Ballard Rehabilitation Hospital

“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: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure safe and effective quality of care for a universe of 31 sampled patients who were admitted on February 2, 2026, when the GB did not provide effective oversight of quality improvement program related to patient safety and quality care for nursing shift assessments (assessment that a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, vital signs including blood pressure measurements, breathing, heart, pain, skin, and safety), wound care implementation, pain medication appropriateness, pain reassessments, and care plan (documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, changes in condition (any significant alteration in the patient’s health status), and specifies the nursing interventions and evaluations required to achieve those goals) initiation and application. (Refer to A0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe environment.”

“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: 51099 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 31 sampled patients who were admitted on February 2, 2026, as evidenced by: 1. The facility did not ensure an ongoing program to monitor, collect data and analyze nursing shift assessment (head-to-toe assessment that a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, vital signs including blood pressure measurements, breathing, heart, pain, skin, and safety) completion, level of consciousness and neurological effects of opioids (strong pain medication cause drowsiness and fog), changes in condition (any significant alteration in the patient’s health status), and injection site rotations (switching the spot prevents the hard lump formation and for the easy absorption of the medicine). (Refer to A-0273) 2. The facility did not maintain an effective and ongoing hospital wide, data driven QAPI program to identify opportunities from the collected data of the issues addressing nursing order implementation, wound care treatment as per the physician order documentation, and pain management and re-assessments. (Refer to A-0283). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem-prone areas, implement effective performance improvement activities, and ensure the provision of quality health care services in nursing services and patient assessments, which could place patients at risk for harm.”

“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: 51099 Based on interview and record review, the facility failed to maintain an effective and organized nursing services for 12 of 31 sampled patients (Patient 1, 2, 4, 5, 6, 7, 21, 22, 24, 25, 27, and 28), as evidenced by: 1. For two patients (Patient 25 and 27), pain management care plans (documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) were not initiated or updated experiencing ongoing and documented pain throughout stay. (Refer to A-0396). 2. For three patients (Patient 4, 5, and 6), the nursing staff did not implement or document appropriate nursing interventions for reported severe pain. (Refer to A-0398) 3. For five patients (Patients 7, 21, 25, 27 and 28), the nursing staff did not reassess pain and evaluate the effectiveness of pain interventions. (Refer to A-0398) 4. For two patients (Patient 22 and 24), the nursing staff did not ensure required nursing assessments (head-to-check assessment a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, breathing, heart, pain, skin, and safety) were completed/documented by a Registered Nurse (RN) within one hour outlined by facility policy. (Refer to A-0398) 5. For one patient (Patient 28), the nursing staff did not ensure ordered wound care treatment orders were carried out and documented. (Refer to A-0398) 6. For one patient (Patient 1), the nursing staff did not take action according to policy when the patient was experiencing low blood pressure (normal adult systolic pressure or top number less than 120 and diastolic pressure or bottom number less than 80, which low pressure can cause adverse outcomes such as dizziness, fainting, and altered level of consciousness). (Refer to A-0398) 7. For one patient (Patient 2), injection sites were not rotated or alternated in accordance with the drug manufacturer instructions. (Refer to A-0405) The cumulative effects of these systemic problems resulted in the facility’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, evaluation, and treatment, which jeopardized the health and safety of the patients.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to identify and ensure patient safety and provide quality care for for 12 of 31 sampled patients (Patient 1, 2, 4, 5, 6, 7, 21, 22, 24, 25, 27, and 28), when the GB did not have an effective oversight on nursing surveillance related to wound care order implementation, consistent nursing shift assessments (assessment that a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, vital signs including blood pressure measurements, breathing, heart, pain, skin, and safety), pain reassessments, pain medication appropriateness, care plan (documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, changes in condition (any significant alteration in the patient’s health status),and specifies the nursing interventions and evaluations required to achieve those goals) initiation and implementation, and alternating injection sites. These failures resulted in the facility’s failure to identify the problem prone areas and deliver care with the GB oversight, and to provide safe patient care environment with adequate supervision, which could jeopardize the health and safety of the patients. Findings: During a review of the facility documents titled, “[Name of Facility] Governing Board Meeting,” dated June 3, 2025, through December 19, 2025, the documents indicated quality care outcomes and identified safety concerns discussed at Quality Assessment and Performance Improvement (QAPI) meetings. The meeting minutes included updates related to dietary issues and facility plant operations, but there was no documented data of nursing surveillance related to nursing shift assessments, pain re-assessments, pain management, care plans, injection sites, change of condition, or wound care. During an interview on February 5, 2026, at 3:20 PM, in the conference room, with the members of the GB: Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO), the survey team’s following findings were discussed: pain reassessments were not completed in accordance with facility policy (Patients 7, 21, 25, 27 and 28); pain management care plans were not initiated nor implemented for patients experiencing pain (Patient 25 and 27); wound care treatment orders were not completed as ordered (Patient 28); nursing shift assessments were not consistently completed within four hours of the starting shift (Patient 22 and 24); injection sites for blood thinner (medication that helps prevent dangerous blood clots) were not rotated (Patient 2); and nursing staff did not properly document patient’s change of condition(Patient 1). The CEO stated the GB was aware of issues with pain management and gaps in timely re-assessments after pain medication administration, but not regarding concerns about wound care order implementation, injection site rotation, or change of condition documentation. The CEO and CNO stated, quality monitoring was limited in scope and focused primarily on select indicators, such as pain assessment documentation and antibiotic (medication that treats bacterial infections) usage. The CEO stated, GB has overall responsibility for the facility and for overall patient safety. During a review of Patient 1’s “Pre-Admission Screening” document signed by Physician 1 (MD 1), dated December 17, 2025, indicated the patient was diagnosed with a comorbidity (disease or medical condition) of “htn [hypertension - high blood pressure].” During a review of Patient 1’s “Nursing Admission Assessment Findings” document signed by Registered Nurse 1 (RN 1), dated December 17, 2025, at 10:23 PM, the assessment indicated “bp [blood pressure] was very low until repositioned and then bp came up but still on the low side.” During a review of Patient 1’s “Change in Condition [any significant alteration in the patient’s health status]” form signed by RN 2, dated December 18, 2025, the form indicated a “Change in Condition” incident was called at 9:36 AM on December 18, 2025. The section of the form titled “SITUATION/What occurred” indicated, “arrived in patients room and completed bedside report, pt arousable, and return to sleep once nurse left. when nurse arrived to pass medication, patient was slightly confused however aox4 [alert and oriented], patient stated she was going swimming with a friend and needed to get dressed, also stated there was construction going on in hospital and to “excuse the mess” informed pt [patient] no construction was taking place at the hospital. Informed MD [name of MD 2] at 0833 [on December 18, 2025] via telephone, stated discontinue morphine [opioid] and retrieved UA [urinalysis - urine test] from patient to rule out UTI [urinary tract infection]. morning continued and pt later go more confused when interacting with Physical therapy, husband arrived and nurse asked if patient has ever acted like this before, stated no, this is new, informed MD again at 0936 about husbands concerns and MD stated to med out [transfer patient out of the facility] patient. Blood pressure 94/52, hr 72. ambulance arrived and vitals 86/52 with them and finger stick glucose 121. Husband requesting for patient to go to [name of Hospital A], EMT [emergency medical technician] initially agreed then stated that bp was too low. Patient left at 1019 with ambulance to [name of Hospital C] with TSLO [Thoracolumbar Sacral Orthosis - rigid medical device to stabilize the spine] brace on as ordered.” During a continued GB interview on February 5, 2026, at 3:30 PM, the CEO stated the hospital (Hospital B) did not make any systemic changes after Patient 1’s incident and transfer to a higher level of care (Hospital C). During a review of the facility’s document titled, “2025 Performance Improvement Plan,” undated, the document indicated, “...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 ...The Governing Board has the ultimate oversight responsibility and delegates’ program responsibility to The Quality Assessment and Performance Improvement (QAPI) committee ...” During a review of the facility’s document titled, “[name of facility] Governing Board Bylaws,” dated November 21, 2019, the document indicated, “ ...Section 2. Functions and Duties of the Governing Board...Quality Assessment and Performance Improvement (QAPI). Consistent with applicable law and regulations, the Governing Board shall require the Medical Staff and staffs of the departments/services to implement a hospital-wide quality assessment and performance improvement plan which reports on the activities and mechanisms for monitoring and evaluating the quality and safety of patient care at the Hospital, for identifying opportunities to improve patient care, and for identifying and resolving problems, including, but not limited to, monitoring and auditing of such departments and service lines of the Hospital. The Governing Board, through the Chief Executive Officer and the Medical Staff’s Chief of Staff, shall support these activities and mechanisms. The Governing Board shall provide for resources and support systems for the quality assessment and improvement and risk management functions related to quality, patient care and safety at the Hospital. The Governing Board shall consider and, if necessary, act upon the results reported from QAPI activities, which activities shall strive to satisfy the following objectives ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51099 Based on interview and record review, the facility did not ensure an effective and ongoing Quality Assessment and Performance Improvement (QAPI -is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for12 of 31 sampled patients (Patient 1, 2, 4, 5, 6, 7, 21, 22, 24, 25, 27, and 28), when the facility failed to monitor, collect data and analyze nursing shift assessment (head-to-toe assessment that a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, vital signs including blood pressure measurements, breathing, heart, pain, skin, and safety) and processes, level of consciousness and neurological effects of pain medication, changes in condition (any significant alteration in the patient’s health status) and alternating injection sites as per manufacturer’s guidance. These failures had resulted in the missed opportunities to identify issues and created changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: During an interview on February 5, 2026, at 2:34 PM, with seven members of the QAPI: Professional Development Coordinator (PDC), Chief Nursing Officer (CNO), Vice President for Case Management (VPCM), Director of Therapy (DOT), Chief Executive Officer (CEO), Quality Management Assistant (QMA), and the Director of Pharmacy (DOP), the facility’s QAPI program was discussed. The QMA stated the quality department oversees the QAPI program, which meets monthly. The QMA further stated, every department has assigned indicators for performance improvement and data gets collected and analyzed to QAPI before being submitted to the Governing Board (GB - a group of people responsible for the overall direction and management of an organization). During a concurrent interview and record review on February 5, 2026, at 2:45 PM, with the facility’s QAPI members, the facility’s QAPI meeting minutes dated November 19, 2025, through January 21, 2026, were reviewed. The documents indicated that the facility actively tracked pain assessments and reassessments, and overall efficacy of pain medication. The CNO confirmed there was no evidence of data collection, tracking, or trending related to nursing shift assessments, level of consciousness and neurological effects related to opioid or pain medication administration, nor injection site rotations (switching the spot prevents the hard lump formation and for the easy absorption of the medicine). During a follow-up interview on February 5, 2026, at 3:00 PM, the survey team brought up some of the issues identified during survey as follows: incomplete nursing shift assessments (Patient 22 and 24), pain management care plans (documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) were not being initiated or documented (Patient 25 and 27), and blood thinner (medication that helps prevent dangerous blood clots) injection sites were not being rotated consistently (Patient 2). The CNO stated that the facility was not aware of these issues but should have been collecting data. The CNO further stated, the facility is tracking patient satisfaction where the nursing staff ask patients regarding controlled pain, but it was applicable only at discharge. The CNO and CEO stated the facility does random audits, but there were no specific indicators for wound order completion, nursing shift assessment completion, or injection site tracking. During a continued QAPI interview on February 5, 2026, at 3:07 PM, the CNO stated the hospital (Hospital B) did not identify anything should have been done differently regarding Patient 1’s incident and transfer to a higher level of care (Hospital C). A record review of the facility’s policy and procedure (P&P) titled, “2025 Performance Improvement Plan,” undated, was reviewed. The P&P indicated, “ ...The 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 staff; Implementing operational activities that are consistent with the Strategic Plan and the Mission, Vision and Values of the hospital ...Evaluating the effectiveness of action taken to improve a process ...Assuring that results, findings and improvement information are communicated ...measurement is the systemic collection of data .... The collected data will be assessed systemically ...””

“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: 51099 Based on interview and record review, the facility did not ensure the Quality Assessment and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) maintained an effective and ongoing hospital wide, data driven program to identify opportunities from the collected data for 12 of 31 sampled patients (Patient 1, 2, 4, 5, 6, 7, 21, 22, 24, 25, 27, and 28), when the QAPI program did not identify the issues regarding pain management, wound care implementation, and did not utilize the collected data for pain reassessments for improvement to patient outcomes to measure its success and the improvements are sustained. This failure resulted in the hospital’s inability to focus on problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment, leading to serious patient safety events, placing patients at risk for harm. Findings: During an interview on February 5, 2026, at 2:34 PM, with seven members of the QAPI: Professional Development Coordinator (PDC), Chief Nursing Officer (CNO), Vice President for Case Management (VPCM), Director of Therapy (DT), Chief Executive Officer (CEO), Quality Management Assistant (QMA), and the Director of Pharmacy (DOP), the facility’s QAPI program was discussed. The QMA stated the quality department oversees the QAPI program, which meets monthly. The QMA further stated, every department has assigned indicators for performance improvement and data gets collected and analyzed to QAPI before being submitted to the Governing Board (GB-a group of people responsible for the overall direction and management of an organization). During a concurrent interview and record review on February 5, 2026, at 2:45 PM, with the facility’s QAPI members, the facility’s QAPI meeting minutes dated November 19, 2025, through January 21, 2026, were reviewed. The documents indicated that the facility actively tracked pain assessments and reassessments, and overall efficacy of pain medication. The documents further indicated, current audits with medication, specifically antibiotics (medication that treats bacterial infections), for medication administration. The CNO confirmed the facility also tracked patient satisfaction in relation to pain control throughout stay, but it was conducted during discharge and not during stay. The CEO confirmed that the facility was tracking wounds on admission and developed during stay but did not audit wound care order implementation or documentation. The CEO stated thatthe facility utilizes tracked data for performance improvement but acknowledges there are gaps in performance improvement. During a follow-up interview on February 5, 2026, at 3:00 PM, the survey team brought up some of the issues identified during survey as follows: pain reassessments were not completed within an hour timeframe (Patients 7, 21, 25, 27 and 28), nursing staff did not document interventions or address pain (Patients 4, 5, and 6), wound care orders were not carried out (Patient 28), and clinical appropriateness of drugs were not assessed prior to administration (Patient 1). The CNO stated, the facility conducts random chart audits that focus on pain assessment and medication administration, but admitted gaps still remain with improvement in performance. The CNO further stated, wounds are also tracked by the facility but not specifically indicators related to wound order implementation. The DOP stated, Pharmacy is focused on certain medications and antibiotics for auditing medication administration, but there is no general tracking done for opioids (strong pain medication). A record review of the facility’s policy and procedure (P&P) titled, “2025 Performance Improvement Plan,” revised, undated, was reviewed. The P&P indicated, “ ...The 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 staff; Implementing operational activities that are consistent with the Strategic Plan and the Mission, Vision and Values of the hospital ...Evaluating the effectiveness of action taken to improve a process ...Assuring that results, findings and improvement information are communicated ...measurement is the systemic collection of data .... The collected data will be assessed systemically ...””

“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: 51099 Based on interview and record review, the facility failed to ensure nursing staff developed and maintained an individualized nursing care plan (documented, organized guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve those goals) per the facility’s policy and procedure (P&P) “Care Planning,” to address pain management for two of 31 sampled patients (Patients 25 and 27), throughout their stay. This failure had the potential to result in unmanaged or inadequately managed pain, lack of coordinated interdisciplinary interventions, and compromised continuity of care necessary to support patient participation in rehabilitation services. Findings: 1. A review of Patient 25’s face sheet (contains medical and demographic information) indicated, Patient 25 was admitted to the facility on January 29, 2026, with diagnoses including ischemic stroke (a blocked blood vessel in the brain, leading to insufficient oxygen to the brain and causing the brain cells to die); hypertension (when blood pushes too hard against the walls of the blood vessels over time); and renal transplant (surgery where a person with kidney failure gets a healthy kidney from a donor). A review of Patient 25’s “Active Orders,” dated January 30, 2026, indicated, Patient 25 was ordered “Acetaminophen [Tylenol - medication that relieves pain and lowers fever] 325MG (milligram - unit of measure) by mouth every six hours PRN (as needed) ...indication: headache ...” During a concurrent interview and record review on February 3, 2026, at 10:44 AM, with the Medical Record Director (MRD) and the Professional Development Coordinator (PDC), Patient 25’s “Vitals Flowsheet” (charting table where nurses and providers record and track a patient’s vital signs over time; includes blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain score), dated January 30, 2026, through February 1, 2026, were reviewed. The “Vitals Flowsheet,” indicated Patient 25’s pain score: - January 30, 2026, at 8:00 AM: pain 6/10 - January 31, 2026, at 3:36 PM: pain 10/10 - January 31, 2026, at 10:04 PM: pain 8/10 - January 31, 2026, at 11:19 PM: pain 8/10 - February 1, 2026, at 4:34 AM: pain 7/10 - February 1, 2026, at 10:34 AM: pain 10/10 - February 1, 2026, at 12:30 PM: pain 6/10 - February 1, 2026, at 10:31 PM: pain 8/10. The MRD and PDC confirmed Patient 25’s medical record indicated repeated documentation of pain throughout stay. During a concurrent interview and record review on February 3, 2026, at 10:48 AM, with the MRD and PDC, Patient 25’s “Care Plan,” dated February 3, 2026, was reviewed. The facility document indicated there was no pain management problem or interventions addressing pain. The MRD confirmed there was no pain management care plan for Patient 25 and stated Patient 25 should have had one initiated since Patient 25 has been experiencing pain throughout the stay. 2. A review of Patient 27’s face sheet indicated, Patient 27 was admitted to the facility on January 27, 2026, with diagnoses including right humeral surgical neck fracture (break in the upper arm bone, right below the shoulder, on the right side) and blunt head trauma (injury to the head or brain caused by a hit, fall, or impact). A review of Patient 27’s “Active Orders,” dated January 27, 2026, indicated, Patient 27 was ordered “Hydrocodone-acetaminophen 10-325MG [Norco - a combination medication used to treat pain] give 1 tablet by mouth every four hours PRN ...for moderate to severe pain (4-10).” During a concurrent interview and record review on February 3, 2026, at 11:20 AM, with the MRD and PDC, Patient 27’s “Vitals Flowsheet,” dated January 28, 2026, through January 30, 2026, were reviewed. The “Vitals Flowsheet” indicated Patient 27’s pain assessment rating at the following dates and times: - January 28, 2026, at 12:34 AM: pain 8/10 - January 28, 2026, at 6:34 AM: pain 8/10 - January 28, 2026, at 1:00 PM: pain 10/10 - January 28, 2026, at 3:15 PM: pain 8/10 - January 29, 2026, at 1:23 AM: pain 9/10 - January 29, 2026, at 6:02 AM: pain 9/10 - January 29, 2026, at 8:30 AM: pain 10/10 - January 29, 2026, at 3:00 PM: pain 10/10 - January 30, 2026, at 7:39 AM: pain 10/10 The MRD and PDC confirmed Patient 27’s medical record indicated repeated documentation of pain throughout the stay. During a concurrent interview and record review on February 3, 2026, at 11:30 AM, with the MRD and PDC, Patient 27’s “Care Plan,” dated February 3, 2026, was reviewed. The facility document indicated there was no pain management problem or interventions addressing pain. The MRD confirmed there was no documented evidence to indicate Patient 27’s pain management care plan was initiated. The MRD further stated facility should have initiated a care plan since Patient 25 has been experiencing pain throughout stay. During a concurrent interview and record review on February 4, 2026, at 3:49 PM, with the Chief Nursing Officer (CNO), the facility’s policy and procedure (P&P) titled, “Care Planning,” revised October 2025, was reviewed. The P&P indicated, “ ...5. The plan of care is maintained and updated based upon ongoing patient assessments and the patients response to care, treatment, and services ...the plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family ....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 mee the needs of the patient’s changing condition ...” The CNO stated the facility did not follow the policy.”

“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: 51828 Based on interview and record review, the facility failed to ensure nursing services were provided in accordance with accepted standards of practice and the facility’s policies and procedures (P&P) to meet the nursing care needs for 11 of 31 sampled patients (Patient 1, 4, 5, 6, 7, 21, 22, 24, 25, 27, and 28) when: 1. For three patients (Patient 4, 5, and 6), the nursing staff failed to implement or document appropriate nursing interventions for reported severe pain despite as needed (PRN) pain medication orders. 2. For five patients (Patient 7, 21, 25, 27 and 28), pain re-assessments were not completed within the timeframe required by facility policy after administration of pain medications. 3. For two patients (Patient 22 and 24), required nursing assessments (head-to-toe assessment that a nurse does at the start of the shift to evaluate how a patient is doing, including checking mental status, breathing, heart, pain, skin, and safety) were not completed or documented by a Registered Nurse (RN) within an hour outlined by facility policy. 4. For one patient (Patient 28), wound care treatments were not completed or documented as per the physician’s order. 5. For one patient (Patient 1), the nursing staff did not take action according to policy when the patient was experiencing low blood pressure (normal adult systolic pressure or top number less than 120 and diastolic pressure or bottom number less than 80, which low pressure can cause adverse outcomes such as dizziness, fainting, and altered level of consciousness). (Refer to A-0398) These failures resulted in the potential for patients to experience unmanaged pain, delayed recognition of changes in condition, interruption in wound healing, and compromised continuity and quality of nursing care, which could increase risk for adverse outcomes and limit their ability to safely participate in rehabilitation services. Findings: 1a. During a review of Patient 4’s “History and Physical” (H&P - a document containing patient history and current medical issues), dated January 30, 2026, the H&P indicated, Patient 4 was admitted on January 29, 2026, with diagnosis including ischemic stroke (a blocked blood vessel in the brain, leading to insufficient oxygen to the brain and causing the brain cells to die). During a concurrent interview and record review on February 3, 2026, at 8:06 AM, with the Professional Development Coordinator (PDC), Patient 4’s “Vital Sign [charting table where nurses and providers record and track a patient’s vital signs over time; includes blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain score],” dated February 1, 2026, through February 4, 2026, were reviewed. Patient 4’s “Vital Sign” indicated, Patient 4’s reported pain as follows: - On February 1, 2026, at 10:02 AM, with pain score (a pain rating scale where 0 indicates no pain, and 10 being the most pain] of 9 out of 10 [9/10]. - On February 1, 2026, at 11:53 PM, with pain score of 8/10. - On February 2, 2026, at 5:57 AM, with pain score of 8/10 - On February 4, 2026, at 8:20AM, with pain score of 9/10. The PDC verified and stated there was no pain medication given to Patient 4’s reported pain scores. 1b. During a review of Patient 5’s H&P, dated January 3, 2026, the H&P indicated, Patient 5 was admitted on January 2, 2026 with diagnoses including a laparoscopic robotic Roux-en-Y gastric bypass (a highly effective, often laparoscopic, weight-loss procedure that staples the stomach into a small egg-sized pouch and redirects the small intestine, restricting food intake and nutrient absorption), seizure (sudden, uncontrollable bursts of electrical activity in the brain that cause temporary changes in movement, behavior, sensation, or awareness), and neuralgia (sharp, shocking nerve pain from irritation or damage, causing burning, tingling, or electric shock sensations along a nerve’s path). During a concurrent interview and record review on February 3, 2026, at 9:46 AM, with the PDC, Patient 5’s “Vital Sign,” dated January 31, 2026, through February 2, 2026, were reviewed. Patient 5’s “Vital Sign” indicated Patient 5 reported pain as follows: - On January 31, 2026, at 7:19 AM, with pain of 7/10. - On February 2, 2026, at 7:21 AM, with pain of 7/10. The PDC verified and stated there was no pain medication given to Patient 5’s reported pain scores. 1c. During a review of Patient 6’s H&P, dated January 31, 2026, the H&P indicated, Patient 6 was admitted on January 29, 2026, with diagnosis of a major multiple trauma - brain and spinal cord injury. During a concurrent interview and record review on February 3, 2026, at 10:42 AM, with the PDC, Patient 6’s “Vital Sign,” dated February 2, 2026, was reviewed. Patient 6’s “Vital Sign” indicated Patient 6 reported pain as follows: - On February 2, 2026, at 7:00 AM, with pain of 8/10. - On February 2, 2026, at 8:08 AM, with pain of 8/10. The PDC verified and stated there was no pain medication given to Patient 6’s reported pain scores. During a concurrent interview and record review on February 4, 2026, at 3:07 PM, with the Chief Nursing Officer (CNO), the facility’s P&P, titled “Pain Assessment and Management,” revised October 2025, was reviewed. The P&P indicated, “ ...Policy: Management of a patient’s pain includes individualized assessment, intervention and evaluation of pain and pain relief. A patient’s self-reported of pain will be accepted as the most reliable indicator of pain ... Assessment: Patients are assessed for pain at the Hospital on admission and then reassessed at least every shift. Patients that are administered pain medication will be reassessed within 1 hour of administration. Follow-up documentation includes a reassessment of the numerical pain intensity scale.” The CNO stated the facility’s P&P was not followed for Patient 4, 5, and 6, and should have been. 2a. During a review of Patient 7’s H&P, dated January 22, 2026, the H&P indicated, Patient 7 was admitted on January 21, 2026, with the diagnosis of major multiple trauma - brain and spinal cord injury (a catastrophic, high-mortality event often resulting from high-impact accidents, falls, or violence). During a concurrent interview and record review on February 3, 2026, at 11:06 AM, with the PDC, Patient 7’s “Vital Sign” and Medication Administration Record (MAR), dated February 2, 2026, were reviewed. The “Vital Sign” and MAR indicated Patient 7’s reported pain as follows: - On February 2, 2026, at 11:18 AM, “Vital Sign” indicated Patient 7 reported pain 8 out of 10 (8/10). The PDC verified Patient 7’s MAR indicated, “Acetaminophen [Tylenol - medication that relieves pain and lowers fever] 500 mg [milligram - unit of measurement]” was administered to Patient 7. The PDC stated there was no evidence of facility reassessment of patient’s pain following medication administration. 51099 2b. A review of Patient 21’s face sheet (contains medical and demographic information), indicated, Patient 21 was admitted to the facility on January 13, 2026, with the diagnoses including cervical spine injury (C-spine injury - injury to the neck part of the spine) quadriplegia (paralysis of all four limbs) and central cord compression (pressure on the center part of the spinal cord). A review of Patient 21’s “Active Orders,” dated February 1, 2026, indicated, Patient 27 was ordered “Hydrocodone-acetaminophen [Norco - a combination medication used to treat pain] 10-325 MG for moderate to severe pain (7-10) ...indication: pain “ During a concurrent interview and record review on February 3, 2026, at 3:44 PM, with the Medical Record Director (MRD) and the PDC, Patient 21’s MAR, dated February 3, 2026, was reviewed. The MAR indicated “Norco -10 MG” was administered on February 1, 2026, at 10:28 AM, for pain rated 9/10. The MAR further indicated that Patient 21 was re-assessed for pain on February 1, 2026, at 1:51 PM (approximately three hours after administration). The MRD and PDC confirmed there was no documentation of pain reassessment within one hour of medication administration for this event. 2c. A review of Patient 25’s face sheet indicated Patient 25 was admitted to the facility on January 29, 2026, with diagnoses including ischemic stroke; hypertension (when blood pushes too hard against the walls of the blood vessels over time); and renal transplant (surgery where a person with kidney failure gets a healthy kidney from a donor). A review of Patient 25’s “Active Orders,” dated January 30, 2026, indicated that Patient 25 was ordered “Acetaminophen 325 MG by mouth every six hours PRN...indication: headache ...” During a concurrent interview and record review on February 3, 2026, at 10:44 AM, with the MRD and PDC, Patient 25’s “Vitals Flowsheet” and MAR, dated January 31, 2026, were reviewed. The “Vitals Flowsheet,” indicated Patient 25 experienced pain on January 31, 2026, at 3:36 PM, rated 10 out of 10. Patient 25’s MAR indicated, Acetaminophen 325 MG, was administered to Patient 25 at the same time. Patient 25 was re-assessed at 10:04 PM (approximately six hours and 30 minutes after administration). The MRD and PDC confirmed there was no documentation of pain reassessment within one hour of medication administration for this event. 2d. A review of Patient 27’s face sheet indicated, Patient 27 was admitted to the facility on January 27, 2026, with diagnoses including right humeral surgical neck fracture (break in the upper arm bone, right below the shoulder, on the right side) and blunt head trauma (injury to the head or brain caused by a hit, fall, or impact). A review of Patient 27’s “Active Orders,” dated January 27, 2026, indicated “Hydrocodone-acetaminophen 10-325 MG for moderate to severe pain (4-10).” During a concurrent interview and record review on February 3, 2026, at 11:20 AM, with the MRD and PDC, Patient 27’s MAR, dated January 27, 2026, was reviewed. The MAR indicated, Hydrocodone-acetaminophen 10-325 MG (1 tablet) was given on January 28, 2026, at 1:13 PM, for pain rated nine out of 10. Patient 27 was re-assessed for pain after medication administration at 6:54 PM (approximately seven hours after administration). The MRD and PDC confirmed there was no documented evidence to indicate pain reassessment was completed within one hour of medication administration. 2e. A review of Patient 28’s face sheet indicated, Patient 28 was admitted to the facility on January 24, 2026, with the diagnoses including debility (general weakness and loss of strength, usually after illness, injury, or long hospital stays); type 2 diabetes mellitus (when the body does not use insulin [hormone that helps sugar move from the blood into the cells so the body uses it for energy] well, so blood sugar stays too high); and hypertension. A review of Patient 28’s “Active Orders,” dated January 24, 2026, indicated that Patient 28 was ordered “Hydrocodone-acetaminophen 10-325MG ...give 1 tablet by mouth every four hours PRN ... for severe pain (7-10) ...” During a concurrent interview and record review on February 3, 2026, at 2:53 PM, with the MRD and PDC, Patient 28’s MAR, dated January 25, 2028, was reviewed. The MAR indicated, “Hydrocodone-acetaminophen 10-325MG” was administered to Patient 28 on January 25, 2026, at 10:04 AM, for pain rated 10 out of 10. Patient 28 was re-assessed for pain after pain medication administration at 12:12 PM (approximately two hours after administration). The MRD and PDC confirmed there was no documented evidence to indicate Patient 28’s pain reassessment was completed within one hour of medication administration. During a concurrent interview and record review on February 4, 2026, at 3:34 PM, with the CNO, the facility’s P&P, titled “Pain Assessment and Management,” revised October 2025, was reviewed. The P&P indicated, “ ...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 ... Documentation in the EMAR on effectiveness must be completed using same scale used for pain assessment within 1 hour ...” The CNO stated the policy was not followed for Patient 7, 21, 25, 27 and 28, as nursing staff did not re-assess within the policy’s expected timeframes. The CNO further stated, it was important to follow up in a timely manner to check for the effectiveness of the medication since it is part of patient recovery and pain should be well-controlled for the patient to actively participate in therapy. 3a. A review of Patient 22’s face sheet indicated, Patient 22 was admitted to the facility on January 29, 2026, with diagnoses including septic shock (life-threatening condition where a severe infection causes very low blood pressure and organ failure); and urinary tract infection (UTI- infection in any part of the urinary system [bladder, kidneys, ureters, or urethra]). During a concurrent interview and record review on February 3, 2026, at 8:47 AM, with the MRD and PDC, Patient 22’s “Nursing Shift Assessment,” dated January 31, 2026, through February 3, 2026, were reviewed. The “Nursing Shift Assessment” was missing from February 2, 2026, at 7:00 PM, through February 3, 2026, at 7:00 AM (night shift, starting from 7:00 PM to 7:00 AM). The MRD and PDC were unable to provide documented evidence to indicate Patient 22’s nursing shift assessments were completed from February 2, 2026, 7:00 PM, through February 3, 2026, 7:00 AM. The PDC further stated, nursing shift assessments must be completed per shift, and it was not done. 3b. A review of Patient 24’s face sheet indicated, Patient 24 was admitted to the facility on January 23, 2026, with diagnoses including impaired mobility (difficulty moving the body safely or independently); systolic congestive heart failure (CHF - heart is weak and cannot pump well) exacerbation (sudden worsening of systolic heart failure symptoms); and hypertension. During a concurrent interview and record review on February 3, 2026, at 9:44 AM, with the MRD and PDC, Patient 24’s “Nursing Shift Assessment,” dated January 28, 2026, through January 29, 2026, were reviewed. The “Nursing Shift Assessment” was missing from January 28, 2026, at 7:00 PM, through January 29, 2026, at 7:00 AM. The MRD and PDC were unable to provide documented evidence to indicate Patient 24’s nursing shift assessment was completed from January 28, 2026, at 7:00 PM, through January 29, 2026, at 7:00 AM. PDC further stated, nursing shift assessments must be completed per shift, and it was not done. During a concurrent interview and record review on February 4, 2026, at 4:15 PM, with the CNO, the facility’s P&P titled, “Patient Assessment/Reassessment,” revised October 2025, was reviewed. The P&P indicated, “2. The routine patient reassessment includes a system review every shift. 3. The RN is responsible for completing a head-to-toe assessment once every 24 hours. Re-assessment will be documented in the interdisciplinary record. 4. The reassessment of the patient is on-going throughout the patient’s course of hospitalization, and based on the identified needs of the patient with collaboration and coordination of the interdisciplinary team ...this policy will be reviewed annually and updated as required by changes in operations, technology, and/ or other laws, rules and regulations ...” The CNO stated the facility did not follow policy. 4. A review of Patient 28’s face sheet indicated, Patient 28 was admitted to the facility on January 24, 2026, with the diagnoses including debility, type 2 diabetes mellitus, and hypertension. A review of Patient 28’s H&P indicated, “ ...multiple abdominal surgeries ...presented for surgical repair of large supraumbilical and infraumbilical recurrent ventral hernias (hernias [part of an organ or tissue pushes through a weak spot in the muscle] above and below the belly button that have come back again) with excision (surgical cut and removal of tissue) of excessive abdominal and mons (soft, fatty area over the pubic bone) skin on 1/19/26 [January 19, 2026] ...Review of Systems: ...Skin: Abdominal incision ...” A review of Patient 28’s “Active Orders,” dated January 26, 2026, indicated, “Wound Care Treatment Daily, Cleanse with: Cleanser, rinse w/ (with) ns (normal saline or salt water), Comments: cover with dry dressing ...” During a concurrent interview and record review on February 3, 2026, at 2:42 PM, with the MRD and PDC, Patient 28’s “Treatment Administration Record” (TAR), dated January 30, 2026, through February 2, 2026, were reviewed. The TAR indicated the daily wound care treatment was missing from January 31, 2026, through February 1, 2026. The MRD and PDC confirmed there was no documented evidence to indicate Patient 28’s daily wound care treatment was completed from January 31, 2026, through February 1, 2026. During a concurrent interview and record review on February 4, 2026, at 3:58 PM, with the CNO, the facility’s P&P titled, “Skin Integrity and Pressure Injury Prevention,” revised October 2025, was reviewed. The P&P indicated, “ ... 4. Obtains, notes and implements qualified health care provider orders ...” The CNO stated the facility did not follow policy. 35335 5. During a review of Patient 1’s “Pre-Admission Screening” document signed by Physician 1 (MD 1), dated December 17, 2025, indicated the patient was diagnosed with a comorbidity (disease or medical condition) of “htn [hypertension - high blood pressure].” During a review of Patient 1’s “Nursing Admission Assessment Findings” document signed by Registered Nurse 1 (RN 1), dated December 17, 2025, at 10:23 PM, the assessment indicated “bp [blood pressure] was very low until repositioned and then bp came up but still on the low side.” During a review of Patient 1’s “Change in Condition [any significant alteration in the patient’s health status]” form signed by RN 2, dated December 18, 2025, the form indicated a “Change in Condition” incident was called at 9:36 AM on December 18, 2025. The section of the form titled “SITUATION/What occurred” indicated, “arrived in patients room and completed bedside report, pt arousable, and return to sleep once nurse left. when nurse arrived to pass medication, patient was slightly confused however aox4 [alert and oriented], patient stated she was going swimming with a friend and needed to get dressed, also stated there was construction going on in hospital and to “excuse the mess” informed pt [patient] no construction was taking place at the hospital. Informed MD [name of MD 2] at 0833 [on December 18, 2025] via telephone, stated discontinue morphine [opioid] and retrieved UA [urinalysis - urine test] from patient to rule out UTI [urinary tract infection]. morning continued and pt later go more confused when interacting with Physical therapy, husband arrived and nurse asked if patient has ever acted like this before, stated no, this is new, informed MD again at 0936 about husbands concerns and MD stated to med out [transfer patient out of the facility] patient. Blood pressure 94/52, hr 72. ambulance arrived and vitals 86/52 with them and finger stick glucose 121. Husband requesting for patient to go to [name of Hospital A], EMT [emergency medical technician] initially agreed then stated that bp was too low. Patient left at 1019 with ambulance to [name of Hospital C] with TSLO [Thoracolumbar Sacral Orthosis - rigid medical device to stabilize the spine] brace on as ordered.” During a review of Patient 1’s “History and Physical” form signed by MD 3 at Hospital B, dated December 18, 2025, at 10:07 AM, indicated, “Patient was evaluated by rehab medicine, therapists, liaison personnel and was determined to require and to meet criteria for comprehensive acute inpatient rehab. Patient was stabilized and transferred to [the name of the facility] on 12/17/25.” During a review of Patient 1’s “Provider Discharge Summary” form signed by MD 3 at Hospital B, dated December 18, 2025, at 10:12 AM, indicated “Patient presenting with new onset ALOC, confusion, and hallucinations. Patient’s husbands states she has never had these symptoms despite being on chronic pain medications. Per IM [internal medicine], transfer [on December 18, 2025] to acute [higher level of care - Hospital C] for further evaluation.” During an interview on February 4, 2026, at 11:09 AM, with the CNO, the CNO stated there was no physician notification policy. She stated on when to notify the physician to refer to the Change of Condition policy. During an interview on February 4, 2026, at 12:34 PM, with the Quality Management Assistant (QMA), the QMA stated “Corporate confirmed physician notification policy is built into the Change of Condition policy.” During a concurrent interview and record review on February 4, 2026, at 2:15 PM, with RN 1 and the CNO, Patient 1’s medical record was reviewed. The Nursing Patient Care Note” signed by RN 1, dated December 17, 2025, at 9:48 PM, indicated, “this pt arrived to [name of the hospital] at 2015 [8:15 PM] via guerney [wheeled stretcher for transporting patients] ... vs [vital signs] taken. pts vs were bp 88/52 and O2sat [oxygen saturation level - measurement of oxygen level in the body] 87. Applied O2 [supplemental oxygen] at 3LNC [liters of nasal cannula - the flow rate delivered through a tube in the patient’s nose]and O2sat came up to 84%. pt was very drowsy. bp was low. Repositioned pt to lay on her back and HOB [head of bed] was put 15 degrees. bp came up to 96/58.” RN 1 stated she did not see any note in the medical record that she reached out to the physician. RN 1 stated, “there was no reason to call the doctor at that time.” During a concurrent interview and record review on February 5, 2026, at 12:28 PM, with the CNO, Patient 1’s medical record was reviewed. The CNO stated there was no reason for the nursing staff to contact the doctor regarding the vital signs when the patient was admitted to the facility. During a review of the facility’s P&P titled, “Change in Condition” dated October 2025, the P&P 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 ...Change in BP from baseline [starting point] that is not intended by therapeutic intervention ... Any BP <90 systolic, >180 systolic ...Notification: (use SBAR [Situation, Background, Assessment, Recommendation communication framework] format to communicate all critical information) It is the Supervisors responsibility to ensure that the house officer or attending physician is notified in a timely manner, the Medical Director should be notified as well as the Administrator-On-Call ...Documentation: The complete assessment should appear in the Electronic Medical Record (EMR) or Nursing flow sheet for those not on EMR. The SBAR form will be used to document communication about the patient to the MD and will be placed in the progress notes section of the medical record.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35335 Based on interview and record review, the facility failed to ensure safe and effective medication administration for one of 31 sampled patients (Patient 2) when the hospital could not demonstrate the injection sites were rotated for the drug enoxaparin (brand name Lovenox - blood thinner) in accordance with the manufacturer’s instructions. This failure had the potential to result in skin injury such as bruising and hardening and other adverse clinical outcomes. Findings: During a review of Patient 2’s medical record, the History and Physical (H&P - a comprehensive patient assessment) note signed by Physician 1 (MD 1) dated December 7, 2025, the H&P indicated the patient was admitted on December 6, 2025. A continued review of the H&P note indicated, “Monitor for: DVT (deep vein thrombosis - blood clot that forms in a deep vein) ...Patient is a high risk for DVT due to limited activity, weakness, and fatigue.” During a review of Patient 2’s medical record, the medical record indicated a physician’s order dated December 6, 2025, for enoxaparin 30 mg (milligrams - a unit of measurement for dose) injection subcutaneously (under the skin) every 12 hours with the indication of deep vein thrombosis prophylaxis (prevention). During a review of the enoxaparin package insert (PI - document on how to safely and effectively use medications) dated October 2022, provided by the hospital, the PI indicated, “Alternate injection sites between the left and right anterolateral [front side] and left and right posterolateral [back side] abdominal wall.” A continued review of the PI indicated, “You can inject into either the right or left side of your stomach area (abdomen), at least 2 inches away from your belly button and out towards your side ...You should alternate between the left or right side of your stomach each time you give yourself an injection.” During a concurrent interview and record review on February 3, 2026, at 3:09 PM, with Registered Nurse 3 (RN 3), the online facility drug reference for enoxaparin, provided by the hospital, was reviewed. RN 3 stated the drug reference indicated, “Change the injection site each time to lessen injury under the skin.” During an interview on February 3, 2026, at 3:19 PM, with RN 4, RN 4 stated the injection sites are rotated because it can damage the skin and “do not want to create a wound”. During a concurrent interview and record review on February 3, 2026, at 3:26 PM, Patient 2’s Medication Administration Record (MAR - section of the medical record where every medication administration is to be documented) was reviewed with the Chief Nursing Officer (CNO). The CNO acknowledged Pateint 2’s MAR could not demonstrate the enoxaparin injection sites were rotated in accordance with the drug manufacturer’s instructions for the following dates and times: a. Right Lower Abdomen - December 7, 2025, at 5:14 AM - December 7, 2025, at 5:02 PM - December 8, 2025, at 5:11 AM b. Right Lower Abdomen - December 10, 2025, at 6:05 AM - December 10, 2025, at 5:47 PM - December 11, 2025, at 5:13 AM c. Right Lower Abdomen - December 14, 2025, at 5:40 PM - December 15, 2025, at 5:27 AM d. Right Lower Abdomen - December 16, 2025, at 5:30 AM - December 16, 2025, at 5:11 AM e. Right Lower Abdomen - December 18, 2025, at 5:27 PM - December 19, 2025, at 5:12 AM f. Right Lower Abdomen - December 24, 2025, at 5:05 PM - December 25, 2025, at 6:02 AM g. Right Lower Abdomen - December 29, 2025, at 5:55 AM - December 29, 2025, at 5:06 PM - December 30, 2025, at 5:45 AM - December 30, 2025, at 5:09 PM - December 31, 2025, at 5:45 AM h. Left Lower Abdomen - December 31, 2025, at 5:56 PM - January 1, 2026, at 5:49 AM During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications,” dated October 2025, the P&P indicated, “PROCEDURE ...4. Follow preparation directions.” During a review of the facility’s P&P titled, “High Risk / High Alert Medications [drugs known to be error-prone or which pose a significant hazard to the patient if not properly handled],” dated October 2025, the P&P indicated, “High Alert Medications may include but are not limited to the medications below (as within the scope of care of the hospital) ...4 ...low-molecular weight heparin [enoxaparin].””

“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: 47360 Based on observation, interview, and record review, the Governing Body (GB-a group of people responsible for the overall direction and management of an organization) failed to ensure a safe environment and effective quality of care was provided for a universe of 51 patients admitted on August 4, 2025, when: 1. The GB did not ensure the environment of care (EOC- the physical hospital), in the pharmacy and kitchen, was safe, functional, and effective space that supports the delivery of high-quality patient care and the well-being of everyone within the hospital when the temperature in the pharmacy department, where patient medication was stored, was not continually monitored after issues with the HVAC (Heating, Ventilation, Air Conditioning) unit were known by the facility and repairs were not scheduled.. (Refer to A-0049) 2. The GB did not ensure a full-time Registered Dietitian was employed to meet the needs of the nutritional needs of the patients. (Refer to A-0049) 3. The GB did not ensure an effective oversight on hospital wide quality improvement opportunities in problem prone areas and an effective quality improvement program. (Refer to A-0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“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: 47360 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 51 patients admitted on August 4, 2025, when: 1. QAPI did not include data and interventions related to issues with the facilities environment of care (EOC- the physical hospital) including: monitoring of temperatures in the pharmacy after the HVAC (Heating, Ventilation, Air Conditioning) unit was known to have required repairs and the only ice machine in the kitchen was not working since April 2025 (Refer to A-0273) 2. QAPI failed to provide oversight of nutritional patient care needs including: comprehensive nutritional assessments did not include patient interview of physical assessment by the Registered Dietitian (RD) for six of 35 sampled patients (Patients 3, 11, 5, 20, 21, and 23); nutrition reassessments for high-risk patients were not performed on time for four of 35 sampled patients (Patients 25, 24, 21 and 3); and a nutritional Plan of Care was not developed for three of 35 sampled patients (Patient 23, 3, and 21). (Refer to A-0273) 3. QAPI did not provide adequate oversight of pharmaceutical services when the facility failed to identify and monitor issues that could lead to a medication error including: inadequate monitoring for a potential drug-to-drug interaction for Patient 4; an incomplete medication order for Patient 29, and inaccurate medication administration and documentation for Patient 6. (Refer to A-286). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) such as ineffective medications which could result in therapeutic (treatment) failure ,food borne illness (food poisoning) which could require continued hospitalization.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 35335 Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services to meet the needs of patients for three of 35 sampled patients (Patient 4, Patient 6, and Patient 29) when: 1. Eight medications were observed stored outside of the manufacturers’ stipulated (required) temperatures range (68-77 Fahrenheit (F- unit of measurement)) in the Pharmacy Department. (Please refer to A-0491). This failure had the potential for inadequate temperature monitoring, patients receiving ineffective medications which could result in therapeutic (treatment) failure or other adverse clinical outcomes due to exposure to elevated room temperatures. 2. For Patient 29, an unclear PRN (as needed) medication order was not clarified. (Please refer to A-0491) This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals. 3. For Patient 6, a medication was inaccurately charted (documented) in the Medication Administration Record (MAR - section of the medical record where administered medications is documented). (Please refer to A-0491). This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals. 4. For Patient 6, a medication was not given as ordered due to a technology issue. (Please refer to A-0491). This failure resulted in a preventable medication error. 5. For Patient 4, monitoring did not occur in accordance with the drug manufacturer’s prescribing information (PI - document on how to safely use medications) regarding drug-drug interactions (reactions between multiple drugs which makes drugs less effective, cause unexpected side effects, or increase the action of a particular drugs which may affect the safety or efficacy). (Please refer to A-0500). This failure had the potential for the patient to experience increased risk of high potassium levels (can cause heart problems requiring immediate medical attention) due to drug-drug interactions and/or adverse clinical outcomes. 6. One of one medication, available for patient use, requiring protection from light was not stored in accordance with manufacturer’s stipulations (requirements). (Please refer to A-0505). This failure had the potential to result in a patient receiving unusable, ineffective, or deteriorated (reduced quality) medication due to preventable light exposure. The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 41337 Based on observation, interview, and record review, the facility failed to maintain an organized dietary service that are directed and staffed by adequate qualified personnel and to ensure the policy and procedure (P&P) was maintained as evidenced by: 1a. The facility was late on follow-up nutrition assessments for three of 35 sampled patients (Patient 25, 24, 21, and 3) when a patient is labeled, High Nutrition Risk the patient should be seen no less than every 7 days, Moderate Nutrition Risk is no less than every 14 days and low nutrition risk reassessed with changes in condition. (Refer to A-0621) 1b. Six of 35 sampled patients (Patient 3, 11, 5, 20, 21, and 23) did not receive a comprehensive nutritional assessment that included a patient, family or representative interview. (Refer to A-0621) 1c. Facility did not include nutrition interventions on the Plan of Care for three of 35 sampled patients (Patient 23, 3, and 21). (Refer to A-0621) 2a. The kitchen was not in a sanitary condition, which is a repeated finding from a state re-licensing survey that took place 2 months prior for a universe of 51 medically compromised patients who received food and drinks from the kitchen. . (Refer to A-0619) 2b. Ice was not readily available and easily assessable for staff to use on tray line (a process where food is held on a steam table and on ice while staff serve each patient’s meal) because the ice machine had been broken since April 2025 for a universe of 51 medically compromised patients who received food and drinks from the kitchen. (Refer to A-0619) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and quality nutrition care and dietetic services and resulted in the potential to cause poor nutrition status and food borne illness for a universe of 51 medically compromised patients who received food and drinks from the kitchen.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47360 Based on observation, interview, and record review, the facility failed to ensure the Governing Board (GB-a group of people responsible for the overall direction and management of an organization) provided the necessary oversight to maintain the resources and hospital personnel required to meet the needs of the hospital’s patients for a universe of 51 patients admitted on August 4, 2025, when: 1a. The temperature in the pharmacy department, where patient medication was stored, was not continually monitored after issues with the HVAC (Heating, Ventilation, Air Conditioning) unit were known by the facility and repairs were not scheduled. This failure resulted in the pharmacy department temperature increasing to a high of 80 degrees Fahrenheit (F- unit of measurement) on August 4, 2025, at 8:13 AM, and exposing multiple medications to temperatures exceeding manufacturers’ recommendations. 1b. The facility’s only ice machine in the kitchen required replacement and had not been replaced since April. This failure resulted in kitchen staff making their own ice to support the needs of meal preparation and serving of meals, as there was not enough ice to accommodate the needs of 51 patients with a secondary ice maker in the patient care unit. 2. The facility did not employ a full-time Registered Dietitian (RD) for a three-month time to perform comprehensive assessments (a thorough evaluation by gathering information from various sources, analyzing data, and formulating recommendations or action plans), reassessments, and ensure the nutritional needs of patients continually assessed and their needs were met. This failure resulted in lack of comprehensive assessment and on-going evaluation of patients’ nutritional needs and lack of follow-up on ordered nutritional interventions. 3.The GB did not provide oversight of the Quality Assurance Performance Improvement (QAPI) program to ensure problem prone areas of patient care were identified and implementation of interventions were initiated to maintain safe and quality patient care throughout the hospital. This failure resulted in inadequate monitoring and implementation of performance improvement processes in the pharmaceutical services department and nutritional services department, and the potential for inadequate quality of care. Findings: 1a. During a record review of the facility document titled, “[Name of Hospital] Work Order”, dated August 4, 2025, the document indicated, the temperature in the pharmacy was 80 degrees Fahrenheit at 8:13 AM. During a concurrent interview and record review, on August 7, 2025, at 5:19 PM, with the GB, the facility “log” titled, “[Name of Hospital] Pharmacy Room Temperature/Humidity” dated July 2025, was reviewed. The “log” indicated, the HVAC was fixed on July 1, 2025, but then continued to have issues maintaining a cool temperature in the pharmacy throughout the month of July 2025 to the survey entrance date on August 4, 2025. The “log” further indicated, temperatures in the room were not being monitored or documented by the facility staff when the pharmacy was closed during the weekend (August 2, 2025 and August 3, 2025). The Regional Chief Executive Officer (RCEO) stated, she knew the HVAC was fixed in July, but she was unaware that the HVAC continued to have problems after it was fixed and was unable maintain a constant cool temperature in the pharmacy. The RCEO further stated that the temperature needs to be monitored during the weekends when the pharmacy is closed to ensure patients’ medications are stored within manufacturers’ recommendations. 1b. During an observation in the kitchen on August 4, 2025, at 11:45 AM, there was a metal pan with ice and the salads were placed on top of the ice, but there was not enough room for all the salads, so some of the salads were just on the counter. Also, the drinks, fruit cups and the turkey sandwiches were not on ice during tray line. During an interview with Patient 18 in her room on August 4, 2025, at 4:00 PM, Patient 18 stated she does not like that the milk is served warm. The milk should be cold when served. During an interview on August 7, 2025, at 5:25 PM, with the GB (GB included with mailnly RCEO, Vice President (VP), Chief Nursing Officer (CNO), and the Medical Director (MD), the RCEO stated, upon her appointment as CEO at this facility at the end of April 2025, she was notified that the ice machine in the kitchen was not working. The RCEO stated there were two other ice machines in the facility, so she did not think it was an immediate need to get the ice machine in the kitchen replaced. The RCEO stated she was not aware that the ice machines in the nursing area and in the staff room did not produce an adequate amount of ice to support the kitchen needs. A review of the facility’s document titled, “[Name of Parent Company] Hospital Governing Board and Bylaws” dated November 21, 2019, indicated, “ ...Section 2. Functions and Duties of the Governing Board. The functions, authority and duties of the Governing Board shall be consistent with the standards of the Medicare Conditions of Participation, the Joint Commission on Accreditation of Health Care Organizations (JACHO)or other accrediting body of all applicable laws and regulations. Such functions shall include but not be limited to the following ...h. Physical Plant and Personnel. The Governing Board shall oversee the Hospital’s physical plant, resources and personnel required to meet the needs of the hospital’s patients, and shall participate in planning to meet the health needs of the community, in accordance with applicable laws and regulations ...k. Expenses. The Governing Board shall have the authority to incur expenses on individual items that do not exceed limits set from time to time by the managers ...”. 2. During an interview on August 6, 2025, at 4:15 PM, with Registered Dietitian (RD 2), RD 2 stated she has not been a part of Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) meetings for patients at this hospital and has not been requested to provide tracking or feedback regarding nutritional patient quality measures (diet history,assessments). During an interview on August 6, 2025, at 4:37 PM, with RD 1, RD 1 stated he does not participate in the IDT meetings for patients and has not been asked to be a part of the IDT. RD 1 stated, he does participate in the QAPI meetings at the facility. RD 1 stated he does provide performance measures when requested but is not included in the discussion or provide feedback because he is not full-time at the facility. During an interview on August 7, 2025, at 5:30 PM with the GB, the RCEO stated that the facility has utilized two Registered Dietitians to provide nutritional services for the inpatient population as the facility has searched for a full-time RD. The RCEO stated she does not have an answer as to why the RDs are not attending the IDT meetings, or why reassessments are not being performed on time, and nutritional care plans are not being completed. The RCEO stated the facility does not currently have a Chief Nursing Officer (CNO). The RCEO further stated, the whole clinical team reports to the CNO, which may be the reason there has not been oversight of the nutrition department. The Medical Director (MD) stated, it was his expectation that the RD meet with the IDT during patient plan of care meetings. A review of the facility document titled, “[Name of Parent Company] Hospital Governing Board and Bylaws,” dated November 21, 2019, indicated, “ ... the Chief Executive Officer shall represent the hospital in all aspects of its operations. He/she shall make periodic reports to the governing board but his/her line of authority shall derive from the managers. The duties of the chief executive officer shall include but not be limited to the following ... Organization and management of the hospital and its services, departments and subdivisions, delegation of duties and establishment of means of accountability of subordinates ...” 3. During a concurrent interview and record review on August 7, 2025, at 5:40 PM, with GB, the facility document titled, “[Name of Hospital] Annual Governing Board Meeting,” dated June 3, 2025, was reviewed. The document indicated quality measures were presented to the GB, but there were no recommendations, actions of follow-ups regarding these quality measures noted in the GB minutes. The MD stated, the meeting minutes do not reflect the meeting itself. The MD stated, there meeting minutes should be more robust and include interventions, evaluation and the GB’s feedback to reflect the conversation had during the GB meeting. During a review of the facility document titled, “[Name of Parent Company] Hospital Governing Board and Bylaws,” dated November 21, 2019, the document indicated, “ ...Section 2. Functions and Duties of the Governing Board. The functions, authority and duties of the Governing Board shall be consistent with the standards of the Medicare Conditions of Participation, the Joint Commission on Accreditation of Health Care Organizations (JACHO)or other accrediting body of all applicable laws and regulations. Such functions shall include but not be limited to the following ...i. Quality Assessment and Performance Improvement. Consistent with applicable law and regulations, the Governing Board shall require the Medical Staff and staffs of the departments/services to implement a hospital wide quality assessment and performance improvement plan which reports on the activities and mechanisms for monitoring and evaluating the quality and safety of patient care at the hospital, for identifying opportunities to improve patient care, and for identifying and resolving problems, including but not limited to, monitoring and auditing of such departments and services lines of the Hospital. The Governing Board, through the Chief Executive Officer and the Medical Staff’s Chief of Staff, shall support these activities and mechanisms ... The Governing Board shall consider and, if necessary act upon the results reported from QAPI activities, which activities shall strive to satisfy the following objectives: (i) Quality and safety of patient care provided by members of the Medical Staff the Hospital’s employees and all others who provide patient care services at the Hospital; (ii) Use of plans and systemic procedures to objectively assess the quality of care provided at the Hospital; (iii) Implementation of corrective action when problems or opportunities for improvement are identified: and, (iv) The provision of one level of patient care throughout the Hospital ...”.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47360 Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 51 patients admitted on August 4, 2025, when 1. QAPI did not include data and interventions related to issues with the facilities Environment of Care (EOC- the physical hospital) including: monitoring of temperatures in the pharmacy after the HVAC (Heating, Ventilation, Air Conditioning) unit was known to have required repairs and the only ice machine in the kitchen was not working since April 2025. This failure resulted in patients’ medications in the pharmacy being stored in temperatures exceeding manufacturers’ recommendations and three months of inadequate ice production in the kitchen to cool patient foods and beverages. 2. QAPI failed to provide oversight of nutritional patient care needs, when there was not a full-time Registered Dietitian (RD) employed, including: comprehensive nutritional assessments did not include patient interview of physical assessment by the Registered Dietitian (RD) for six of 35 sampled patient (Patients 3, 11, 5, 20, 21, and 23); nutrition reassessments for high-risk patients were not performed on time for four of 35 sampled patients (Patients 25, 24, 21 and 3); and a nutritional Plan of Care was not developed for three of 35 sampled patients (Patient 23, 3, and 21). This failure resulted in assessments being performed without patient interviews, reassessments being missed and the potential to cause poor nutrition status for eight of 35 medically compromised sampled patients and missed opportunities to identify any potential issues of the facility’s performance and to create any changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: 1. During an interview on August 7, 2025, at 10:45 AM, with the Regional Director of Plant Operations (RPO), the RPO stated that the HVAC compressor was replaced on July 1, 2025, but the unit has tripped the breaker several times since it was repaired, which accounts for the temperature rising to 80 degrees Fahrenheit (F- unit of measurement) on August 4, 2025, at 8:13 AM. The RPO stated that the temperatures were not monitored over the weekend when the pharmacy was closed, so there were no temperatures recorded for August 3, 2025, or August 2, 2025. The RPO stated that the facility has been working on a replacement for the kitchen ice machine since April 2025, and a new ice machine is scheduled to arrive on August 11, 2025. The RPO stated, he does not have the installation for the new ice machine scheduled. The RPO further stated, he does not have documentation of a work order for the HVAC unit or the kitchen ice machine, nor documentation to track the process of resolution of these items. The RPO stated, he is not a part of the quality committee and does not participate in any committees here at this facility. During a concurrent interview and record review on August 7, 2025, at 3:19 PM, with the Regional Director of Quality, Risk and Compliance (RDQ) and the Quality Management Assistant (QMA), the facility document titled, “Quality Assurance Performance Improvement (QAPI) Committee,” dated July 25, 2025, was reviewed. The document included a section titled “EOC” which included monitoring for monthly inspection of fire extinguishers and a “Capital Projects Reporting” section, but the section was blank. There was no other quality indicators tracked in the EOC section. The RDQ stated, QAPI had not been monitoring facility specific repair issues such as the HVAC unit or ice machine. 2. During an interview on August 6,2025, at 4:15 PM, with Registered Dietitian (RD 2), RD 2 stated she has not been a part of Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) meetings for patients at this hospital and has not been requested to provide tracking or feedback regarding nutritional patient quality measures. During an interview on August 6, 2025, at 4:37 PM, with RD 1, RD 1 stated he does not participate in the IDT meetings for patients and has not been asked to be a part of the IDT. RD 1 stated, he does participate in the QAPI meetings at the facility. RD 1 stated he does provide performance measures when requested but is not included in the discussion or provide feedback because he is not full-time at the facility. During a concurrent interview and record review on August 7, 2025, at 3:37 PM, with the RDQ and QMA, the facility document titled, “Quality Assurance Performance Improvement (QAPI) Committee,” dated July 25, 2025, was reviewed. The document indicated, nutrition performance indicators being tracked in included: the initial nutrition assessment completed within 72 hours, accuracy of meals served to patients and tube feeding (patient requiring nutrition through a tube in the stomach because they are unable to eat food). The RDQ stated she does not have an answer as to why nutrition reassessments, for Patients 25, 24, 21 and 3, were not done and nutrition plan of care for Patients 23, 3, and 21 were not done. The RDQ stated, these quality measure indicators are not being tracked. The RDQ stated, she was not aware Patients 3, 11, 5, 20, 21, and 23 comprehensive nutrition assessment did not include a patient interview or a physical assessment. The RDQ stated, she does not know the reason the RDs do not participate in the IDT meetings. The RDQ stated, that the RDs would report to the Chief Nursing Officer (CNO), but since that role is vacant, the RDs report to the Chief Executive Officer. The RDQ stated, that the CEO does join the QAPI meetings, but the issues have not been identified as process improvement areas. Durning a review of the facility’s document titled, “2025 PERFORMANCE IMPROVEMENT PLAN,” undated, the document indicated, “ ...The 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 Parent Company] Healthcare. 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. Maintaining the confidentiality of data and information resulting from performance improvement activities. Assuring that results, findings and improvement information are communicated ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47360 Based on interview and record review, the facility failed to identify and track opportunities to reduce medication errors for three of 35 sampled patients (Patients 4, 29, and Patient 6) when: Patient 4 was prescribed multiple medications that may result in hyperkalemia (potassium levels that are too high in the blood, which can cause an irregular heart beat) medication and Patient 4’s potassium levels were not monitored, Patient 29 was prescribed a topical anesthetic (numbing medication) and orders were not complete, and medication was inaccurately documented for Patient 6). These failures had the potential to result in confusion among the health care team and preventable medication errors, which could significantly affect the health and safety of Patient 4, 29 and 6). Findings: During an interview on August 7, 2025, at 3:07 PM, with the Regional Director of Quality, Risk and Compliance (RDQ) and the Quality Manager Assistant (QMA), the following pharmaceutical findings were reviewed including: Patient 4 prescribed two medications that had the potential to cause hyperkalemia and Patient 4’s potassium levels were not monitored. Patient 29 was prescribed a topical anesthetic and the order did not include a specific site(s) to administer the medication, and a medication that was administered to Patient 6 was not accurately documented by nursing. The RDQ stated, QAPI did not track those specific indicators, but did track medications errors. During a concurrent interview and record review on August 7, 2025, at 3:25 PM, with the RDQ and the QMA, the facility document titled, “Quality Assurance Performance Improvement (QAPI) Committee,” dated July 25, 2025, was reviewed. The document included a pharmacy section which included tracking of medication errors, but did not include specific issues that led to the medication errors with specific analysis and improvement measures to address the medication error issues. The RDQ stated, the pharmacy reports and tracks these issues through Medication Error Reporting and Prevention (MERP) and Pharmacy and Therapeutic Committee (PTC) who then report directly to the Medical Executive Committee (MEC), so those specific issues are not necessarily tracked nor the process improvement plans initiated through QAPI. During a concurrent interview and record review on August 7, 2025, at 3:45 PM, with the RDQ, the facility document titled, “2025 PERFORMANCE IMPROVEMENT PLAN,” undated, was reviewed. The document indicated that all facility committees, including MERP and PTC, report directly to QAPI, then QAPI reports directly to the MEC. The RDQ stated that she miss spoke about which departments report to QAPI. The RDQ further stated, it is ultimately the responsibility that the committees report to QAPI and ensure they are accountable for the reporting of their departments.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 35335 Based on observation, interview, and record review, the facility failed to ensure medications were stored within the temperature range (68-77 Fahrenheit (F- unit of measurement)) required by the drug manufacturer’s approved labeling and policies were implemented to minimize drug errors for two of 35 sampled patients (Patient 6 and Patient 29) when: 1. Eight medications were observed stored outside of the manufacturers’ stipulated (required) temperatures range in the Pharmacy Department. This failure had the potential for patients receiving ineffective medications which could result in therapeutic (treatment) failure or other adverse clinical outcomes due to exposure to elevated room temperatures for an universe of 51 patients. 2. For Patient 29, PRN (as needed) medication for diclofenac (drug to relieve pain and inflammation) sodium 1% (concentration) order was unclear and not clarified. This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals. 3. For Patient 6, a medication daptomycin (an antibiotic) was inaccurately charted (documented) in the Medication Administration Record (MAR - section of the medical record where administered medications are documented); and This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals. 4. For Patient 6, a medication pantoprazole (drug to reduce the amount of acid the body produces) was not documented as administered on August 5, 2025, as per the order when the electronic chart sytem had some issues. This failure resulted in a preventable medication error by missing the dose or receiving an extra dose. Findings: 1. During a review of the air condition vendor’s “QUOTE No. 1491” dated May 9, 2025, the “JOB SUMMARY” indicated “[the name of the vendor] PERFORM AN INSPECTION OF AC [air conditioning] -10 AND FOUND THE COMPRESSOR [device] GROUNDED. THE UNIT HAS ONE OPERATING COMPRESSOR AT THIS TIME. [the name of the vendor] IS PROPOSING TO REPLACE THE FAILED COMPRESSOR.” During a review of the “PHARMACY Room TEMPERATURE/HUMIDITY” logs, the room temperature was logged as 93 Fahrenheit (F- a temperature scale) on June 16, 2025. During a review of “CAPITAL EXPENTIURE REQUEST” for “SBH-2025-5” dated May 12, 2025, the hospital project “Compressor Replacement Unit 10” was approved by the facility’s representatives on June 18, 2025. During a review of the vendor’s invoice for “SBH-2025-5” dated July 1, 2025, the vendor replaced the grounded compressor on AC-10. During a review of the “PHARMACY Room TEMPERATURE/HUMIDITY” logs, the room temperature was recorded as 80F on July 4, 2025. During a concurrent observation and interview on August 4, 2025, at 8:46 AM, with Staff Pharmacist 1 (RPH 1) in the Pharmacy Department, the room temperature was measured 78F at that time. RPH 1 acknowledged the pharmacy room temperature of 78F. During a concurrent observation and interview on August 4, 2025, at 9:01 AM, with RPH 1 in the Pharmacy Department, the following eight injectable medications were observed with the drug manufacturer’s product labeling to store at a temperature no greater than 77F: Mycamine (brand name antifungal drug for fungal infections) 100 mg/vial, piperacillin and tazobactam (antibiotic) 3.375 grams per vial, piperacillin and tazobactam 4.5 grams per vial, penicillin G sodium (antibiotic) 5 million units, nafcillin (antibiotic) 2 grams per vial, azithromycin (antibiotic) 500 mg, oxacillin (antibiotic) 2 grams per vial, and ketorolac (anti-inflammatory pain medication) 30 mg. RPH 1 acknowledged the product labeling of the eight injectable medications to store at a temperature no greater than 77F. During a concurrent observation and interview on August 4, 2025, at 10:06 AM, with the Director of Pharmacy (DOP) in the Pharmacy Department, the number of each of the 8 different injectable vials available for patient use was counted. The DOP stated there were four (4) vials of Mycamine, 40 vials of piperacillin and tazobactam 3.375 grams per vial, 33 vials of piperacillin and tazobactam 4.5 grams per vial, eight (8) vials penicillin G sodium 5 million units, 21 vials of nafcillin 2 grams per vial, 12 vials of azithromycin 500 mg, 31 vials of oxacillin 2 grams per vial, and 15 vials of ketorolac 30 mg. During an interview on August 4, 2025, at 10:08 AM, with the Maintenance Supervisor (MS), the MS acknowledged that it took “a little bit of time to cool down” the Pharmacy Department. During a follow up interview on August 4, 2025, at 2:57 PM, with the MS, the MS stated the Pharmacy Department was set to 74F and the air turns on at 6:30 AM every morning. During a concurrent interview and record review on August 4, 2025, at 3:50 PM, with RPH 1, the hospital work order “362481” indicated the pharmacy room temperature was 80F on August 4, 2025, at 8:13 AM. RPH 1 stated the pharmacy room temperature was 80F on August 4, 2025, at 8:13 AM. During a concurrent interview and record review on August 7, 2025, at 10:00 AM, with the DOP, the facility’s policy and procedures (P&P) titled, “Storage of Medications,” dated December 2024, was reviewed. The P&P indicated, “Medications will be stored at appropriate temperatures ...room temperature will be maintained between 20C [Celsius - a temperature scale] (68F) and 25C (77F).” The DOP acknowledged the policy. During a telephone interview on August 7, 2025, at 11:04 AM, with the Regional Director of Plant Operations (RPO), the RPO could not explain why it took so long to cool down the Pharmacy Department. During a telephone interview on August 7, 2025, at 11:22 AM, with the RPO, the RPO was unable to articulate why the air conditioner issue since April 2025, was still not fixed. 2. During a review of Patient 29’s “History and Physical” (H&P - a comprehensive patient assessment), dated July 28, 2025, was reviewed. The H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of debility (physical weakness, especially due to illness) and fractures (broken bones). During a review of Patient 29’s medical record, the physician’s order indicated a medication order dated July 27, 2025, for acetaminophen (pain medication) 500 milligrams (mg - a unit of measurement for dose) every 6 hours PRN mild pain. During a review of Patient 29’s medical record, the physician’s order indicated a medication order dated July 27, 2025, for oxycodone (strong pain medication) 5 mg every 4 hours PRN moderate to severe pain. During a review of Patient 29’s medical record, the physician’s order indicated a medication order dated July 27, 2025, for diclofenac (drug to relieve pain and inflammation) sodium 1% (concentration) 4 grams each dose to apply topically (on the surface/ directly over the skin) four times daily PRN pain to the affected area. During a concurrent interview and record review on August 7, 2025, at 9:45 AM, with the Director of Pharmacy (DOP), Patient 29’s multiple PRN pain medications were reviewed. The DOP acknowledged the PRN diclofenac medication order was not clear and should have been clarified. A continued review with the DOP, the facility’s policy and procedure (P&P) titled, “Clarification of Medication Orders,” dated October 2024, was reviewed. The P&P indicated, “I. Clarification or verification - any medication order which does not contain the required elements of a complete order ...must be clarified with the prescribing physician prior to dispensing.” The DOP acknowledged the policy. 3. During a review of Patient 6’s “History and Physical” (H&P), dated July 28, 2025, the H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of right foot osteomyelitis (bone infection), bacteremia (bacteria in the blood), diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Patient 6’s medical record, the physician’s order indicated a medication order dated July 29, 2025, for daptomycin (an antibiotic) intravenously (IV - into the patient’s vein) every 48 hours. The daptomycin medication order indicated the first 350 mg bag out of two bags was scheduled to be administered at 5:30 PM. The daptomycin medication order indicated the second 350 mg bag out of two bags was scheduled to be administered at 6:00 PM. During a review of Patient 6’s medical record, the Medication Administration Record (MAR) indicated the first bag of daptomycin 350 mg was administered on July 31, 2025, at 5:24 PM, by Registered Nurse 1 (RN 1). The MAR indicated the second bag of daptomycin 350 mg was administered on July 31, 2025, at 5:24 PM, by RN 1. During a review of Patient 6’s medical record, the MAR indicated the first bag of daptomycin 350 mg was administered on August 2, 2025, at 5:22 PM, by RN 3. The MAR indicated the second bag of daptomycin 350 mg was administered on August 2, 2025, at 5:22 PM, by RN 3. RN 3 was not available for interview. During an interview on August 4, 2025, at 9:53 AM, with the DOP, the DOP stated the Pharmacy Department was not currently compounding intravenous (IV - into the patient’s vein) medications. During a concurrent interview and record review on August 5, 2025, at 3:43 PM, with RN 1 and RN 2, Patient 6’s medical record was reviewed. RN 1 stated they were an orientee and RN 2 stated they were the preceptor. RN 1 and RN 2 stated the daptomycin medication order indicated the first 350 mg bag out of two bags was scheduled to be administered at 5:30 PM. RN 1 and RN 2 stated the daptomycin medication order indicated the second 350 mg bag out of two bags was scheduled to be administered at 6:00 PM. RN 1 and RN 2 stated the resource nurse told them the daptomycin were two separate medication orders. RN 1 and RN 2 stated they forgot to fix the charting to show both daptomycin medications were administered at the right time. During a concurrent interview and record review on August 5, 2025, at 3:43 PM, with the RN 1 and RN 2, the facility’s P&P titled, “Administration of Medications,” dated October 2024, was reviewed. The P&P indicated, “16. Document the administered dose on the MAR after given.” RN 1 and RN 2 acknowledged the policy. During an interview on August 7, 2025, at 2:15 PM, with the Nurse Manager (NM), the NM stated the Pharmacy Department is not compounding medications right now. The NM stated the expectation is for nursing staff to scan medications real-time and not pre-scan medications. 4. During a review of Patient 6’s “H&P”, dated July 28, 2025, was reviewed. The H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of right foot osteomyelitis, bacteremia, diabetes, and hypertension. During an interview on August 7, 2025, at 9:42 AM, with the DOP, the DOP stated even if there was a computer glitch on the type of medication order entered, the medication order due should still show up on the Medication Administration Record (MAR). During a concurrent interview and record review on August 7, 2025, at 12:16 PM, with the Regional Director of Quality, Risk, and Compliance (RDQ), Patient 6’s medical record was reviewed. The physician’s order indicated a medication order dated August 4, 2025, for pantoprazole (drug to reduce the amount of acid the body produces) 40 mg by mouth daily. The MAR indicated the pantoprazole was first administered on August 4, 2025, at 8:43 AM. The second time the pantoprazole was administered was on August 6, 2025, at 5:38 AM. The RDQ acknowledged the pantoprazole daily dose was not documented as administered on August 5, 2025. The RDQ stated the medication dose was missed due to the way the nurse entered the pantoprazole medication order. During an interview on August 7, 2025, at 2:15 PM, with the NM, the NM stated the expectation was for nursing staff to read all the “flags” when entering medication orders. During a concurrent interview and record review on August 7, 2025, at 2:20 PM, with Licensed Vocational Nurse 1 (LVN 1), Patient 6’s medical record was reviewed. LVN 1 stated she entered the medication order for pantoprazole 40 mg by mouth daily. During a review of the facility’s P&P titled, “Administration of Medications,” dated October 2024, was reviewed. The P&P indicated, “PROCEDURE ...3. Follow the 7 “R’s [rights of medication administration]” ...7. Double check the medication(s) to be administered with the MAR for accuracy.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 35335 Based on interview and record review, the facility failed to provide patient safety for medication use for one of 35 sampled patients (Patient 4) when potassium level in the blood monitoring did not occur in accordance with the drug manufacturer’s prescribing information (PI - document on how to safely use medications) regarding drug-drug interactions (reactions between multiple drugs which makes drugs less effective, cause unexpected side effects, or increase the action of a particular drugs which may affect safety or efficacy) for lisinopril (blood pressure medication) and potassium chloride supplement. This failure had the potential for the patient to experience increased risk of high potassium levels (can cause heart problems requiring immediate medical attention) due to drug-drug interactions and/or adverse clinical outcomes. Findings: During a review of Patient 4’s “History and Physical” (H&P - a comprehensive patient assessment), dated July 27, 2025, the H&P indicated Patient 4 was admitted to the facility on July 26, 2025, with diagnoses of debility (physical weakness, especially due to illness), generalized weakness, and right humeral (upper arm) fracture (broken bone). The H&P indicated medications prior to admission were acetaminophen (for mild pain), Norco (combination pain medication with acetaminophen and hydrocodone), and levofloxacin (antibiotic). During a review of Patient 4’s “Basic Metabolic Panel [blood test]” dated July 27, 2025, it indicated a potassium level of 4.4 millimoles per liter (mmol/L - unit of measurement with normal range 3.5 to 5 mmol/L). During a review of Patient 4’s “physician’s order” indicated a medication order dated August 1, 2025, for potassium chloride packet 20 milliequivalents (mEq - a unit of measurement for dose) daily. The medical record indicated the patient was given potassium chloride 20 mEq on August 2, 2025, August 3, 2025, August 4, 2025, and August 5, 2025. During a review of Patient 4’s medical record, the physician’s order indicated a medication order dated August 1, 2025, for lisinopril (blood pressure medication) 30 milligrams (mg - a unit of measurement for dose) daily. The medical record indicated the patient was given lisinopril 30 mg on August 2, 2025, August 3, 2025, August 4, 2025, and August 5, 2025. During a concurrent interview and record review on August 5, 2025, at 10:55 AM, with the Director of Pharmacy (DOP), Patient 4’s medical was reviewed. The DOP stated there was no potassium monitoring since July 27, 2025. During a concurrent interview and record review on August 7, 2025, at 10:04 AM, with the DOP, the prescribing information (PI) for potassium chloride packets, provided by the hospital, was reviewed with the DOP. The PI indicated “DRUG INTERACTIONS ...Renin-angiotensin-aldosterone inhibitors [class of drugs including lisinopril]: Monitor for hyperkalemia [high potassium levels] ...”7 DRUG INTERACTIONS ...7.2 Renin-Angiotensin-Aldosterone System Inhibitors. Drugs that inhibit the renin-angiotensin-aldosterone system (RAAS) including angiotensin converting enzyme (ACE) inhibitors [class of drugs including lisinopril] ...Closely monitor potassium in patients receiving concomitant [at the same time] RAAS therapy.” The DOP further stated there was no policy on monitoring. During a telephone interview on August 7, 2025, at 2:57 PM, with the DOP, the DOP stated the medications documented prior to admission were acetaminophen, Norco, and levofloxacin. The DOP acknowledged that there was no documentation of potassium chloride and lisinopril being administered prior to admission. During a review of the facility’s policy and procedure (P&P) titled, “Policy Creation, Review and Revision,” dated January 2025, “3. Develop policies using recommendations and practice guidelines set forth by any of the following: a. State or federal law, rules or regulations ...c. Professional organizations; d. Industry best practices; e. Evidence-based medicine.” During a review of the facility’s P&P titled, “Clarification of Medication Orders,” dated October 2024, “II. Interpretation - a Pharmacist must review all medication orders for the following ...5. Real or potential interactions between the prescribed medication and other medications.””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 35335 Based on observation, interview, and record review, the facility failed to ensure one of one medication (Mycamine (brand name antifungal medication to treat fungal infections), available for patient use, requiring protection from light was stored in accordance with manufacturer’s stipulations (requirements). This failure had the potential to result in a patient receiving unusable, ineffective, or deteriorated (reduced quality) medication due to preventable light exposure for a universe of 51 patients. Findings: During a review of the Prescribing Information (PI - document on how to safely use medications) for Mycamine (brand name antifungal medication to treat fungal infections), dated December 2024, the PI document indicated “Storage ...Protect from light.” During a concurrent observation and interview on August 4, 2025, at 9:01 AM, with Staff Pharmacist 1 (RPH 1), an inspection of the pharmacy was conducted. One single-dose vial of Mycamine 100 milligrams (a unit of measurement for dose) for injection (into the patient’s vein) with the product labeling on the vial “Protect from light” observed stored on open shelving under overhead lighting outside of the medication carton. RPH 1 acknowledged the Mycamine product labeling on the loose vial indicated to protect from light and the medication was stored outside of the medication carton under overhead lighting without protection from light. During a concurrent interview and record review on August 7, 2025, at 10:00 AM, with the Director of Pharmacy (DOP), the facility’s policy and procedures (P&P) titled, “Storage of Medications,” dated December 2024, was reviewed. The P&P indicated “Medications must be stored under proper conditions of ...light ...as determined ...manufacturer’s labeling, as well as in compliance with applicable federal and state laws/regulations.” The DOP acknowledged the policy.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 41337 Based on observation, interview, and record review, the facility failed to effectively organize the food and dietetic services department when: 1. The kitchen was not in a sanitary condition, which is a repeated finding from a state re licensing survey the took place 2 months prior. 2. Ice was not readily available and easily accessible for staff to use on the tray line (a process where food is held on a steam table and on ice while staff serve each patient’s meal) because the ice machine had been broken since April 2025. This lack of effective organization had the potential to cause food borne illness to 51 medically compromised patients who received food from the kitchen which may contribute prolonged hospitalization. Findings: 1. During an observation in the kitchen and concurrent interview with the Dietary Supervisor (DS) on August 4, 2025, at 8:48 am, the outside of the steamer had food splash and grease build-up, there was a shelf storing oils and bulk seasonings that was lined with paper and the paper was saturated with oil and crumbs. The floors under the cooking line (consisting of the stove, fryer and steamer) had a build-up of grease and old food. The DS stated they need one more staff person, they do not currently have enough staff to keep up with the deep cleaning. During an observation in the kitchen on August 4, 2025, at 9:09 am, there was a metal table that held the rack to store the food domes (Keep meals insulated from kitchen to patient), that was covered in rust, in the dry storage room there was a liquid yellow colored spill on the bottom shelf on the right side when you walk in. There were multiple red bins on the shelves used to store dry goods that had food debris. During a subsequent observation in the kitchen on August 4, 2025, at 9:17 am, the walk-in freezer floor had food under the shelves on the floor and in the back corners. There were also clear bins used to organize frozen food, and the bins had food debris. During an interview on August 7th, 2025, at 3:10 pm, the DS stated that all the areas identified should be kept clean. During a review of the facility policy titled “Food: Preparation”, dated February 2023, it indicated “all foods are prepared in accordance with FDA [Food and Drug Administration] Food Code.” During a review of the FDA Food Code, dated 2022, 4-601.11 indicated “(C) Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” In addition, “The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.” 2. During an observation in the kitchen on August 4, 2025, at 11:34 am, there was a metal pan with ice and the salads were placed on top of the ice, but there was not enough room for all the salads, so some of the salads were just on the counter. Also, the drinks (soda,juice, water and milk), fruit cups and the turkey sandwiches were not on ice during tray line. During an interview with Patient 18 in her room on August 4, 2025, at 4:00 pm, Patient 18 stated she does not like that the milk is served warm. The milk should be cold when served. During a review of the facility policy titled “Food: Preparation”, dated February 2023, indicated, “13. All foods will be held at appropriate temperatures, less than 41 degrees Fahrenheit (F- unit of measurement) for cold food holding. During a review of the facility’s email provided, dated April 18, 2025, indicated the Maintenance Supervisor (MS) emailed [company name] customer service to request a quote for a new ice machine. [Company name] responded with a quote on April 22, 2025.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 41337 Based on observation, interview, and record review, the facility failed to effectively supervise the nutritional aspects of patient care and perform and document nutrition assessments as per the facility’s policy and procedure (P&P) when there was not a Registered Dietitian (RD 1 and RD 2) available on site at necessary times (RD 1 worked completely remote and RD 2 worked 6-8 hours per month at the facility) to accurately assess and monitor patients’ nutritional status when : 1. The facility was late on follow-up nutritional assessments for four of 35 sampled patients (Patient 25, 24, 21, and 3) when a patient is labeled, High Nutrition Risk the patient should be seen no less than every 7 days, Moderate Nutrition Risk is no less than every 14 days and low nutrition risk reassessed with changes in condition. 2. Six of 35 sampled patients (Patient 3, 11, 5, 20, 21, and 23) did not receive a comprehensive nutritional assessment that included a patient, family or representative interview. 3. Facility did not include nutrition interventions on the Plan of Care (an individualized plan for the medical care of a patient) for three of 35 sampled patients (Patient 23, 3, 21). These failures had the potential to cause poor nutrition status for eight of 35 medically compromised sampled patients (Patient 3,5, 11, 20, 21, 23, 24, and 25). Findings: 1. During a review for Patient 25, document titled “Adult Nutritional Assessment”, dated July 23, 2025, indicated, “Nutritional Risk Assessment, Nutritional Risk Level: High.” During a medical record review for Patient 25, document titled, “Dietitian Follow-up”, dated August 4, 2025, by RD 1 was completed 12 days after the initial Nutritional Assessment. “Pt [patient] has a height of 5’0”, BMI (Body Max Index) of 17.4 (underweight), actual body weight of 40.5 kg [kilogram]. Pt has had an average meal intake of 41% for the past three days. Pt is not likely meeting a majority of estimated needs. There is also no documentation of [brand name] supplement intake. Also concerning that pt’s (patients) weight has down trended. Pt (patient) was weighing 41.1 kg on July 24, 2025 ... Pt remains a high-risk acuity, due to poor appetite underweight.” During a medical record review for Patient 21 and concurrent interview with the Regional Director of Quality, Risk and Compliance (RDQ), on August 7, 2025, 11:45 am, document titled “Adult Nutritional Assessment”, dated July 18, 2025, indicated, “Nutritional Risk Assessment, Nutritional Risk Level: Moderate.” Follow-up due on August 1, 2025. RDQ stated there was no nutrition Follow-up in the medical record. During a medical record review for Patient 24, document titled “Adult Nutritional Assessment”, dated July 25, 2025, indicated, “Nutritional Risk Assessment, Nutritional Risk Level: High.” During a medical record review for Patient 24, document titled, “Dietitian Follow-up”, dated August 4, 2025, by RD 1 completed 10 days after the initial Nutritional Assessment. During a medical record review for Patient 3, document titled “Adult Nutritional Assessment”, dated July 26, 2025, indicated, “Nutritional Risk Assessment, Nutritional Risk Level: High.” During a medical record review for Patient 3, document titled, “Dietitian Follow-up”, dated August 4, 2025, by RD 1 completed 9 days after the initial Nutritional Assessment. During an interview with the Registered Dietitian 1 (RD 1) on August 6, at 4:37 pm, he stated he has limited time to do work for the facility because he has another full-time job, he prioritized the initial assessments over the follow-ups. RD 1 stated it was hard to meet the dates for follow-ups because of his full-time schedule at another facility. He stated there needs to be major changes to the nutrition care system to provide the best care for patients, they need to have a full-time registered dietitian on-site to be able to facilitate those changes. During an interview with the Registered Dietitian 2, (RD 2) on August 6,2025, at 5:15 pm, RD 2 stated she worked at the facility 6-8 hours per month. RD 2 stated that all nutrition assessments and follow-up assessments should be done on time. During a review of the facility’s policy and procedure (P&P), titled “Nutrition Care Process- Nutrition Assessment”, dated August 2024, the P&P indicated “3. Nutrition risk level-assigned by the dietitian during the assessment and reassessment process (a) guides the frequency of follow-up monitoring. Level: Low Risk- Monitor Reassess with changes in condition, Moderate Risk- Monitor no less than every 14 days, High Risk- Monitor no less than every 7 days. 2. During an interview with the Registered Dietitian 1 (RD 1) on August 6, 2025, at 4:37 pm, RD 1 stated he logs in to do nutrition assessments for the facility late at night, Saturdays and Sundays are the best days for him and he usually starts working at 7:00 pm or 8:0 0pm, and sometimes until 1:00 am. RD 1 stated it’s about 50% hit or miss if he can reach either the patient by phone or a nurse to get more information on the patient for the patient assessments since he works completely remotely. RD 1 further stated the patients usually don’t answer the phone. During an interview with the Registered Dietitian (RD 2) on August 6, 2025, at 5:10 pm, RD 2 stated nutrition assessments always include a review of the patient chart and interview with the patient. RD 2 comes up with a plan of care and makes sure the patient agrees with the plan. During a subsequent interview with RD 1 on August 7, 2025,at 4:28 pm, RD 1 stated if he works late at night then obviously, he does not speak to the patients and the night nurses do not know as much about the patients as the daytime nurses. During an interview with the Medical Doctor (MD), on August 7, 2025, at 5:03 pm, MD stated he expects all his staff including RD to speak with the patients when doing an assessment. During a medical record review of Patient 3, document titled “Dietitian Follow-up”, dated August 4, 2025, at 11:00 pm, there was no indication in the note that the RD spoke with the patient, nurse or family member. During a medical record review of Patient 11, document titled “Dietitian Follow-up”, dated August 6, 2025, at 9:04 pm, no indication in the note that the RD spoke with the patient, nurse or family member. During a medical record review of Patient 5, document titled “Adult Nutritional Assessment”, dated August 5, 2025, at 8:30 pm, no indication in the note that the RD spoke with the patient, nurse or family member. During a medical record review of Patient 20, document titled “Dietitian Follow-up”, dated August 6, 2025, at 9:27 pm, no indication in the note that the RD spoke with the patient, nurse or family member. During a medical record review of Patient 21, document titled “Adult Nutritional Assessment”, dated July 18, 2025, at 10:46 pm, no indication in the note that the RD spoke with the patient, nurse or family member. During a medical record review of Patient 23, document titled “Adult Nutritional Assessment”, dated August 5, 2025, at 10:38 pm, no indication in the note that the RD spoke with the patient, nurse or family member. During a review of the facility policy titled, “Patient Assessment/Reassessment”, dated December 2024, indicated “Procedure: 1. Information may be obtained from the patient, a family member, or other service providers (registered nurse,medical doctors etc). During a review of the facility policy, titled “Nutrition Care Process- Nutrition Assessment”, dated August 2024, indicated “Nutritional Assessment: 1. It is the Registered Dietitians responsibility to complete a comprehensive nutritional assessment on all patients ...” During a review of the standard of practice document from ASPEN (American Society for Parenteral and Enteral Nutrition) document titled “Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults”, dated January 2011, indicated, “Nutrition assessment has been defined by A.S.P.E.N. as “a comprehensive approach to diagnosing nutrition problems that uses a combination of the following: medical, nutrition, and medication histories; physical examination; anthropometric measurements; and laboratory data. A nutrition assessment provides the basis for a nutrition intervention. Nutrition assessment performed by a nutrition support clinician is a rigorous process that includes obtaining diet and medical history, current clinical status, anthropometric data, laboratory data, physical assessment information, and often functional and economic information; estimating nutrient requirements; and, usually, selecting a treatment plan.” 3. During an interview with the Registered Dietitian 1 (RD 1) on August 6, 2025, at 4:37 pm, RD 1 stated he has never completed a plan of care for a patient, and he does not participate in the Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) Meetings for patients. During a review of the Medical Record for Patient 3, document titled “Adult Nutritional Assessment”, dated July 26, 2025, indicated “Nutritional Risk Assessment: Nutrition risk level- High. Nutrition diagnosis: inadequate oral intake related to acute illness as evidence by need for EN (enteral nutrition- the delivery of nutrients and fluids directly into the stomach or small intestine through a tube) via PEG Tube (percutaneous endoscopic gastrostomy tube, is a feeding tube placed through the abdominal wall directly into the stomach) to meet estimated needs. Comments: unable to perform a physical exam, however pt (patient) is TF (Tube Feed) dependent. Has a BMI (body mass index) of 21.8, may benefit from on site evaluation from RD (registered dietitian) when possible, to rule out protein calorie malnutrition. During a review of the medical record for Patient 3, document titled, “Plan of Care”, dated July 25, 2025- July 29, 2025, indicated there was no nutrition interventions included in the plan of care. During a review of the Medical Record for Patient 21, document titled “Adult Nutritional Assessment”, dated July 18, 2025, indicated “Nutritional Risk Assessment: Nutrition risk level- Moderate” During a review of the medical record for Patient 21, document titled, “Plan of Care”, dated July 17 - 21, 2025, indicated there were no nutrition interventions included in the plan of care. During a review of the Medical Record for Patient 23, document titled “Adult Nutritional Assessment”, dated August 4, 2025, indicated “Nutrition risk level- High, Nutrition Diagnosis: inadequate energy intake related to sub-optimal oral intake AEB (as evidenced by) pt (patient) consumed 41% average meal intake of meals, likely not meeting estimated needs.” During a review of the medical record for Patient 23, document titled, “Plan of Care”, dated August 2-6, 2025, indicated there was no nutrition interventions included in the plan of care. During a review of the policy titled “Care Planning”, dated December 2024, the P&P indicated, “care, treatment and services are planned to ensure that they are individualized to the patients’ needs. The Hospital staff shall provide an individualized, interdisciplinary (a group of professionals from different fields who collaborate to provide comprehensive patient care) plan of care for all patients. 3. Care planning will be implemented through the integration of assessment findings. 5. The plan of care is maintained and updated based upon ongoing patient assessments and the patient’s response to care, treatment and services.””