Specialty Hospital

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to comply with applicable state regulations. This deficient practice was evidenced by failure of the hospital to use the State’s designated repository (The Louisiana Office of State Police, Bureau of Criminal Identification and Information) for criminal history information pursuant to the laws cited La R.S.15: 575 on non-licensed personnel prior to employment for 2 of 2 (S7CNA, S8CNA) non-licensed personnel records reviewed. Findings: The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State ’ s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau ’ s Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized Agents, and (3) submission of applicants ’ fingerprints. Review of the personnel records for S7CNA and S8CNA revealed they were current employees. Further review revealed their criminal background checks were conducted by a company that was not authorized by Louisiana State Police to perform criminal background checks. On 08/18/2026 at 11:15 AM, S3CEO confirmed that the background checks performed for the unlicensed staff at the hospital, including S7CNA and S8CNA, were not from an authorized agency of the Louisiana Office of State Police.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50453 Based on observation, record review, and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure the glucometer Quality Control Solutions were properly labeled upon opening with an open date or beyond use date. Findings: Review of the package insert for the Accu-chek Inform II Controls revealed in part: “Note: Write the discard date on the bottle label. The control solution is stable for 3 months after opening or until the expiration date on the bottle label, whichever comes first.” Observations on 08/18/2026 from 8:23 AM - 8:37 AM revealed 3 different glucometers and 3 separate sets of Quality Control Solutions currently being used that were not labeled with a legible opening date or beyond use date. Observations of the first glucometer quality control solutions revealed in part the following: Control 1: Lot #: 24700538; expiration date: 01/02/2027; and Control 2: Lot #: 25700543; expiration date: 08/28/2027. Further review failed to reveal a legible opening date or beyond use date labeled on the control solution bottles. In an interview on 08/18/2026 at 8:27 AM, S11RN confirmed that the expiration date from when the bottles were opened is illegible and she is unable to verify when the discard date is from the date is controls were opened. Observations of the second glucometer quality control solutions revealed in part the following: Control 1: Lot #: 25700543; expiration date: 08/22/2027; and Control 2: Lot #: 25700543; expiration date: 08/28/2027. Further review failed to reveal a legible opening date or beyond use date labeled on the control solution bottles. In an interview on 08/18/2026 at 8:32 AM, S12RN confirmed that the expiration date from when the bottles were opened is illegible and she is unable to verify when the discard date is from the date is controls were opened. Observations of the first glucometer quality control solutions revealed in part the following: Control 1: Lot #: 24700549; expiration date: 03/03/2028; and Control 2: Lot #: 25700530; expired: 03/21/2026. Further review failed to reveal a legible opening date or beyond use date labeled on the control solution bottles. In an interview on 08/18/2026 at 8:36 AM, S13RN confirmed that the expiration date from when the bottles were opened is illegible and she is unable to verify when the discard date is from the date is controls were opened.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that all patients have the right to be free from physical restarints as evidenced by failing to provide nursing assessment and clinical justification for 1 of 1 patient whose record was reviewed for restraints (Patient #4) in a total sample of 30. Findings: Review of the medical record for Patient #4 revealed an admission date of 06/16/2026 at 11:16 AM with diagnoses including cerebral hemorhage and respiratory failure. Review of a physician order dated 06/16/26 at 12:03 PM revealed an order for bilateral soft wrist restraints to prevent patient from interrupting care and treatments. Review of the admission nursing assessment dated 06/16/2026 at 2:00 PM revealed no mention of the patient being in restraints. Review of the restraint documentation form revealed the first documented evidence of the patient being in restraints was dated 06/16/2026 at 7:25 PM, when the nurse documented restraints continued, “restraint started prior to shift change.” Review of the electronic medical record with S1CNO revealed no documented evidence of a comprehensive assessment prior to placing the patient in restraints. Interview withe S1CNO on 08/19/2026 at 8:50 AM confirmed there was no documented assessment of the patient prior to placing the patient in bilateral wrist restraints and there was no documented evidence of the exact time when the patient was placed in wrist restraints.”

“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: 48051 Based on record review and interview, the hospital failed to ensure data collected encompassed the monitoring and reporting of the effectiveness and safety of services and quality of care being measured, analyzed and tracked. This deficient practice was evidenced by the Performance Improvement program failing to adequately reflect the practices of the housekeeping department/services. Findings: A review of the hospital policy titled, “Performance Improvement Plan,” Policy Number: 1-6.7.0, with an effective date of 01/01/2025, revealed in part: “PURPOSE: The purpose/objective of the Performance Improvement Plan at Priority Hospital Group hospital is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver care that is optimal in an environment of minimal risk. PROCEDURE: I. GOALS OF PERFROMANCE IMPROVEMENT The primary goal of the Performance Improvement Plan is to continually and systematically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care. To achieve the primary goal, the plan strives to: 4. Provide for a hospital-wide program that assures the facility designs processes well and systematically measures, assesses and analyzes, and improves its performance to achieve optimal patient health outcomes in a collaborative, interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of the patients and their families, staff and others; 5. Assure that the improvement process is organization-wide, monitoring, assessing and evaluating the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified; and 7. Provide appropriate reporting of information to the Governing body to furnish it with the information it needs in fulfilling its responsibility for the quality of patient care and safety. II. Scope of Activities The scope of the Performance Improvement Program includes an overall assessment of the efficacy of performance improvement activities with a focus on continually improving care provided throughout the hospital. A. At quarterly meeting of the medical staff committees, findings of the continuous performance improvement activities of the medical staff and all appropriate departments/services and disciplines that impact patient care and medical staff services within the medical staff service committee will be reviewed, assessed, and evaluated. IV. METHODOLOGY The “Plan-Do-Check-Act” Performance Improvement Process is utilized to plan, design, measure, assess/analyze and improve functions and processes relate to patient care and services throughout the organization: Plan: Identify important key aspects of care. Do: Display data in aggregate format to identify patterns and trends. Check: Data Collection: Monitor, assess and improve the important aspects/processes of care by assessment data collected. Data is collected and monitored monthly and analyzed quarterly which allows the hospital to identify objective and statistically valid performance measures for monitoring and improving performance aspects/processes of care. Evaluate/Analyze: Aggregating, analyzing, and evaluating data allows the hospital to draw conclusions about its performance in relation to a process or the nature of an outcome. Act: Report: Communicate the results of the monitoring, assessment, evaluation process to relevant individuals, departments or services, the Performance Improvement Committee and the Governing Body. A review of the hospital’s last three quarterly meeting minutes titled, “Performance Improvement Committee Meeting, and dated, 01/21/2026, 04/22/2026, and 07/22/2026 revealed the same information on each report: “Topic: New Infection Control Report; Findings/Analysis: Housekeeping and Clean Equipment logs 100%; Recommendations: The housekeeping service contact and processes were discussed. Issues relating to cleaning and daily housekeeping services were followed up with the supervisor and the cleaning staff; Evaluation/Follow-up: Housekeeping issues were addressed, and staff education completed. All rooms to be cleaned thoroughly and inspection by DON and ADON will be conducted weekly and prior to admission of any pt. Continue to have meetings with the Host environmental services team to discuss progress and issue with Cleaning.” A review of the hospital’s monthly and quarterly metrics report revealed the report from 01/2026 to 06/2026. The indicator by the group name titled “Housekeeping,” had the corresponding data for each month (01/2026 to 06/2026) as 10 out of 10 or 100%. The metrics failed to reveal an issue as was indicated in the previously mentioned quarterly meeting minutes. The previously mentioned quarterly meeting minutes failed to reveal the issues with housekeeping; failed to reveal issues discussed with the housekeeping staff and their respective supervisor; failed to identify which staff (housekeeping and/or hospital, etc.) was educated; failed to reveal measurable monitoring activities initiated to track and analyze housekeeping services; and if there was measurable monitoring activities initiated, what did the collected data indicate (any improvements, etc.). In an interview on 08/19/2026 at 3:00 PM, S1CNO confirmed the above-mentioned findings. In an interview on 08/19/2026 at 3:00 PM, S4Compliance confirmed the reported data on the PI metrics report did not adequately reflect activities associated with the contracted services of housekeeping.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1) Failure to ensure a patient’s wounds were treated daily per physician orders (Patient #13); 2) Failure to ensure that a patient’s wounds were assessed upon admission (Patient #14); 3) Failure to ensure daily blood glucose levels were monitored and elevated levels were reported to the provider (Patient #23) and 4) Failure to ensure vital sign performance and documentation were consistent with the provider’s order in 4 (Patient #12, #21, #23, #25) of 12 medical records reviewed for vital signs in a total sample of 30. Findings: 1) Failure to ensure a patient’s wounds were treated daily per physician orders (Patient #13) Review of the medical record for Patient #13 revealed an admission date of 08/03/2026 with diagnoses including suspected osteomyelitis, infected PEG site and multiple wounds. Review of admission physician orders dated 08/03/2026 revealed orders to treat Stage 4 sacral and right buttocks wounds daily and to treat to the infected PEG site daily. Review of the patient’s treatment MAR revealed no documented evidence that the sacral and right buttocks wounds received ordered treatment on the following dates: 8/10/26, 08/11/2026, 08/14/2026, 08/15/2026, 08/16/2026, 08/17/2026. Review of the patient’s treatment MAR revealed no documented evidence that the PEG site received ordered treatment on the following dates: 08/06/2026, 08/10/2026, 08/11/2026, 08/14/2026-08/17/2026. On 08/19/2026 at 11:00 AM, interview with S1CNO confirmed the patient did not receive daily dressing changes as ordered by the physician. 2) Failure to ensure that a patient’s wounds were assessed upon admission (Patient #14) Review of the medical record for Patient #14 revealed an admission date of 08/15/2026 with diagnoses including chronic osteomyelitis to left ischium and stage 4 pressure sore to left buttocks. The history and physical stated the patient was admitted for intravenous antibiotics and wound care. Review of the admission nursing assessment dated 08/15/2026 at 2:55 PM revealed the patient had dressings to the left heel, left lower leg, left ankle and buttocks. The nurses note stated the dressings were clean, dry and intact. There was no documented assessment of the wounds. Review of wound care documentation sheet revealed the first time the patient’s wounds were assessed was on 08/17/2026 by the wound care nurse (2 days after admit). Review of physician orders revealed the first orders to treat the wounds was dated 8/17/2026 (2 days after admit). On 08/19/2026 at 1:15 PM, interview with S1CNO revealed that since the patient was admitted on a weekend, there was no assessment or treatment of the wounds since the wound care nurse does not work weekends. When asked if a patient should sit through the weekend with no assessment or treatment of wounds, S1CNO stated no. When asked if the weekend floor nurses were capable of assessing and treating wounds, S1CNO stated yes. 3) Failure to ensure daily blood glucose levels were monitored and elevated levels were reported to the provider for 1 patient (Patient #23) A review of Patient #23 medical record on 08/19/2026 at 10:00 AM revealed follow: -A review of the History and Physical (H & P) dated 08/15/2026 at 11:58 AM by S9MD revealed Patient #23 was admitted for aspiration pneumonia of right lung and prior medical history included diabetes mellitus, hypertension, dysphasia, anxiety, gastroesophageal reflux disease, seizures, sacral decubitus ulcer stage IV, a functional quadriplegic and a current peg tube in place. The H & P revealed blood glucose lab values upon admission as: 08/12/2026: 181; 08/14/2026: 166; and 08/15/2026: 140. A review of the H & P subsection: Assessment and Plan, failed to reveal an active problem related to diabetes mellitus. A review of the patient’s lab results revealed 3 basic metabolic panels (BMP) and the analysis of the blood glucose component as follows: -Blood drawn on 08/16/2026 at 5:15 PM: Glucose Level: 381 with reference range (or normal range): 70 - 100 mg/dl; -Blood drawn on 08/18/2026 at 4:51 AM: Glucose Level: 364 with reference range (or normal range): 70 - 100 mg/dl; and at 2:44 AM: Glucose Level: 374 with reference range (or normal range): 70 - 100 mg/dl. A review of provider progress notes revealed the following: Progress note dated 08/17/2026 at 7:20 PM by S10MD revealed in part, the following subsection: --Assessment/Plan: “Principal Problem: Pneumonitis due to inhalation of food or vomitus (HCC). Active Problems: Sacral decubitus ulcer, stage IV(HCC); Type 2 diabetes mellitus without complications, without long-term current use of insulin (HCC); Pressure injury of deep tissue of back; Traumatic blister of abdominal wall.” Further review of this subsection failed to reveal a plan for the active problem: diabetes mellitus. This progress note failed to reveal the provider’s identification and any subsequent treatment for the blood glucose value of 381 mg/dl on the BMP dated 08/16/2026 at 5:15 PM. A review of provider orders revealed an intravenous order initiated by S10MD on 08/17/2026 at 8:30 PM: “dextrose 5% with KCL 20mEq/L infusion.” Further review of the provider orders failed to reveal an order for a diabetic medication such as insulin or an order for nursing to perform capillary blood glucose monitoring per fingerstick. A review of the nursing notes and documentation from 08/16/2026, day shift, until the present time of review of this medical record failed to reveal nursing documentation related to the elevated blood glucose results of the previously mentioned BMP; and Progress note dated 08/18/2026 at 9:37 PM by S10MD revealed in part, the following subsections: --Subjective information: “Interval History: ... Patient has diabetes type 2. Patient sodium is still high 156 and we still continue with free water hydration. Will also continue with Levaquin 500 mg daily for his aspiration pneumonia and his infected skin decubiti. His white blood cell count is trending downward and now is at 11.2.” --Assessment/Plan: “Principal Problem: Pneumonitis due to inhalation of food or vomitus (HCC). Active Problems: Sacral decubitus ulcer, stage IV(HCC); Type 2 diabetes mellitus without complications, without long-term current use of insulin (HCC); Pressure injury of deep tissue of back; Traumatic blister of abdominal wall.” Further review of this subsection failed to reveal a plan for the active problem: diabetes mellitus. This progress note failed to reveal the provider’s identification and any subsequent treatment for the blood glucose value of 364 mg/dl on the BMP dated 08/18/2026 at 4:51 AM. In an interview on 08/19/2026 at 10:25 AM and navigating the electronic medical record for this medical record review, S2ADON confirmed the above-mentioned findings and further confirmed the blood glucose values should have been reported to the provider upon the initial elevated value being received. 4) Failure to ensure vital sign performance and documentation were consistent with the provider’s order in 4 (Patient #12, #21, #23, #25) of 12 medical records reviewed for vital signs A review of the hospital policy titled, “Vital Signs,” Policy Number: 9-6.21.0, with an effective date of 12/01/2025, revealed in part: “PURPOSE: To ensure patients are monitored appropriately through assessment of their vital signs. POLICY: Vital signs shall be monitored per a physician’s order and documented in the patient’s medical record. Vital signs will be taken by certified nursing assistants (CNAs), nurses, respiratory therapists, or other trained licensed personnel. PROCEDURE: Take temperature, pulse, respirations (T. P. R.), blood pressure (B/P), and oxygen saturation (SaO2) at the time of admission and as ordered by the physician. Report any abnormal findings to the Charge Nurse. Collaborate with the Charge Nurs to determine if the physician should be notified. If the physician is notified, the nurse should report the abnormal findings and any corresponding symptoms or complaints.” A review of electronic medical records (EMR) revealed the provider orders for vital sign frequency and the subsequent documentation of vital signs in the EMR (if the vital sign is not listed, the EMR failed to reveal a vital sign for that time frame): Patient #12: Provider order: Vital Signs, Frequency: every 8 hours, initiated on 08/10/2026 at 10:00 PM. Vital sign flowsheet: 08/11/2026 PM shift: -7:36 PM: T.: 98.3°, P.: 78, R.: 20, B/P: 132/58, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/12/2026 AM shift: -7:54 AM: T.: 98°, P.: 97, R.: 18, B/P: 125/68, SaO2: 96%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/12/2026 PM shift: -7:49 PM: T.: 97.8°, P.: 95, R.: 18, B/P: 122/70. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. Further, vital sign documentation failed to reveal the performance of the vital sign SaO2. 08/13/2026 AM shift: -7:00 AM: T.: 97.7°, P.: 80, R.: 18, B/P: 123/60, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/13/2026 PM shift: The EMR failed to reveal documentation of vital sign performed during this shift. 08/14/2026 AM shift: -8:11 AM: T.: 97°, P.: 100, R.: 24, B/P: 159/85, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/14/2026 PM shift: -8:30 PM: T.: 98.6°, P.: 80, R.: 20, B/P: 123/61, SaO2: 96%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/15/2026 AM shift: -8:06 AM: T.: 96.4°, P.: 92, R.: 24, B/P: 122/66, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/15/2026 PM shift: -8:00 PM: T.: 97.8°, P.: 82, R.: 18, B/P: 124/63, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. Patient #21: Provider order: Vital Signs, Frequency: every 8 hours, initiated on 08/05/2026 at 2:00 PM. Vital sign flowsheet: 08/05/2026 PM shift: -8:00 PM: T.: 98°, P.: 74, R.: 18, B/P: 173/76. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. Further, vital sign documentation failed to reveal the performance of the vital sign SaO2. 08/06/2026 AM shift: -8:00 AM: T.: 98°, P.: 66, R.: 18, B/P: 174/76, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/06/2026 PM shift: -8:10 PM: T.: 97.5°, P.: 66, R.: 18, B/P: 114/59, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/07/2026 AM shift: -8:23 AM: P.: 78, R.: 18, B/P: 146/70, SaO2: 96%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. Further, vital sign documentation failed to reveal the performance of the vital sign T. 08/07/2026 PM shift: -7:20 PM: T.: 99.3°, P.: 83, R.: 20, B/P: 148/71, SaO2: 96%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/08/2026 AM shift: -7:25 AM: T.: 99.9°, P.: 86, R.: 18, B/P: 178/84, SaO2: 97%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/08/2026 PM shift: -8:20 PM: T.: 99.8°, P.: 75, R.: 14, B/P: 137/71, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/09/2026 AM shift: -7:25 AM: T.: 98°, P.: 80, R.: 15, B/P: 175/87, SaO2: 97%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/09/2026 PM shift: -7:38 PM: T.: 97.6°, P.: 62, R.: 18, B/P: 119/73, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/10/2026 AM shift: -7:50 AM: T.: 97.5°, P.: 66, R.: 18, B/P: 103/63, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/10/2026 PM shift: -8:11 PM: T.: 97°, P.: 67, R.: 18, B/P: 112/55, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. Patient #23: Provider order: Vital Signs, Frequency: every 4 hours, initiated on 08/14/2026 at 9:50 AM. Vital sign flowsheet: 08/14/2026 PM shift: -7:20 PM: T.: 96.9°, P.: 110, R.: 18, B/P: 125/71, SaO2: 92; -10:00 PM: P.:105, R: 18, SaO2: 95%; and -3:30 AM: P.: 99, R: 18, SaO2: 96. Vital sign documentation failed to reveal vital signs being taken every 4 hours. T. and B/P were documented once during this shift, and the next documented performance of these vital signs was approximately 12 hours (see next shift times). 08/15/2026 AM shift: -7:40 AM: T.: 97.9°, P.: 92, R.: 17, B/P: 131/68; -8:35 AM: P.: 110, R.: 18, SaO2: 99%; and -3:09 PM: P.: 102, R.: 18. Vital sign documentation failed to reveal vital signs being taken every 4 hours. T., B/P and SaO2 vital signs were documented once during this shift, and the next documented performance of these vital signs was approximately 12 hours (see next shift times). 08/15/2026 PM shift: -8:22 PM: T.: 100.7°, P.:114, R: 19, B/P: 125/70, SaO2: 92%; -12:50 AM: T.: 99.6°; and -3:00 AM: P.: 101, R.: 18. Vital sign documentation failed to reveal vital signs being taken every 4 hours. T., B/P and SaO2 were documented once during this shift and , and the next documented performance of these vital signs was approximately 11 - 12 hours (see next shift times). 08/16/2026 AM shift: -7:22 AM: T.: 99.3°, P.:103, R: 17, B/P: 124/74; -8:49 AM: P.:89, R: 18, SaO2: 98%; and -3:10 PM: P.:91, R: 18. Vital sign documentation failed to reveal vital signs being taken every 4 hours. T., B/P and SaO2 vital signs were documented once during this shift, and the next documented performance of these vital signs was approximately 12 hours (see next shift times). 08/16/2026 PM shift: -7:40 PM: T.: 98.2°, P.:99, R: 18, B/P: 127/77, SaO2: 96%; -12:00 AM: T.: 98.6°, P.: 95, R: 18, B/P: 134/82, SaO2: 98%; and -3:32 AM: T.: 98.6°, P.:102, R: 18, B/P: 133/82, SaO2: 97%. 08/17/2026 AM shift: -9:00 AM: T.: 97.8°, P.: 97, R: 21, B/P: 118/82, SaO2: 96%; -12:38PM: T.: 97.9°, P.: 95, R: 19, SaO2: 96%; and -3:46 PM: T.: 99.7°, P.: 95, R: 18, B/P: 134/71, SaO2: 100%. B/P documentation failed to reveal this vital sign being taken every 4 hours and appeared to be documented every 6 hours (see prior shift times and next shift times for trend). 08/17/2026 PM shift: -8:25 PM: T.: 97.4°, P.: 83, R: 18, B/P: 122/82, SaO2: 100%; -9:29 PM: P.: 104, B/P: 120/76; -10:46 PM: P.: 84, R.: 16; and -4:16 AM: P.:90, R.: 17. T. and B/P documentation failed to reveal these vital signs being taken every 4 hours. T., B/P and SaO2 vital signs were documented once during this shift, and the next documented performance of these vital signs was approximately 12 hours (see next shift times). 08/18/2026 AM shift: -8:00 AM: T.: 97.7°, P.: 95, R: 18, B/P: 115/78, SaO2: 99%. Patient #25: Provider order: Vital Signs, Frequency: every 8 hours, initiated on 08/07/2026 at 2:28 PM. Vital sign flowsheet: 08/08/2026 AM shift: -8:00 AM: T.: 97°, P.: 71, R.: 18, B/P: 107/53, SaO2: 96%; and -3:41 PM: P.:85, R: 29, B/P: 145/65, SaO2: 95%. T. documentation failed to reveal the vital sign being taken every 8 hours and appeared to be documented once per shift. 08/08/2026 PM shift: -9:00 PM: T.: 97.8°, P.: 90, R.: 20, B/P: 134/61, SaO2: 97% Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/09/2026 PM shift: -9:03 PM: T.: 97.9°, P.: 84, R.: 16, SaO2: 94%; and -9:12 PM: B/P: 110/53. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/10/2026 AM shift: -8:00 AM: T.: 97.1°, P.: 86, R.: 18, B/P: 104/53, SaO2: 92% Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/10/2026 PM shift: -8:00 PM: T.: 97.8°, P.: 75, R.: 19, B/P: 110/53, SaO2: 98%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/11/2026 AM shift: -7:37 AM: T.: 97.7°, P.: 74, R.: 18, B/P: 120/80, SaO2: 96%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/11/2026 PM shift: -7:21 PM: T.: 97.8°, P.: 76, R.: 18, B/P: 103/51, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/12/2026 AM shift: -7:37 AM: T.: 97°, P.: 68, R.: 16, B/P: 91/51, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. 08/12/2026 PM shift: -7:36 PM: T.: 98.1°, P.: 77, R.: 20, B/P: 109/56, SaO2: 95%. Vital sign documentation failed to reveal vital signs being taken every 8 hours and the vital signs appeared to be documented once per shift. In an interview on 08/19/2026 at 3:00 PM and navigating the electronic medical record for medical record review, S2ADON confirmed the above-mentioned findings. S2ADON further confirmed the hospital’s vital sign schedule is every 4 hours or every shift. 48051”

“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: 17450 Based on record review and interview, the hospital failed to ensure that all drugs were administered in accordance with the orders of the practitioner responsible for the patient’s care for 5 of 5 (Patient #7, #10, #12, #18, #21) records reviewed for patients with ordered antibiotics in a total sample of 30. Findings: Review of the policy titled, Medication Administration (dated 11/07/2025), revealed in part that time critical scheduled medications are those for which an early or late administration of greater than 30 minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. Scheduled medications identified as time critical must be administered within 30 minutes before or after their scheduled time. Examples of time critical scheduled medications include antibiotics. 1. Review of the medical record for Patient #7 revealed an admission date of 08/14/2026 with a diagnosis of right shoulder septic arthritis. Review of the physician order dated 08/14/2026 revealed an order to administer oxacillin (antibiotic) 2 grams intravenous every 4 hours. Review of the patient’s MAR revealed the following dates/times when the medication was not administered every 4 hours as ordered: 08/16/2026 - dose given and 12:30 AM and next dose at 6:00 AM (time between doses 5 hours, 30 minutes) 08/16/2026 - dose given at 6:00 AM and next dose at 11:25 AM (time between doses 5 hours, 25 minutes) 08/17/2026 - dose given at 5:43 AM and next dose at 11:05 AM (time between doses 5 hours, 22 minutes) 08/17/2026 - dose given at 11:05 AM and next dose at 1:46 PM ( time between doses 2 hours, 41 minutes) 08/18/2026 - dose given at 3:59 PM and next dose at 9:51 PM (time between doses 5 hours, 52 minutes) 2. Review of the medical record for Patient #18 revealed an admission date of 08/13/2026 with a diagnosis of septic arthritis of the left knee. Review of the physician order dated 08/13/2026 revealed an order to administer oxacillin (antibiotic) 2 grams intravenous every 4 hours. Review of the patient’s MAR revealed the following dates/times when the medication was not administered every 4 hours as ordered: 08/15/2026 - dose given and 5:38 PM and next dose at 10:32 PM (time between doses 4 hours, 54 minutes) 08/16/2026 - dose given at 6:00 AM and next dose at 11:25 AM (time between doses 5 hours, 25 minutes) 08/17/2026 - dose given at 5:20 PM and next dose at 10:039 PM (time between doses 5 hours, 19 minutes) 08/18/2026 - dose given at 6:04 PM and next dose at 9:03 PM (time between doses 2 hours, 59 minutes) On 08/19/2026 at 1:30 PM, interview with S1CNO confirmed that Patient #7 and Patient #18’s antibiotics were not administered every 4 hours as ordered by the physician. 3. Review of the medical record for Patient #10 revealed an admission date of 07/27/2026 with the diagnoses of long-term antibiotic use after respiratory failure due to aspiration and sepsis. Review of the physician orders revealed an order dated 07/28/2026 to administer vancomycin (antibiotic)1.25 grams intravenously every 18 hours and an order dated 07/31/2026 to administer meropenem (antibiotic) 1 gram intravenously every 8 hours. Review of the patient’s MAR revealed the following dates/time when the medication was not administered every 8 hours as ordered: Vancomycin: 08/14/2026 - dose given at 5:26 PM and next dose on 08/15/2026 at 9:59 AM (time between doses 16 hours, 33 minutes); 08/15/2026 - dose given at 9:59 AM and next dose on 08/16/2026 at 4:45 AM (time between doses 18 hours, 44 minutes); 08/16/2026 - dose given at 4:45 AM and next dose at 9:09 PM (time between doses 16 hours, 31 minutes); and 08/17/2026 - dose given at 3:03 PM and next dose on 08/18/2026 at 11:55 AM (time between doses 20 hours 52 minutes). Meropenem: 08/16/2026 - dose given at 8:23 AM and next dose at 6:55 PM (time between doses 10 hours, 32 minutes); and 08/17/2026 - dose given at 10:04 AM and next dose at 4:52 PM (time between doses 6 hours, 48 minutes). 4. Review of the medical record for Patient #12 revealed an admission date of 07/28/2026 with the diagnoses of long-term antibiotic continuation after right hemicolectomy and subsequent mass drainage and continued JP drainage management. Review of the physician order dated 07/28/2026 revealed an order to administer meropenem (antibiotic) 1 gram intravenously every 8 hours. Review of the patient’s MAR revealed the following dates/time when the medication was not administered every 8 hours as ordered: 08/16/2026 - dose given at 8:29 AM and next dose at 5:47 PM (time between doses 9 hours, 18 minutes); 08/18/2026 - dose given at 1:54 AM and next dose at 8:18 AM (time between doses 6 hours, 24 minutes); and 08/18/2026 - dose given at 8:18 AM and next dose at 5:16 PM (time between doses 8 hours, 58 minutes). 5. Review of the medical record for Patient #21 revealed an admission date of 08/05/2026 with the diagnoses of infected hardware of the left ankle. Review of the physician order dated 08/05/2026 revealed an order to administer meropenem (antibiotic) 2 gram intravenously every 8 hours. Review of the patient’s MAR revealed the following dates/time when the medication was not administered every 8 hours as ordered: 08/15/2026 - dose given at 4:54 PM and next dose was on 08/16/2026 at 2:24 AM (time between doses 9 hours, 30 minutes); 08/16/2026 - dose given at 10:35 AM and next dose 5:06 PM (time between doses 6 hours, 31 minutes); 08/16/2026 - dose given at 5:06 PM and next was on 08/17/2026 at 2:50 AM (time between doses 9 hours, 44 minutes); and 08/17/2026 - dose given at 2:50 AM and next was at 9:02 AM (time between doses 6 hours, 48 minutes). In an interview on 08/19/2026 at 2:22 PM, S2ADON confirmed Patients #10, #12, and #21’s antibiotics were not being administered as ordered by the physician. 48051”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 48051 Based on observations, record review and interview, the hospital failed to ensure medical record documentation included the performance of a central line dressing change in 2 (#15, #25) of 12 medical records reviewed for central line dressing changes in a total sample of 30. Findings: A review of the hospital policy titled, “Intravenous Therapy,” Policy Number: 9-4.0.0, with an effective date of 12/01/2025, revealed in part: “PURPOSE: To provide guidance and best practice for the administration of intravenous therapy in the hospital setting. PROCEDURE: B. Central Venous IV Therapy 5. Gauze Dressing that prevent visualization of the insertion site should be changed immediately if the integrity of the dressing is compromised and at least every 48 hours. Transparent dressings that allow visualization of the insertion site should be changed at least every 7 days and as needed.” Patient #15: An observation of Patient #15’s central line dressing (CVC) on 08/19/2026 at 12:55 PM, revealed a transparent dressing on the left side of the patient’s neck with an associated date transcribed on the dressing as “08/13/2026.” A review of Patient #15’s medical record revealed the placement of a left internal jugular CVC on 08/10/2026. The medical record failed to reveal an associated entry related to a dressing changed being performed on 08/13/2026. Patient #25 A review of Patient #25’s medical record revealed the placement of a PICC line on 07/15/2026 and prior to the patient’s admission on 08/04/2026. The medical record reflected the patient’s central line dressing changed on 08/08/2026 and indicated the next dressing change to take place on 08/15/2026. However, the medical record failed to reveal the central line dressing being changed since 08/08/2026. In an interview on 08/19/2026 at 1:00 PM, S2ADON confirmed the above-mentioned findings. S2ADON further confirmed the date transcribed on the central line dressing would indicate the date the dressing was changed.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety as evidenced by expired supplies being available for patient use. Findings: Observations during a walk-through of Room “e” on 08/18/2026 from 09:00 AM to 09:15 AM revealed a container of Sani-Cloth Bleach Germicidal Disposable wipes with an expiration date of 07/2023 available for patient use. In an interview on 08/18/2026 and present during this walk through of Room “e”, S19PT confirmed the above-mentioned findings.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure the infection prevention and control program employed methods for preventing and controlling the transmission of infections within the hospital as evidenced by 1) failing to maintain a sanitary environment and 2) failing to ensure staff donned proper PPE when caring for patients. Findings: 1) Failing to maintain a sanitary environment On 08/17/2026 at 9:10 AM, tour of the hospital with S1CNO and S3CEO revealed the following: 1. Room a (clean room) had an overbed table with a dried red substance on the side of it. Dust was coated on all horizontal surfaces in the room, including the blood pressure cuff that was stored in a wall box, bed frame, headboard and on the picture frame hanging on the wall. The IV pump in the room was not bagged or tagged as being cleaned and disinfected. Brown splatters were observed on the wall near the bathroom. Mold was observed in the floor and sides of the shower stall. 2. Room b (clean room) had an overbed table with trash and debris in the drawers of it. Brown splatters were observed on the bottom of the bed frame. The IV pump had a plastic bag over it but also had a strip of opened IV port protectors hanging from the pole from the last patient. Dust build-up was observed on all horizontal surfaces. 3. Room c (clean room) had a bedside chair in the room with a tear in the vinyl on the seat, with the insides exposed. A tube feeding pump was in the room with a plastic bag over it, and multiple brown drips were noted on the pump and on the floor under it. At this time, S6Housekeeping Supervisor entered the room and stated that housekeeping did not clean the actual pumps (such as IV and tube feeding), but only the poles of the pumps because housekeepers did not know what chemicals were supposed to be used to clean the actual machines and did not want to mess them up. S1CNO and S3CEO were also present during this interview and confirmed that they were unaware that housekeeping was only cleaning the poles and not the actual IV and feeding tube pumps. 4. An electric lift was observed in the hallway near Room c. There was a dried brown substance on the control area of the machine that was easily wiped off by S6Housekeeping Supervisor. 5. Room d (clean room) had old tape stuck to the bed siderail. A build-up of dust was observed on all horizontal surfaces. Dried red drips were observed on the wall near the foot of the bed. An IV pump was in the room that had no indication that it had been disinfected (no plastic bag over it and no hang tag indicating clean). Further observations of the closet in the room revealed multiple personal items left from the previous patient. 6. The rolling blood pressure machine in the hallway near Room d was coated with a thick build up of dust and grime. On 08/17/2026 at 10:45 AM, interview with S1CNO and S3CEO confirmed that the hospital’s housekeeping services were contracted from the host hospital. They further stated that the above areas were in need of further cleaning. 7. Observations during a walk-through of Room “e” on 08/18/2026 from 09:00 AM to 09:15 AM revealed a patient wheelchair available for patient use having grey fuzzy substances on all its surfaces. Further, the covering on the seat and both arm rests of this wheelchair was cracked and peeling which inhibits these surfaces from being properly cleaned after patient use. In an interview on 08/18/2026 and present during this walk through of Room e, S19PT confirmed the above-mentioned findings and indicated the wheelchair should be taken out of use. 2) Failing to ensure staff donned proper PPE when caring for patients On 08/17/2026 at 1:45 PM, observation revealed the door to Patient #7’s room was more than half way open. Observation revealed a sign on the door indicating contact precautions. PPE supplies (gown, gloves) were observed hanging on the door and staff were in the room assisting the patient. One of the staff in the room, S5LPN, was observed with the “computer on wheels” in the room. S5LPN was also observed to be wearing gloves only, and no gown. The staff was assisting the patient after a bowel movement. At 1:50 PM, observation revealed S5LPN exited the room (without disinfecting the “computer on wheels”) and began pushing the “computer on wheels” down the hallway. At that time, the surveyor asked S5LPN why the patient was on contact precautions and she stated the patient has suspected Clostridium Difficile infection. When asked why she was not wearing a gown while in the room, S5LPN had no response. Review of the medical record for Patient #7 revealed a physician order dated 08/14/2026 for the patient to be placed in “contact plus isolation” for possible Clostridium Difficile infection. Review of the policy titled, Management of Patients with Clostridium Difficile (dated 01/01/2025), revealed in part that patients with suspected Clostridium Difficile will be placed on maximum contact precautions. Review of the policty titled, Isolation Precautions (dated 01/01/2025), revealed in part that a gown will always be worn when entering the room of a patient requiring maximum contact precautions. On 08/18/2026 at 3:00 PM, interview with S1CNO confirmed that S5LPN should have worn a disposable gown when in the room of Patient #7. 48051”

“ORDERS FOR REHABILITATION SERVICES CFR(s): 482.56(b) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 48051 Based on record review and interview the hospital failed to ensure rehabilitation services are provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This deficient practice was evidenced by the failure to obtain provider orders for physical therapy services after the performance of an evaluation in 2 (#12, #25) of 7 medical reviewed for physical therapy orders. Findings: A review of the hospital policy titled, “Initiation of Therapy Service,” Policy Number: 12-3.1.0, with an effective date of 12/01/2025, revealed in part: “PURPOSE: To outline a process for the initiation of physical therapy, occupational therapy and/or speech pathology services. PROCEDURE: The therapist will check the medical record for an order for therapy services. The initial order for therapy services will be to evaluate the patient and formulate a treatment plan. Evaluations are to be completed within 3 calendar days of receiving the order. The therapist will communicate the plan to the licensed practitioner. The licensed practitioner will initiate an order for therapy services based on the therapist’s treatment plan. It is acceptable for a licensed staff member to take a telephone order from a physician pertaining to a therapy service in one’s own discipline.” Patient #12: A review of the provider’s orders revealed an order dated, 07/28/2026 by S18MD as, “PT Eval and Treat,” and the frequency as, “Once 07/28/2026 1346 - 1 occurrence.” A review of the medical record’s physical therapy evaluation, dated 07/29/2026 at 10:16 AM by S19PT revealed in part, “Recommendation: Long-term therapy in post-acute facility; PT Frequency: 3-5x/wk; Equipment Recommendation: Will further assess; Gym Candidate: Yes.” The medical record revealed the continued performance of physical therapy on 08/10/2026, 08/12/2026, 08/13/2026, 08/17/2026 and 08/18/2026, however the medical record failed to reveal a provider’s order for the performance of physical therapy after the initial order for evaluation and treatment x 1. Patient #25: A review of the provider’s orders revealed an order dated, 08/04/2026 by S20MD as, “PT Eval and Treat,” and the frequency as, “Once 08/04/2026 1550 - 1 occurrence.” A review of the medical record’s physical therapy evaluation, dated 08/05/2026 at 9:46 AM by S19PT revealed in part, “Recommendation: Long-term therapy in post-acute facility; PT Frequency: 3-5x/wk; Equipment Recommendation: Will further assess; Gym Candidate: Yes.” The medical record revealed the continued performance of physical therapy on 08/06/2026, 08/07/2026, 08/10/2026, 08/13/2026, 08/17/2026 and 08/18/2026, however the medical record failed to reveal a provider’s order for the performance of physical therapy after the initial order for evaluation and treatment x 1. In an interview on 08/19/2026 at 10:35 AM, S21PT confirmed the above-mentioned findings. In an interview on 08/19/2026 at 1:55 PM, S2ADON confirmed the above-mentioned findings.”