email document indicated the city’s Code Enforcement Unit inspected the kitchen floor crack and gave the hospital an initial deadline of 11/17/25 to have the flooring repair completed and be ready for reinspection. The facility requested an extension on 11/4/25 and the city granted the request with a new deadline of 12/5/25 and re-inspection set for 12/8/25. During an interview on 11/13/25 at 3:30 p.m. with the CEO and the Chief Clinical Officer (CCO) the CCO stated a requisition was in place to have the floor in the kitchen replaced. When asked why a proposal was sent in July of 2025 and the floor had not been replaced as of November 2025, the CEO stated he made the decision to hold off on the repair for financial reasons. The CEO stated he did not believe anyone had fallen from the crack, but acknowledged the crack was an infection control issue. The CEO stated he did not consider the floor repair an emergent issue but an urgent issue and would be fixed at the beginning of December. During an interview on 11/14/25 at 10:55 a.m. with the Chief Nursing Officer (CNO), the CNO stated her expectation was when staff saw an issue with the physical environment such as peeling paint, cracks in the floor, a new crack, or a piece of equipment not working properly to put in a work order and take the piece of equipment out of service. The CNO stated her expectation was for the physical environment to be safe and clean for patients, visitors and staff. During an interview on 11/17/25 at 9:25 a.m., with the ICPC, the ICPC stated, floors should be clean or be in good repair so they can be clean. If floors cannot be cleaned, the floors can harbor bacteria. During a review of the hospital’s P&P titled, “Safety Surveys - Environmental Rounds”, dated 1/15/19, indicated, “ ...The environmental safety rounds team shall consist of persons from the following departments: Environmental Services Facilities Maintenance Department Director of designee (responsible for the area being surveyed) Infection Control ... The structural and physical integrity of the hospital buildings, exteriors and grounds will be checked as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. Special emphasis will be placed on locating any defects (loose brick, roofing, broken walkways, trip hazards) which may pose a danger to patients, visitors, employees and other personnel. Any defect located which constitutes a hazard will be appropriately identified and repaired in a timely manner. The interior of all buildings will be inspected as a part of the preventive maintenance program by individuals designated by the Director for Plant Operations. These inspections will be carried out in order to locate any physical or mechanical defects in the building or equipment which may pose a hazard to any person. If employees notice a defect or unsafe situation, they should report it to their department head and/or the Director of Plant Operations, or complete a Maintenance work order request ...” During a review of the hospital’s P&P titled, “Preventative Maintenance Program”, dated 1/15/19, indicated, “ ...The Plant Operations personnel of the Hospital will perform all preventative maintenance within our facility that is not covered by Biomedical or service contracts. The supervision of said program shall be the responsibility of the Director of Plant Operations ... [name of program] preventive maintenance/work order web based program is the corporate preferred means to manage and document equipment maintenance activities. Maintenance personnel will follow manufacturer’s recommended procedures and maintenance schedules on all equipment. Hard copies of maintenance activities/logs in lieu of [name of program] will be stored in the Maintenance/ Engineering Department ...”. During a review of the professional reference article from Health Facilities Management, dated August 16, 2019, titled, “The Role of Maintenance in Infection Prevention,” retrieved from https://www.hfmmagazine.com/articles/3728-how-maintenance-can-help-or-hurt-infection-prevention, the article indicated, “ ... Because of their random nature, miscellaneous HAI (Hospital Acquired Infection) concerns can sometimes be the hardest to spot. Some things to look for include: ... Evidence of water damage. Water damage that is not quickly repaired can result in mold. ...Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern. ...Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable and also is an infection prevention concern. ...Damaged plastic laminate, upholstery, doors and similar items. Plastic laminate casework is frequently damaged, resulting in a surface that cannot be cleaned properly. ...Damaged materials must be repaired or replaced to provide a cleanable surface ...”. 3 c. During a concurrent observation and interview on 11/5/25 at 2:40 p.m. with the DNS in the hospital’s kitchen, it was noted the kitchen was poorly maintained. The walls and ceiling exhaust vents were covered in dust and grime, and the floors had trash, food remnants, and grease. The hanging fan in the prep area was dirty and blowing air over cooking areas. The DNS admitted that there was no deep cleaning schedule for the ceilings and that cleaning would require shutting down the kitchen. The walls behind stored pans had grease and dust, peeling paint was observed, and floor drains contained trash and food bits. The DNS stated that spot cleaning occurred, and deep cleaning happened quarterly but acknowledged that the cleaning schedule should be increased due to the visible grime. During an interview on 11/17/25 at 9:25 a.m., with the ICPC, the ICPC stated, floors should be clean or be in good repair so they can be cleaned appropriately. The ICPC stated, if floors cannot be cleaned they can harbor bacteria. The ICPC stated all areas in the kitchen should be clean and sanitary to prevent foodborne (an illness that comes from eating contaminated food) illnesses. During a review of the hospital’s P&P titled, “Physical Plant and Equipment-Department Security”, dated 1/23, indicated, “ ...E. Floors 1. Floors and equipment are cleaned routinely. 2. Hoods over stoves and dish washing machines are cleaned once a month by food service employees ...”. During a review of the “FDA Food Code, Section 6-201.11 Floors, Walls, and Ceilings, dated 2022, indicated, “ ...floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.” During a review of the professional reference titled, “ 2022 FDA Food Code Annex 3, 6-202.12 Heating, Ventilating, Air Conditioning System Vents”, dated 2022, indicated “ ...Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents ...”. 3d. During a concurrent interview and observation on 11/5/25 at 2:33 p.m. in the Kitchen with the DNS, the Ice Machine in the kitchen was noted to have brown debris along the inside white plastic casing in the bin and on the ice deflector (a component that directs ice flow to prevent spillage and improve efficiency) where the ice drops into the holding bin, under the door. The DNS stated kitchen staff were responsible for cleaning the outside of the ice machine and maintenance staff were responsible for cleaning the inside. The DNS did not recall the last time the inside was cleaned. The DNS stated the Preventative maintenance (PMs) was provided by an outside company. The DNS stated the ice machine should be clean without debris to prevent infection. During an interview on 11/7/25 with the RDPO, the RDPO stated he did not have a maintenance log or cleaning log for the kitchen ice machines, but the hospital used an outside vendor for preventative maintenance. The RDPO stated the ice machines should not have brown debris on them due to the risk of spreading infections. The RDPO stated he was unable to find the invoice for the last work completed by the contracted vendor. During a review of a hospital document titled, “Planned Service Agreement (PSA)”, dated 9/12/16, the “PSA” indicated, the vendor would provide preventative maintenance services for three ice machines. The “PSA” indicated the agreement took effect on 10/1/16 and continued until 9/30/19. During an interview on 11/13/25 at 9:22 a.m. with the IPCP, the ICPC stated the ice machines should be cleaned according to the manufacture instructions, hardwater makes them not smooth so bacteria can stick. During an interview on 11/14/25 at 11:15 a.m. with the CNO, the CNO stated, her expectation was for ice machines to be cleaned routinely as the manufacturer requires to prevent buildup and reduce risk of infection. During a review of the hospital document titled “Instruction for Use (IFU) S Model Ice Machines”, dated 12/19, the IFU indicated, “ ...You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Maintenance procedures are not covered by the warranty. Descale and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. [Name of Company] Ice Machine Cleaner and Sanitizer are the only products approved for use in [Name of Company] ice machines. ... CLEANING/SANITIZING PROCEDURE This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized. All ice produced during the cleaning and sanitizing procedures must be discarded. Removes mineral deposits from areas or surfaces that are in direct contact with water. REMEDIAL CLEANING PROCEDURE Perform this procedure if you have some or all of these symptoms. ... Your water has a high concentration of minerals. The ice machine has not been on a regular maintenance schedule. DETAILED DESCALING/SANITIZING PROCEDURE This procedure must be performed at least once every six months. The ice machine and bin must be disassembled, descaled and sanitized. All ice produced during the descaling and sanitizing procedures must be discarded ...”. During a review of the “FDA Federal Food Code 4-602.11”, dated 2022, the Food Code indicated, “ ...ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.”. 3. e. During a concurrent observation and interview on 11/5/25 at 2:41 p.m. with the MNS and the DNS, in the kitchen, a small chest freezer was against the south wall, and it had an open bag of chicken patties sitting at the top and french fries loosely spilled on the bottom. The freezer had approximately one inch of frost on the sides of the freezer walls and approximately one-half inch of frost on the lid. The freezer did not have a thermometer or a temperature log. The MNS stated the freezer was used for café foods. The DNS stated the chef defrosted the freezer weekly and there was a log. The log was requested but not received. The DNS stated the freezer should be temperature monitored. During an interview on 11/13/25 at 9:45 a.m. with the ICPC, the ICPC stated the chest freezer in the kitchen should not have a buildup of frost and should not have open food in the freezer, due to infection control. During a review of the hospital’s P&P titled, “Physical Plant and Equipment -Department Security”, dated 10/16, indicated, “ ...Equipment is operated according to manufacture instructions. ... Storage areas are designed and maintained to protect foods from spoilage and contamination. ... Perishable foods are stored at proper temperatures. Refrigerator and freezer temperatures are monitored by Food and Nutrition Services Staff ...”. During a review of the hospital document titled, “Instruction for Use (IFU)Chest Freezer”, “undated”, the IFU indicated, “ ...DEFROSTING & DRAINING o Defrost whenever the frost becomes 1/8” thick. Never use a sharp or metallic instrument to remove the frost as it may damage the cooling coils. CLEANING AND MAINTAINING The freezer should be cleaned and maintained once a month. During a review of the professional reference titled, “US Food and Drug Administrations Are You Storing Food Safety”, dated 1/18/23, indicated, “ ...Refrigerator/freezer thermometers should be monitored. Refrigerator/freezer thermometers may be purchased in the housewares section of department, appliance, culinary, and grocery stores. Place one in your refrigerator and one in your freezer, in the front in an easy-to-read location. Check the temperature regularly-at least once a week. 3. f. During a concurrent observation and interview on 11/5/25 at 2:46 p.m. with the DNS in the Kitchen where the cutting boards were stored, a total of 8 of 17 cutting boards were scratched, scored, and stained. The white cutting boards had deep scoring marks with black staining indicating the inability to clean and sanitize them thoroughly. The DNS stated the deep scoring and excessive wear on the cutting boards were, “food safety issues for sure.” The DNS stated they were aware new cutting boards were needed. The DNS stated, “We do the best we can with what we have.” When asked if requests were made for new equipment, the DNS stated yes. During an interview on 11/5/25 at 2:59 p.m. with Cook (CK) 1, CK 1 stated the cutting boards were scratched and stained and should not be used due to the risk of cross-contamination and the staff’s inability to completely clean them. CK 1 stated the bacteria can stay in the scratches. CK 1 stated staff tried to use the cleanest of the cutting boards. CK 1 stated staff have requested new ones from the leadership but have not received any. During an interview on 11/13/25 at 9:26 a.m. with the ICPC, the ICPC stated cutting boards should be in good repair and not be worn or have gouges. The ICPC stated cutting boards could harbor (hold) bacteria and cause cross-contamination. During an interview on 11/14/25 at 11:25 a.m. with the CNO, the CNO stated, If the cleaning boards were not cleanable, they should be replaced. During a review of the professional reference titled, “FDA Food Code Section 4-501.12 Cutting Surfaces”, dated 2022, the reference indicated, “ ...Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced ...”. During a review of the professional reference titled, “FDA Food Code Annex 3”, dated 2022, indicated, “ ...Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces ....”. 4. During a concurrent observation and interview on 11/5/25 at 4:38 p.m. with NS 1 in the Nutrition Room 2262, under the ice and water dispenser, the wood was observed damaged and crumbling where the water lines went from the sink to the dispenser. NS 1 stated that the wood should not be damaged, and the cabinet should not be dirty. The combination ice and water machines had visible white colored and white flaky buildup around the inside of the dispensing chute. NS 1 stated the inside of the ice machine should be clean. During an interview on 11/7/25 at 3:20 p.m. with the RDPO, and the DQM, the RDPO stated, there should not be water damage under the sinks, and this could be a risk for infection. The RDPO stated environmental services (EVS) department cleaned the outside of the water and ice machines, but there was no log for cleaning the preventative maintenance and cleaning of the ice machines in the nutrition room. The RDPO stated the machines were cleaned but he did not know the last time. During an interview on 11/13/25 at 9:18 p.m. with the ICPC, the ICPC stated bacteria could stick to the white flaky debris because of the non-smooth surface. The ICPC stated bacteria stick to non-smooth surfaces, and EVS should be going around to clean the dispensing chutes, so no calcification builds up. During an interview on 11/14/25 at 11:20 a.m. with the CNO, the CNO stated, her expectation was for the ice machines to be cleaned and maintained according to schedule, to decrease risk of infection. During a review of the hospital document titled, “Operation and Service Manual [Name of Machine] Ice and Water Dispensers (Manuel)”, “undated” the Manuel indicated, “ ...Cleaning/descaling and sanitizing use with potable water sources. The presence, or suspected presence, of infectious agents may call for additional measures, including the replacement of components and more comprehensive disinfection measures. [Manufacturer name] recommends that these cleaning and sanitizing procedures be reviewed with the appropriate infectious agent subject matter experts to assure complete remediation. Periodic cleaning/descaling and sanitizing of [Manufacturer name] ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate. Cleaning of the condenser can usually be performed by facility personnel. Cleaning/descaling and sanitizing of the ice machine system should be performed by your facility’s trained maintenance staff or a [Manufacturer name] authorized service agent. Regardless of who performs the cleaning, it is the operator’s responsibility to see that this cleaning is performed according to the schedule below. Service problems resulting from lack of preventive maintenance will not be covered under the [Manufacturer name] warranty. Recommended cleaning/descaling and sanitizing intervals* [Name of Machine] Frequency Drain Line weekly, Drain Pan/Drip Pan weekly. Exterior as needed, Condenser monthly (air-cooled only), Dispenser and Components semi-annually, Ice Machine semi-annually Transport Tube semi-annually, Ice Storage Area/Bin semi-annually ...” During a review of the “FDA Federal Food Code 4-602.11”, dated 2022, the Food Code indicated, “ ...ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.” 5. During a concurrent observation and interview on 11/5/25 at 3:20 p.m. with NS 1 in the 2 North MS Multipurpose Room, the linoleum flooring was gouged (groove, hole or indentation) and cracked, with pieces of the plastic baseboard missing. The walls had black scuffs, deep scratches, and peeling paint, ceiling tiles had brown stains, and the window had areas where the caulking at the floor was pushed inward two inches by a flaky bumpy brown substance. NS 1 stated the floors, walls, and ceiling tiles were infection control issues due to bacteria and was unsure about the substance around the window, which appeared to be pushing the seal away from the window. During an interview on 11/7/25 at 3:17 p.m. with the RDPO, the RDPO stated that ceiling tiles should not be stained, and caulking should be free of cracks. The RDPO stated, paint should not be chipped or peeling, and the linoleum should not be scratched or have missing pieces of baseboard, as these could present infection control issues and trip hazards. During an interview on 11/13/25 at 9:25 a.m. with the ICPC, the ICPC stated floors should be clean or be in good repair so they can be cleaned. The ICPC stated that when floors cannot be cleaned, they could harbor bacteria. During an interview on 11/14/25 at 10:55 a.m., the CNO stated that infection rates could rise without proper maintenance and cleaning. She expected staff to report broken equipment, enter a work order, and remove it from service. The CNO emphasized the importance of maintaining a safe and clean environment for patients, visitors, and staff. During a review of the hospital’s P&P titled, “General Cleaning”, dated 1/24, indicated, “ ...The procedures below where applicable will be used to effectively maintain the facility in cleanly condition and minimize the risk of spreading infection. ... SERVICE AREA Service areas differentiate from critical and sub critical areas in that they do not require maximum aseptic procedures in a day-to-day cleaning. These areas do require full attention and should be maintained with a high standard of cleaning. This includes offices, dining rooms, lobbies, waiting rooms, chapels, doctors and nurse’s lounges...”. According to an article in Health Facilities Management, dated August 16, 2019, titled, “The Role of Maintenance in Infection Prevention,” retrieved from https://www.hfmmagazine.com/articles/3728-how-maintenance-can-help-or-hurt-infection-prevention, the article indicated, “ ... Because of their random nature, miscellaneous HAI (Hospital Acquired Infection) concerns can sometimes be the hardest to spot. Some things to look for include: ... Evidence of water damage. Water damage that is not quickly repaired can result in mold. ...Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern. ...Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable and also is an infection prevention concern. ...Damaged plastic laminate, upholstery, doors and similar items. Plastic laminate casework is frequently damaged, resulting in a surface that cannot be cleaned properly. ...Damaged materials must be repaired or replaced to provide a cleanable surface ...”. 6. During an observation and interview on 11/5/25 at 3:38 p.m. with NS 1, in MS Clean Storage room 2210, four foam mattress toppers were upright in a clear plastic bin on the floor, each rolled and covered in a plastic bag. NS 1 emphasized that nothing should be stored on the floor due to the risk of it getting wet or dirty, which poses an infection control risk. During an observation and interview on 11/5/25 at 3:54 p.m. with NS 1, in MS Clean Respiratory Therapy (RT) storage room 2216, multiple boxes of RT equipment and supplies were found on the floor under the shelving. Some boxes contained non-functional equipment marked with notes. NS 1 stated that nothing should be stored on floors to prevent cross-contamination from bacteria being transferred to patients. NS 1 stated broken equipment should not be stored with functional equipment. During an observation and interview on 11/5/25 at 4:38 with NS 1, in MS Clean storage room 2262, five foam mattress toppers were upright in a clear plastic bin on the floor, each rolled and covered in a plastic bag. NS 1 stated nothing should be stored on the floor. During an interview on 11/13/24 at 9:20 a.m. with the ICPC, the ICPC stated Nothing should be stored on the floor, to prevent infection from cross contamination. During an interview on 11/14/24 at 10:49 a.m., with the CNO, the CNO stated, patient supplies should not be on the floor, because cross contamination was possible. During a review of the professional reference titled, “The role of the surface environment in healthcare-associated infections”, dated August 2013, the professional reference indicated, “ ...Hospital surfaces are frequently contaminated with important healthcare-associated pathogens (bacteria). Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of nosocomial (originating from the hospital) pathogens ...”. During a review of the professional reference titled, “Good Storage and Distribution Practices for Medical Products”, (retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7) dated 6/17/20, the professional reference indicated, “ ...Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, ...cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination ...”. 7. Patient pillows (D1) and boxes of electrocardiogram (ECG- disposable, adhesive medical devices used to monitor the heart’s electrical activity) electrodes (D2) were observed stored in the cabinets of two dirty utility rooms on the MS Unit, which was not in accordance with professional standards of practice. During an interview on 11/13/25 at 9:21 a.m. with the ICPC, the ICPC stated no clean items should be stored in the dirty utility room, due to cross contamination. Everything in the room is considered dirty. During an interview on November 14, 2025, at 10:50 a.m., the Chief Nursing Officer (CNO) stated that staff should not store any items in the dirty utility room. The CNO explained that there was a high risk of cross-contamination in the soiled utility environment, potentially spreading infections from one individual to another. During the review of professional reference titled, “What is the difference between a clean and dirty utility room? (WID)”, dated 9/4/18, the “WID” indicated, “ ... ‘Dirty’ doesn’t refer to visible mess. It simply means a patient has come into contact with the item, so it either needs to be made sanitary for the next use or disposed of completely. When items from the clean utility room are sent to a patient, the dirty utility room (or sluice room) is where the used items end up, in order to be cleaned or disposed of. Generally, these will be containers which have been used to collect and hold human waste. If waste items aren’t managed correctly, adhering to thorough infection control guidelines, they can become a serious HCAI [Healthcare-associated infection, infection resulting from a healthcare intervention] risk. So, this is where the reference to ‘dirty’ comes into play - potentially, these utensils can harbor microbes which are extremely dangerous if allowed to spread ...”.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 42321 Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist (professionals who make sure healthcare workers and patients are doing all the things they should do to prevent infections) effectively oversaw the facility’s Infection Control Program and facility practices for the adherence of infection prevention and control policies and procedures and best practices when the Infection Preventionist was not aware of the hospital-wide infection problems, did not have a systemic approach to track and monitor infection control practices and did not make rounds in all areas of the hospital, including the kitchen. As a result of these failures all patients, visitors and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: During an interview on 11/13/25 at 9:13 a.m. with the ICPC, the ICPC stated she held multiple roles besides Infection control including Nurse Educator. The ICPC stated she had worked at the hospital for 1.5 years, and this hospital was her first infection control role. The ICPC stated she had a two-week orientation, and a one-day orientation with a corporate lead. The ICPC stated she does participate in the Environment of Care (EOC) rounds but had not done any rounds in the kitchen. ICPC stated she did not take any infection control classes about food safety but understood the importance due to the risks of food borne illnesses. The ICPC stated no one educated her about the kitchen and where to start. The ICPC stated her focus for infection prevention had been hospital acquired infections (HAI)’s, hand hygiene, and ensuring high touch areas were cleaned correctly. When asked if she noticed a need for other projects she stated, “I honestly don’t know”. Review of EOC (Environment of Care) round (rounds conducted by a team, usually on a scheduled basis, to ensure the safety and well-being of patients, staff, and visitors. These rounds may focus on maintenance of the environment, versus infection control, in the facility), rounds documentation was requested but was not received. During a review of hospital documents titled, “EOC Meeting Minutes” dated 5/13/25, 6/11/25,7/10/25, 8/12/25,9/19/25, and 10/17/25, the “EOC Meeting Minutes” indicated, only one meeting discussed any issues in the Kitchen. The meeting on 8/12/25 the crack on the floor was discussed. None of the other meetings discussed any other infection control issues relating to the environment of care throughout the hospital. During a review of the hospital’s P&P titled, “Infection Control & Prevention”, dated 1/25, indicated, “ ...Identification of healthcare acquired infections through completion of infection control surveillance. All hospitals will utilize National Healthcare Safety Network criteria for defining an infection. The governing board has ultimate responsibility for hospital performance, including infection prevention. ...The Medical Executive Committee is responsible for overseeing the Infection Control Program and delegates the responsibility of monitoring infection control processes and procedures to the Infection Control Committee ... The Infection Preventionist assumes the responsibility of managing and carrying out the infection surveillance, prevention and control functions within the hospital. This person has training in infection surveillance, prevention and control. ...The Infection Preventionist is responsible for coordinating activity within the Infection Control Committee and reporting findings to the Quality Assurance and Performance Improvement Committee ...”. During a record review meeting minutes from the last six IPC meetings were requested, only July 2025 was provided, and it was a slideshow and not the minutes from the meeting. Review of the “Infection Prevention & Control Committee Meeting” dated 7/14/25, showed the committee discussing monitoring and evaluating infections: Review of Healthcare infections. The data presented was hand hygiene, and personal protective equipment, and number of hospitals acquired infections. There was no mention of the Nutrition Services Department in the IPC Meeting. During a review of the hospital’s P&P titled, “Environment of Care Committee (ECC) - Meetings and Accessibility”, dated 10/24, indicated, “ ...in order to effectively carry out the task of monitoring and implementing action plans related to management of the Environment of Care, the committee will meet at least quarterly and will include representation from Administration, Clinical Services and other Support Services as required ...””