Louisiana Extended Care Hospital of Natchitoches

“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 and interview, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the nurse call system was functioning via call buttons located on the side rails of the patient’s beds in 5 (Rooms ‘a’, and ‘c’ - ‘f’) of 19 rooms observed. Findings: Observations made during a walk-through on 07/22/2026 from 2:45 PM - 2:59 PM revealed Room ‘a’, and Rooms ‘c’ - ‘f’ were missing the extension to connect the patient bed to the wall. Each of the above-mentioned rooms contained a nurse call button located on its interior sides (mattress sides). When each of the call buttons were depressed, it did not activate the nurse call system at the nurses’ station, illuminate the call light above the entry door or activate an audible sound that would be indicative of a patient calling for assistance. This had the potential to place undue distress and/or harm on a patient and/or a family member attempting to call staff for assistance. In an interview during the tour, S2DON confirmed the above-mentioned findings.”

“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: 51596 Based on record review and interview, the hospital failed to thoroughly analyze all adverse patient events and implement preventive action. The deficient practice was evidenced by failure to document and track medication variances. Findings: Review of the hospital’s policy titled “Medication Management - Administration of Medications: General” revised 05/2026, revealed in part: POLICY: To administer medications to the patients as ordered by the physician accurately and on time. COMPLIANCE WITH MEDICATION ORDERS: Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient’s care and accepted standards of practice. STANDARD MEDICATION ADMINISTRATION TIMES: Doses that are late, missed ...will be reported to the prescribing physician and to the hospital medication error reporting program. MEDICATION ADMINISTRATION PROCEDURE: Report medication administration errors ...immediately to the attending physician. Prepare and submit reports as required by the facility. Review of the hospital’s policy titled “Medication Variance” revised 02/05/2026, revealed in part: POLICY: A medication variance is defined as any preventable event that may cause or lead to inappropriate medication use and/or patient harm. Such events may be related to any aspect of the medication use process. This definition includes those events that result in patient harm, as well as circumstances or incidents that have the potential to cause patient harm. Employees accountable for medication variances may include licensed nurses ...pharmacists as well as any other licensed employees whose scope of practice allows administration of medication. PROCEDURE: Types of variances are as follows: Order transcribed on wrong patient, order transcribed for wrong drug, order transcribed for wrong dose, order transcribed for wrong dosing schedule, medication dispensed to the wrong patient, wrong medication dispensed, wrong dose dispensed, medication dispensed at wrong time (late), wrong dose administered, medication administered at the wrong time, and omitted dose. Near Miss: Any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. Performance Improvement and Safety/Risk: The DON shall review and analyze all medication variances for trends and possible system improvements at least quarterly. Medication variances will be reported at the Safety/Risk Committee meeting. Plans of correction will be instituted in accordance with the PI Plan. Review of the hospital’s “Performance Improvement Committee Meeting” minutes dated 04/23/2026 for the 1st Quarter of 2026 revealed 0 medication errors and 0 adverse drug reactions. Review of the hospital’s undated “Performance Improvement Committee Meeting” minutes for the 4th Quarter of 2025 revealed 0 medication errors and 0 adverse drug reactions. Review of the hospital’s undated “Performance Improvement Committee Meeting” minutes for the 3rd Quarter of 2025 revealed 0 medication errors and 0 adverse drug reactions. In an interview on 07/21/2026 at 8:48 AM, S2DON revealed “I used to report the variances, now I just report the errors.” When asked the difference between a medication variance and a medication error, S2DON replied, “That’s a good question. I really don’t know.” Following review of the hospital’s “Medication Variance” policy, S2DON confirmed there had been medication variances which had been labeled “near misses”, and were not documented or reported as medication variances, but should have been.”

“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: 50453 Based on record review and interview, the hospital failed to ensure that a registered nurse evaluated the care of each patient as evidenced by failing to notify the physician of a patient’s critical lab result for 1 (#3) of 30 medical records reviewed. Findings: Review of hospital policy titled, “Critical Values,” revised 02/05/2026, revealed in part: “PURPOSE: To define a process for communicating critical values to the licensed responsible caregiver and the physician/licensed independent practitioner (LIP). PROCEDURE: When the nurse is notified of the critical value, the critical value will be reported to the physician/LIP immediately but no later than one hour after the nurse is notified.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 7/07/2026 at 2:30 PM with a diagnosis of Debility secondary to severe sepsis due to pneumonia. Review of Patient #3’s laboratory results revealed the following critical ammonia values: 07/16/2026 at 12:53 PM: 128.1 High (normal range 11.0-51.0); 07/18/2026 at 5:50 AM: 128.4 High; and 07/20/2026 at 6:30 AM: 95.5 High. Further review of Patient #3’s medical record failed to reveal documented evidence that the above critical lab results were reported to the physician within 1 hour per policy by the nurse. In an interview on 07/22/2026 at 10:34 AM, S2DON confirmed there was no documented evidence that the above-mentioned critical lab values were reported to the physician within 1 hour per policy by the nurse.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all patient medical records contained all documentation related to the inpatient stay and was completed in a timely fashion. This deficient practice was evidenced by failure to ensure discharge planning was documented in the patient’s medical record within 72 hours of admission according to hospital policy for 7 (#13, #15, #17, #18, #20, #22, and #24) of 30 medical records reviewed. Findings: Review of the hospital’s policy titled “Discharge Planning and Post-Acute Referral Process” revised 12/21/2025, revealed in part: POLICY: A discharge plan will be developed for every inpatient within 3 days of admission. Patient #13 Review of Patient #13’s medical record revealed Patient #13 was admitted on 05/11/2026 and discharged on 05/19/2026. Further review of Patient #13’s medical record failed to reveal documentation of discharge planning. In an interview on 07/22/2026 at 11:03 AM, S1ADM confirmed discharge planning was not documented in Patient #13’s medical record. In an interview on 07/22/2026 at 12:29 PM, S1ADM stated she had paper records that she kept separately for case management. In an interview on 07/22/2026 at 1:04 PM, S1ADM confirmed the paper records for discharge planning should have been included in the electronic medical records. Patient #15 Review of Patient #15’s medical record revealed Patient #15 was admitted on 01/22/2026 and discharged on 01/30/2026. Further review of Patient #15’s medical record failed to reveal documentation of discharge planning. In an interview on 07/22/2026 at 1:04 PM, S1ADM confirmed discharge planning was not documented in Patient #15’s medical record. Patient #17 Review of Patient #17’s medical record revealed Patient #17 was admitted on 03/11/2026 and discharged on 03/20/2026. Further review of Patient #17’s medical record failed to reveal documentation of discharge planning. In an interview on 07/22/2026 at 1:41 PM, S1ADM confirmed discharge planning was not documented in Patient #17’s medical record. Patient #18 Review of Patient #18’s medical record revealed Patient #18 was admitted on 05/20/2026 and discharged on 05/24/2026. Further review of Patient #18’s medical record failed to reveal documentation of discharge planning. In an interview on 07/22/2026 at 1:55 PM, S1ADM confirmed discharge planning was not documented in Patient #18’s medical record. Patient #20 Review of Patient #20’s medical record revealed Patient #20 was admitted on 05/15/2026 and discharged on 05/22/2026. Further review of Patient #20’s medical record failed to reveal documentation of discharge planning. In an interview on 07/22/2026 at 2:24 PM, S1ADM confirmed discharge planning was not documented in Patient #20’s medical record. Patient #22 Review of Patient #22’s medical record revealed Patient #22 was admitted on 06/19/2026 and discharged on 07/01/2026. Further review of Patient #22’s medical record failed to reveal documentation of discharge planning within 72 hours of admission. In an interview on 07/22/2026 at 8:58 AM, S3CL confirmed discharge planning was not documented in Patient #22’s medical record within 72 hours of admission. Patient #24 Review of Patient #24’s medical record revealed Patient #24 was admitted on 04/23/2026 and discharged on 05/21/2026. Further review of Patient #24’s medical record failed to reveal documentation of discharge planning within 72 hours of admission. In an interview on 07/22/2026 at 11:00 AM, S3CL confirmed discharge planning was not documented in Patient #24’s medical record within 72 hours of admission. 51596”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 44763 50453 Based on record reviews and interviews, the hospital failed to ensure a medical history and physical was completed and placed in the medical record within 24 hours of admission for 6 (#7, #10, #20, #25, #27, and #28) of 30 medical records reviewed. Findings: Review of the hospital’s Medical Staff Bylaws and Rules and Regulations revealed in part, 11.1 Admissions: (b) The admitting practitioner shall be responsible for the coordination of medical care, treatment, and services of the patient, for the prompt completion and accuracy of the medical record, including performance of the History and Physical (within twenty four (24) hours of admission), for necessary instructions to Hospital personnel, and for communicating reports of the condition of the patient. Patient #7 Review of Patient #7’s medical record revealed the patient was admitted on 06/15/2026 at 3:45 PM. Review of Patient #7’s medical record revealed the medical history and physical was completed on 06/16/2026 at 6:07 PM. In an interview on 07/22/2026 at 1:13 PM, S2DON confirmed the medical history and physical for Patient #7 was not completed within 24 hours of admission. Patient #10 Review of Patient #10’s medical record revealed the patient was admitted on 03/04/2026 at 2:50 PM. Review of Patient #10’s medical record revealed the medical history and physical was completed on 03/05/2026 at 4:29 PM. In an interview on 07/22/2026 at 2:25 PM, S2DON confirmed the medical history and physical for Patient #10 was not completed within 24 hours of admission. Patient #20 Review of Patient #20’s medical record revealed Patient #20 was admitted on 05/15/2026. Review of Patient #20’s medical history and physical revealed it was completed on 05/18/2026. In an interview on 07/22/2026 at 2:16 PM, S1ADM confirmed Patient #20’s medical history and physical was completed on 05/18/2026 and was not within 24 hours of admission. Patient #25 Review of Patient #25’s medical record revealed Patient #25 was admitted on 06/15/2026 at 6:40 PM. Further review failed to reveal documentation of a medical history and physical. In an interview on 07/22/2026 at 11:00 AM, S3CL confirmed Patient #25 did not have a medical history and physical completed and placed in the medical record within 24 hours of admission. Patient #27 Review of Patient #27’s medical record revealed Patient #27 was admitted on 05/06/2026 at 4:10 PM. Review of Patient #27’s medical history and physical revealed it was completed on 05/08/2026 at 11:06 PM. In an interview on 07/22/2026 at 1:30 PM, S3CL confirmed Patient #27 did not have a medical history and physical completed and placed in the medical record within 24 hours of admission. Patient #28 Review of Patient #28’s medical record revealed Patient #28 was admitted on 05/26/2026 at 3:50 PM. Review of Patient #28’s medical history and physical revealed it was completed on 05/27/2026 at 11:13 PM. In an interview on 07/22/2026 at 1:40 PM, S3CL confirmed Patient #28 did not have a medical history and physical completed and placed in the medical record within 24 hours of admission. 51596”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed per hospital policy for 2 (#23 and #27) of 30 medical records reviewed. Findings: Review of the hospital’s policy titled “Informed Consent” revised 02/05/2026, revealed in part: POLICY: Informed consent is a process in which the physician provides adequate information for the patient or patient’s legal representative to make an informed decision of the proposed treatment. PROCEDURE: (A) All patients or authorized persons will sign an Admission Consent to Treat upon admission. (C.5) Telephone consent may be obtained from an authorized person if the given consent is deemed informed. Phone consent shall be conducted by two nurses. Two witnesses will sign, time and date the informed consent form. Patient #23 Review of Patient #23’s medical record revealed an admission date of 05/06/2026 at 5:45 PM. Review of Patient #23’s Admission Consent to Treat revealed verbal consent of Patient #23’s POA was documented on 05/08/2026 and witnessed by one nursing staff member. In an interview on 07/22/2026 at 9:49 AM, S3CL confirmed the above-mentioned finding and that the verbal consent should have been witnessed by two nursing staff members, but was not. Patient #27 Review of Patient #27’s medical record revealed an admission date of 05/06/2026 at 4:10 PM. Review of Patient #27’s Admission Consent to Treat revealed verbal consent of Patient #27’s POA was documented on 05/07/2026 and witnessed by one nursing staff member. In an interview on 07/22/2026 at 1:22 PM, S3CL confirmed the above-mentioned finding and that the verbal consent should have been witnessed by two nursing staff members, but was not.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure all practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient’s condition were contained in patients’ medical records. This deficient practice was evidenced by failure to ensure an order for a Do Not Resuscitate (DNR) was included in 1 (#3) of 30 medical records reviewed. Findings: Review of hospital policy titled “Do Not Resuscitate,” last revised 02/05/2026, revealed in part: “G. Properly Written DNR Order: There are two components of a properly written DNR order. There must be (1) documentation in the medical record that indicates that the patient/representative decision maker understands DNR status or limitations of treatment and there must be (2) an order written in the medical record.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 07/07/2026 at 2:30 PM with a diagnosis of Debility secondary to severe sepsis due to pneumonia. Review of Patient #3’s medical record revealed a DNR Status Acknowledgement form was signed by Patient #3’s husband on 07/16/2026 at 6:26 PM. Further review of Patient #3’s medical record failed to reveal a written order in the medical record per policy. In an interview on 07/22/2026 at 10:15 AM, S2DON confirmed that Patient #3’s medical record did not have a DNR order.”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure STAT diagnostic radiologic services were resulted within one hour for 3 (Patient #21, Patient #22, and Patient #23) of 30 medical records reviewed. Findings: Review of the facility’s spreadsheets tracking the length of time from when STAT radiology tests were ordered to when they were performed revealed the following: 05/2026: 6 tests were performed over one hour after being ordered; and 06/2026: 2 tests were performed over one hour after being ordered. In an interview on 07/21/2026 at 10:58 AM, S2DON revealed the facility did not have a written policy regarding the timing of STAT orders, but that STAT orders should have been completed within one hour. Patient #21 Review of Patient #21’s medical record revealed STAT CT of Abdomen & Pelvis was ordered on 06/19/2026 at 3:12 PM and completed on 06/19/2026 at 7:09 PM In an interview on 07/21/2026 at 3:25 PM, S2DON confirmed the above-mentioned finding and revealed the STAT CT should have been resulted within one hour, but was not. Patient #22 Review of Patient #22’s medical record revealed STAT Venous Doppler Bilateral Lower Extremity was ordered on 06/21/2026 at 10:00 AM and completed on 06/21/2026 at 12:40 PM. In an interview on 07/21/2026 at 3:53PM, S2DON confirmed the above-mentioned finding and revealed the STAT Venous Doppler should have been resulted within one hour, but was not. Patient #23 Review of Patient #23’s medical record revealed the following x-rays were ordered on 05/14/2026 at 12:57 PM and resulted on 05/14/2026 at 2:36 PM. STAT X-Ray Right Forearm; STAT X-Ray Left Forearm; Urgent Portable CXR; STAT X-Ray Right Humerus; STAT X-Ray Left Humerus; STAT X-Ray Right Hand; and STAT X-Ray Left Hand. In an interview on 07/21/2026 at 4:20 PM, S2DON confirmed the above-mentioned finding and revealed STAT and Urgent XRs should have been resulted within one hour, but were not.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure STAT laboratory services were resulted within one hour for 1 (#21) of 30 medical records reviewed. Findings: In an interview on 07/21/2026 at 10:58 AM, S2DON revealed the facility did not have a written policy regarding the timing of STAT orders, but that STAT orders should have been completed within one hour. Review of Patient #21’s medical record revealed the following: Amylase STAT, BMP STAT, Lipase STAT, and Liver Function Panel STAT were ordered on 06/19/2026 at 3:18 PM and resulted on 06/19/2026 at 5:51 PM. In an interview on 07/21/2026 at 3:25 PM, S2DON confirmed the above-mentioned findings and revealed STAT labs should have been resulted within one hour, but were not.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 51596 Based on observation, record review and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This was evidenced by failing to ensure preventative maintenance was maintained on all hospital equipment. Findings: Review of the hospital’s “Medical Equipment Management Plan” revised 04/2025, revealed in part: (II) PURPOSE: The Medical Equipment Management Plan describes the process it implements to manage the effective, safe, and reliable operation of medical equipment. (III) OBJECTIVE: The objective...is to minimize the risks of using medical equipment through inspection, scheduled maintenance, and education in the safe use of medical equipment. (IV.A) Medical Equipment: Equipment used for the diagnosis, care, treatment, life support, and monitoring of patients. The equipment may be powered by electricity, mechanical forces, pneumatics, hydraulics, manually, or other means. (B) High-Risk Equipment: Medical Equipment for which there is a risk of serious injury or death to a patient or staff member should the equpment fail. Includes life support equipment but is not limited to it. (C) Non High-Risk Equipment: All medical equipment that is not classified as High Risk. (EC.02.04.03 EP1: Initial and Post Repair Performance Testing) All medical equipment, regardless of ownership will be tested for performance and saftey prior to use on patients. (EC.02.04.03 EP3: Testing of Non-High-Risk Equipment) All Non-High-Risk Equipment will be testing according to determined intervals in a timely manner. Maintenance activities...will be completed at 100%. Observations during a tour of the hospital on 07/20/2026 between 12:20 PM and 1:31 PM revealed the following: - Room ‘q’ box fan had no evidence of a PM sticker; and - Room ‘j’ box fan had no evidence of a PM sticker. In interviews conducted at the time of the observations, S3CL confirmed the above-mentioned findings and confirmed the box fans should have had PM stickers, but did not. Observation during a tour of the hospital on 07/20/2026 between 12:20 PM and 1:31 PM revealed the following: - Room ‘r’ contained 2 Computer-On-Wheels, 3 battery chargers for Computer-On-Wheels, and 6 rechargeable batteries for Computer-On-Wheels without evidence of PM stickers. In an interview conducted at the time of the observation, S2DON confirmed the above-mentioned findings and confirmed the equipment should have had PM stickers, but did not.”

“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: 44763 50453 51596 Based on observation and interview, the hospital failed to ensure facilities, supplies, and equipment were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by: 1) failure to ensure expired or unusable supplies were removed from the patient care area; and 2) failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Findings: 1) Failure to ensure expired or unusable supplies were removed from the patient care area. Review of hospital policy number 9-7.9.0, titled “Management of Patient Care Supplies,” last revised 02/05/2026, revealed in part: “PURPOSE: To provide guidelines for the management of patient care supplies needed to meet the patient’s health care needs. PROCEDURE: Purchasing personnel, or designee, is responsible for checking expiration dates on patient care items. All dated items that have reached the “expiration date” will be removed from service.” Observations during a tour on 07/23/2026 from 12:20 PM - 1:31 PM revealed the following expired supplies that were available for patient use: Room ‘m’: -Iodosorb Iodine Gel, 10g, expired 05/01/2026, quantity 3; - Culture swab collection and transport system, expired 05/20/2026, quantity 10; -Xeroform Occlusive Gauze Strip, 5”x9”, expired 05/31/2024, quantity 1; and -Swab tip male disinfection cap, expired 06/01/2025, quantity 215. In an interview during the tour, S3CL confirmed the above-mentioned findings. Room ‘o’: -6ml pink laboratory tube, expired 12/01/2025, quantity 1; -4ml green laboratory tube, expired 06/30/2026, quantity 35; and -Culture swab collection and transport system, expired 06/19/2026, quantity 8. In an interview during the tour, S2DON confirmed the above-mentioned findings. Room ‘p’: -5500 Diagnostic Tab Electrodes, expired 02/13/2026, quantity 2 opened packages. In an interview during the tour, S2DON confirmed the above-mentioned findings. 2) Failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Observations during a tour on 07/23/2026 from 12:20 PM - 1:31 PM revealed the following: Room ‘i’: -Peeling paint on wall behind toilet; -Multiple small holes to wall; -Unfinished spackle to wall; -Torn wallpaper ; -Wallpaper not adhered to wall; -Damage to exterior surface of door to room, exposing particle board-like material; and -Baseboard not adhered to wall in the corner behind the toilet. Room ‘q’: -Torn wallpaper; -Multiple small holes to wall; -Unfinished spackle to wall; -Broken towel bar in bathroom; -Damage to exterior surface of door to room, exposing particle board-like material; and -Baseboard not adhered to wall on either side of the bathroom door. Room ‘j’: -Torn wallpaper; and -Wallpaper not adhered to wall. Room ‘l’: -Toilet seat broken and not secured. Room ‘h’: -Exposed sheetrock to wall near the door. Room ‘g’: -Floor tile not secured near the toilet in the bathroom. In interviews during the tour, S3CL confirmed the above-mentioned findings.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure the Infection Control Professional was qualified through education, training, experience, or certification in infection prevention and control. This deficient practice was evidenced by failure to document certification or formal training or education related to directing an infection control program in a hospital setting. Findings: Review of S2DON’s personnel record failed to reveal documentation of a certification or formal training or education related to directing an infection control program in a hospital setting. In an interview on 07/21/2026 at 2:25 PM, S2DON confirmed she was the infection control officer for the hospital. S2DON further confirmed she did not have a certification or formal training or education in infection control.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44763 51596 Based on observation, record review, and interview, the hospital failed to have an effective infection prevention and control program. This deficient practice was evidenced by: 1. failure to ensure a clean and sanitary environment; and 2. failure to ensure food was stored in a safe and sanitary manner. Findings: Review of the hospitals policy titled “Patient Care Equipment” revised 09/2023, revealed in part: DEFINITIONS: Cleaning - cleaning is the removal of foreign material. Cleaning physically removes rather than kills microorganisms. Cleaning is always essential prior to disinfection or sterilization. An item that has not been cleaned cannot be assuredly disinfected or sterilized. PROCEDURE: (II.a.) Equipment may be designated clean by placing a plastic bag over the item. 1. Failure to ensure a clean and sanitary environment. Observations of cleaned equipment and rooms during a tour of the hospital on 07/20/2026 between 12:20 PM and 1:31 PM revealed: - Room ‘i’: No bag over shower chair; Used toilet paper in the toilet bowl; and Dried brown substance to wallpaper. - Room ‘q’: Brown, sticky residue to left armrest of yellow chair at bedside; Dried white gum to surface of Guardian Angel sign; Dried brown substance to wallpaper, casing of box fan, rear of IV pump, and base of bedside table; Debris on seat of grey chair and on floor under bed; No bag over shower chair, walker, box fan, or IV pump/pole; Clear tape to light switch plate cover; and Dried beige substance to exterior surface of door to room. - Room ‘j’: Dried brown substance to floor near bathroom; Dust to blades of box fan; Dried white substance to handle on bathroom door; Wrapper for Dulcolax Suppository on floor; and Yellow and brown discoloration to door frame near hand sanitizer dispenser. -Room ‘g’: 2 bedside commodes stored in the bathroom uncovered; and Dust to the air vent in the bathroom. -Room ‘u’: Bedside commode stored in the shower uncovered; and Dust to the air vent in the bathroom. -Room ‘k’: Dried brown, yellowish substance under the arm rest of the geri-chair. -Room ‘n’: Multiple pillows and feeding pumps on open shelving stored uncovered; and IV pole stored uncovered. There were 5 pillows stored on top of the clean linen cart uncovered in the hallway. The following surfaces could not be appropriately disinfected : -Torn upholstery to both arm rests and seat of black and white wheelchair in hallway; -Torn upholstery to left arm rest of blue geri-chair in hallway; -Torn upholstery to both the arm and leg rests of the bariatric geri-chair in hallway; -Room ‘q’: rust to IV pole; -Room ‘g’: tear in the vinyl covering of a cushioned wedge that was stored in the closet; and -Room ‘u’: torn upholstery to the arm rest of the geri-chair. In interviews conducted at the time of the observations, S3CL confirmed the above-mentioned findings and confirmed the findings were an infection control issue. 2. Failure to ensure food was stored in a safe and sanitary manner. Observations of cleaned equipment and rooms during a tour of the hospital on 07/20/2026 between 12:20 PM and 1:31 PM revealed the following: - Room ‘t’: Multiple undated personal food items in the patient refrigerator; and Two opened and unlabeled/undated 236mL cartons of milk. In an interview conducted at the time of the observation, S3CL revealed the name of the patient and the date was required on all items placed in the patient refrigerator. S3CL confirmed the above-mentioned findings and confirmed the findings were an infection control issue.”