Sage Rehabilitation Hospital

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 50453 Based on record review and interviews, the facility failed to ensure respiratory services were administered in accordance with hospital policy. This deficient practice was evidenced by failing to document respiratory care for 1 (Patient #F1) of 1 medical records reviewed for respiratory therapy documentation. Findings: Review of hospital policy titled, “Respiratory Therapy Documentation Requirements,” last approved 03/2026, revealed in part: “POLICY: Respiratory therapist must document all patient care activities in the patient’s medical record. Documentation includes, but not limited to: Date and time of treatment; Type of respiratory therapy performed; Device settings (for CPAP/BiPAP/Ventilation); Patient assessment findings; Patient tolerance of treatment; Changes in respiratory status; Communication with physician or nursing staff.” Review of hospital policy titled, “Documentation in Medical Record,” last approved 02/2024, revealed in part: “POLICY: Each patient’s medical record shall contain an accurate representation of the actual experiences of the patient and include enough information to provide a picture of the patient’s progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the patient’s medical record in accordance with state and federal law. 2. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the patient’s care and/or response to care. c. Documentation shall be timely and in chronological order. 3. Late Entry: When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as “late entry”.” Review of the list provided by SF10QI on 04/06/2026 at 12:30 PM revealed in part: Patient #F1 as the only patient with a CPAP/BiPAP (Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure) order since the date of the plan of correction. On 04/06/2026 at 1:06 PM, review of Patient #F1’s medical record was initiated and navigated by SF4RN. Review of Patient #F1’s medical record revealed the following order: CPAP/BiPAP at bedtime, start date/time 04/02/2026 at 9:00 PM. Review of Patient #F1’s medical record revealed the following nursing note: -04/02/2026 11:00 PM: Patient seen by SF12RT - CPAP machine inspected and mask adjusted for a better fit. Further review of Patient #F1’s medical record failed to reveal documentation by the respiratory therapist regarding the care provided to Patient #F1 per policy. In an interview on 04/06/2026 at 1:28 PM, SF4RN confirmed the above-mentioned findings. Continued review of Patient #F1’s medical record revealed that on 04/06/2026 at 1:50 PM, SF12RT electronically signed a note back dated for 04/02/2026 at 10:45 PM as a “late entry” in Patient #F1’s medical record. In an interview on 04/06/2026 at 2:11 PM, SF4RN confirmed that the above mentioned documentation by SF12RT was not initiated prior to starting the medical record review for Patient #F1.”

“RESPIRATORY CARE SERVICES CFR(s): 482.57 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This Condition is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Respiratory Services as evidenced by: 1) Failure to document patient care provided; 2) Failure to ensure that all respiratory orders were completed; 3) Failure to maintain a schedule to ensure coverage of respiratory therapist; 4) Failure to ensure the respiratory therapist has a competency for all job duties performed. (See Tag A- 1154)”

“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: 48050 Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice is evidenced by: 1)failure of the physician/practitioner to review/sign plan of care with 96 hours of admission for 1 (#8) of 14 (#1-#14) reviewed medical records; and 2) failure of the physician/practitioner to review/sign IDT (interdisciplinary team) conference 1(#11) of 14 (#1-#14) reviewed medical records. Findings: 1) Failure of the physician/practitioner to review/sign plan of care with 96 hours of admission for 1 (#8) of 14 (#1-#14) reviewed medical records. Review of Patient #8’s medical record revealed Patient #8 was admitted on 02/11/2026 with Critical Illness Myopathy. Further review of Patient #8’s medical record revealed the Plan of Care was initiated on 02/12/2026, but not signed by the physician until 02/17/2026. In an interview on 02/24/2026 at 2:00 PM, S10DCS verified physician/practitioners are to review/sign the patients’ POC within 96 hours of admission. 2) Failure of the physician/practitioner to review/sign IDT (interdisciplinary team)conference 1(#11) of 14 (#1-#14) reviewed medical records. Review of Patient #11’s medical record revealed Patient #11 was admitted on 02/09/2026 with a diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Further review revealed an IDT conference dated 02/10/2026 which was not signed by the physician/practitioner. In an interview on 02/24/2026 at 2:15 PM, S10DCS verified physician/practitioners are to review/sign the patients’ IDT conferences.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50453 53243 Based on record review and interview, the hospital failed to ensure each patient was notified of their rights. This deficient practice was evidenced by failing to document patients were informed of their rights in 3 (#25, #26, #27) of 30 records reviewed for notification of patient rights. Findings: Review of the hospital policy titled “Patient Rights and Responsibilities” last approved date 10/2025, revealed in part: “Purpose: To ensure all hospital staff and contract staff shall observe these patients’ rights. Policy: The Statement of Patient Rights shall include, but is not limited to, the patient’s right to: Become informed of his/her rights as a patient in advance of, or when discontinuing, the provision of care. The patient may appoint a representative to receive this information should he/she so desire.” Review of the hospital policy titled “ Patient and Family Grievances” last approved date 10/2025, revealed in part: “Policy: the hospital will protect and promote patient’s rights, provide the patient notice of rights and inform each patient or patient’s representative of the patient’s rights prior to providing or discontinuing patient care whenever possible.” Patient #25 Review of Patient #25’s medical record revealed an admit date of 2/11/2026 to facility B. Further review failed to reveal documented evidence that the patient/ representative was notified of the patient’s rights prior to furnishing care. Patient #26 Review of Patient #26’s medical record revealed an admit date of 2/9/2026 to facility B. Further review failed to reveal documented evidence that the patient/ representative was notified of the patient’s rights prior to furnishing care. Patient #27 Review of Patient #27’s medical record revealed an admit date of 2/20/2026 to facility B. Further review failed to reveal documented evidence that the patient/ representative was notified of the patient’s rights prior to furnishing care. In an interview on 2/25/2026 at 9:08 AM, S8DOP verified there was no documented evidence that the patient/representative was notified of the patient’s rights prior to furnishing care.”

“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 care in a safe setting as evidenced by: 1) failure to ensure the nurse call device is accessible to a patient lying on the bathroom floor; 2) failure to ensure a nurse call device is accessible and within reach of the patient shower; 3) failure to run quality controls on glucometer in emergency crash cart; 4) failure to ensure testing supplies for the glucometer were acceptable for use and not opened longer than manufacturer recommendations; and 5) failure to ensure the emergency cart remained locked to ensure contents were available if needed during an emergency. Findings: Review of the 2014 Edition of the FGI Guidelines 2.1-8.3.7 revealed in part: Call Systems: Hospital signaling and nurse call equipment includes four types of call stations: patient stations, bath stations, staff emergency stations, and code call stations. 2.1-8.3.7.3 Bath Stations: A bath station that can be activated by a patient lying on the floor shall be provided at each patient toilet, bathtub, sitz bath, or shower stall. (2) Bath stations in shower stalls and tubs shall be located 5 to 6 feet above the floor, within normal view of the user and within reach of staff without the need to step into the shower or tub. (3) Bath stations shall be located to the side of toilets, within 12 inches of the front of the toilet and 3 to 4 feet above the floor. (4) A bath station shall be permitted to serve a toilet and a shower or other fixture if it is accessible to each. 1) Failure to ensure the nurse call device is accessible to a patient lying on the bathroom floor. Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed the following: -The nurse call device located next to the toilet failed to reveal an attached extension of the call device that could be activated by a patient while lying on the floor for the following: Room ‘c’; Room ‘g’; Room ‘i’; and Room ‘k’. -The nurse call device located next to toilet failed to reveal an attached and functioning extension due to the attachment being wrapped around the handrail. Further observation failed to reveal that the call device could be activated by a patient while lying on the floor for the following: Room ‘d’; Room ‘f’; Room ‘h’; Room ‘j’; and Room ‘l’. During the tour, S2DON confirmed the above-mentioned findings. S2DON also confirmed that if a patient were lying on the floor, they would not be able to reach the call device located on the wall next to the toilet. 2) Failure to ensure a nurse call device is accessible and within reach of the patient shower. Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed 10 semi-private patient rooms containing 1 bathroom. Observations of each bathroom revealed 1 nursing call device located next to the toilet. Further observation failed to reveal a nurse call device that could be accessed by a patient from the shower in Room ‘c’ - Room ‘l’. During the tour, S2DON confirmed that there was no nurse call device within reach of the patient shower. S2DON further confirmed the only nurse call device in the bathroom is on the opposite side of the bathroom. 3) Failure to run quality controls on glucometer in emergency crash cart. Review of hospital policy titled “Glucometer Quality Testing,” last approved 01/2026, revealed in part: “POLICY: The Quality Control on the glucometer will be performed to ensure accurate and reliable testing using the low and high level control solutions. Quality Control testing will be performed nightly by the nursing staff. Quality control log is maintained on the nursing unit and results are monitored by the DON/Designee.” Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed a glucometer located inside the emergency crash cart, available for patient use. Further observation failed to reveal documented evidence that quality controls have been performed on the glucometer. In an interview during the tour, S2DON stated this glucometer is no longer in use by the facility. S2DON further confirmed that staff can access the equipment in the emergency crash cart for patient use. 4) Failure to ensure testing supplies for the glucometer awere acceptable for use and not opened longer than manufacturer recommendations. During tour of Facility “B” on 01/23/2026, inspection of the glucometer and testing strips used in the facility revealed the testing strips were open and were not labeled with the date of opening. In interview on 02/23/2026 at 2:48 PM S11ADO verified the packaging indicated that the strips needed to be used within 6 months of opening and the strips were not labeled with the date of opening. 5) Failure to ensure the emergency cart remained locked to ensure contents were available if needed during an emergency. Tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM revealed an unlocked code cart. In interview at the time of discovery, S12AAdm verified the cart should be locked prevent staff from removing items that would be needed in an emergency.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 44495 Based on observation and interview, the facility failed to ensure all drugs an biologicals were kept in a secure area and locked when appropriate. Findings: Tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM revealed an unlocked wound care cart with topical medications and medical supplies. In interview at the time of discovery, S12AAdm verified the cart should have been locked.”

“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: 50453 Based on observation and interview, the hospital failed to ensure expired and unusable drugs were not available for patient care use. This deficient practice was evidenced by 1) expired Influenza vaccines available for patient use; and 2) open containers with medication not labeled with the date of opening. Findings: 1) Expired Influenza vaccines available for patient use. Review of hospital policy titled “Expiration and Beyond-Use Dates,” last approved 06/2025, revealed in part: “EXPIRATION DATE MONITORING: Expiration dates of medications and devices shall be checked during routine medication area inspections and all medications and devices scheduled to expire during the next month shall be removed from stock.” Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed the following: Room ‘b’: -Influenza Vaccine, 0.5 ml dose, quantity 9, expiration date of 05/31/2025. In an interview during the tour, S2DON confirmed the above-mentioned findings. 2) Open containers with medication not labeled with the date of opening. Tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM revealed an unlocked wound care cart with topical medications and medical supplies. Among the unopened supplies, the surveyor found: A vial of lidocaine 1%- opened and not labeled with the date of opening; Plurogel 0.25 oz. tube- opened and not labeled with the date of opening; Adapt Ostomy Paste- opened and not labeled with date of opening; In interview at the time of discovery, S12AAdm verified the items needed to be discarded. S12AAdm also verified the policy of the facility was to label all open multi-use medications with the date of opening.”

“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: 50453 Based on observation and interview, the hospital failed to ensure supplies and equipment were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by: 1) failure to ensure expired supplies were removed from the patient care area; and 2) failure to ensure Vac-Assist Suction Unit were maintained. Findings: 1) Failure to ensure expired supplies were removed from the patient care area. Review of hospital policy titled “Central Supply,” last approved 01/2024, revealed in part: “PROCEDURE: 5. Supplies that are expired shall be removed from central supply and discarded. 7. Supplies are routinely checked for expiration dates and discarded and replaced as necessary.” Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed the following: Room ‘a’: -Jevity 1.2, 8 fluid ounce bottle, quantity 9, expiration date of 12/01/2025. -Jevity 1.2, 33.8 fluid ounce bottle, quantity 2, expiration date of 01/2026. Crash Cart: -7ml red lab tube, expiration date 01/31/2026, quantity 1. In an interview during the tour, S2DON confirmed the above-mentioned findings. 2) Failure to ensure Vac-Assist Suction Unit were maintained. Observations during a tour of Facility ‘A’ on 02/23/2026 from 11:53 AM - 1:06 PM revealed the following: -Portable Medline/Vac Suction unit in the bottom drawer of the crash cart. Further observation revealed a Biomedical Inspection due date of 05/2023. In an interview during the tour, S2DON confirmed the above-mentioned findings.”

“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: 44495 Based on observation and interview, the facility failed to ensure an effective survelliance program for the prevention of infections. The deficient practice is evidenced by 1) worn surfaces in the facility which prevented proper disinfection; 2) open single use items in the wound care cart; 3) storage of clean and dirty supplies and equipment in the same space. Findings: 1) Worn surfaces in the facility which prevented proper disinfection During tour of Facility “B” on 01/23/2026 between 2:30 PM and 3:10 PM, inspection of the main therapy room revealed 2 large therapy mats with torn coverings, 2 stools with abraded sitting surface and threadbare areas, a standing frame with a torn seat cover and exposed foam, a wedge with the covering torn on the corner, a bike with a worn/ torn seat and several foam weights with cracked surfaces. In interview at the time of discovery, S11ADO verified the worn and torn areas could not be adequately cleaned and were an infection control issue. During tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM, observation revealed missing laminate exposing the wood on the counter in the restroom in the therapy area. Further observation revealed patients using a stained piece of foam with holes as part of the therapy. The staff member stated that the stains were due to coffee spills. In interview during the tour, S12AAdm verified the exposed wood in the restroom and the foam therapy item could not be cleaned and were infection control issues. 2) open single use items in the wound care cart Tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM revealed an unlocked wound care cart with topical medications and medical supplies. Among the unopened supplies, the surveyor found: An open single use package of Kerlix style wrap; and A single use Xerofoam petroleum dressing cut open on one edge. In interview at the time of discovery, S12AAdm verified the open items needed to be discarded. . 3) Storage of clean and dirty supplies and equipment in the same space. Tour of Facility “B” on 01/23/2026, observation in a closet for clean supplies revealed 2 large floor polishers and a broom with hair-like debris stored in the closet with toilet paper, paper hand towels and other unopened cleaning supplies. In interview at the time of discovery, S11ADO verified there was dirty equipment stored in the clean supply room. Tour of Facility “C” on 02/24/2026 between 11:30 AM and 12:15 PM revealed a laundry room with a centrifuge with a test tube in it and biohazard signs in an alcove to the right inside the entry area of the room. Progression further into the room revealed the clean linens were stored in closets and were covered. In interview at the time of discovery, S12AAdm verified the lab equipment was in a clean space with no barrier to separate the two areas. S12Aadm verified staff had to travel past the dirty lab area on their way out with clean linens.”

“ADEQUATE RESPIRATORY CARE STAFFING CFR(s): 482.57(a)(2) There must be adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with State law. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to ensure the respiratory services department was staffed in a manner to meet the needs of the patients as evidenced by 1) failure to document patient care provided; 2) failure to ensure that all respiratory orders were completed as ordered by the provider; 3) failure to maintain a schedule to ensure coverage of respiratory therapists; and 4) failure to ensure the respiratory therapist had competencies for all job duties performed. Findings: 1) Failure to document patient care provided. Review of Patient #10’s medical record revealed an admission date of 02/20/2026 with a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The provider ordered CPAP/BIPAP on 02/20/2026 at 9:00 PM. Further review of Patient #10’s medical record revealed no documentation done by the respiratory therapist, but a nursing note dated 02/20/2026 revealed RRT at bedside with BIPAP set up. Review of Patient #31’s medical record revealed an admission date of 12/31/2025 with a diagnosis of Critical Illness Myopathy. The provider ordered CPAP/BIPAP on 12/31/2025 at 9:00 PM. Further review of Patient #31’s medical revealed no documentation done by the respiratory therapist, but a nursing note dated 01/01/2026 revealed S9RT set up BIPAP for patient. Review of Respiratory Therapist Job Description established 07/26/2016 revealed in part: Job Descriptions and Responsibilities: 15. Appropriate documentation of patient activities, findings, and observations. In an interview on 02/25/2026 at 11:00 AM, S2DON verified the above information mentioned. 2) Failure to ensure that all respiratory orders were completed as ordered by the provider. Review of the hospital policy titled, “Noninvasive Ventilation (CPAP, BiPAP, AVAPs, Trilogy)” last approved/revised on 03/2025 revealed in part: Policy: It is the policy of this facility to provide noninvasive ventilation as per physician/licensed independent practitioner orders and current standards of practice. Policy Explanation and Compliance Guidelines: 3. The CPAP, BiPAP, AVAPS, or Trilogy device must be set up by a Respiratory Therapist. Review of Respiratory Therapist Job Description established 07/26/2016 revealed in part: Job Descriptions and Responsibilities: 15. Appropriate documentation of patient activities, findings, and observations. Review of Patient #32’s medical record revealed an admission date of 12/26/2025 with a diagnosis of Metabolic Encephalopathy. The provider ordered CPAP/BIPAP 01/01/2026 at 9:00 PM. Further review of Patient #32’s medical record revealed no documentation from the respiratory therapist or nurse that CPAP/BIPAP was initiated. Review of Patient #33’s medical record revealed admission dates of 01/05/2025 with a diagnosis of Metabolic Encephalopathy and on 01/20/2026 with a diagnosis of Metabolic Encephalopathy. The provider ordered CPAP/BIPAP on 01/06/2026 at 9:00 PM and 01/20/2026 at 9:00 PM. Further review of Patient #33’s medical record revealed no documentation from the respiratory therapist or nurse that CPAP/BIPAP was initiated on either admission. Review of Patient #34’s medical record revealed an admission date of 01/21/2026 with a diagnosis of Hemiplegia and Hemiparesis related to CVA. The provider ordered CPAP/BIPAP 01/21/2026 at 9:00 PM. Further review of Patient #34’s medical record revealed no documentation from the respiratory therapist or nurse that CPAP/BIPAP was initiated. In an interview on 02/25/2026 at 11:30 AM, S2DON verified the above information mentioned. 3) Failure to maintain a schedule to ensure coverage of respiratory therapists. Review of Facility A’s employee list provided by S1ADM revealed S9RT is the only respiratory therapist employed. Review of Facility B’s employee list provided by S1ADM did not reveal any respiratory therapists employed. Review of Patient #31’s nursing notes dated 12/31/2025 at 8:56 PM documented called S9RT at 4:31 PM and left a voicemail and never received a call back. So RN texted at 5:56 PM, and just received notice that RT is out of town for New Year’s Eve, and can do set up for CPAP/BiPAP when he returns tomorrow. Notified patient and night charge RN. In an interview on 02/25/2026 at 12:00 PM, S1ADM confirmed S9RT is the only respiratory therapist employed by the hospital. S1ADM further confirmed S9RT does not have a schedule when he is available or not available to cover respiratory services at the facility. S1ADM states S9RT works at another facility within the corporation 7 days on and 7 days off but is available after hours and weekends. 4) Failure to ensure the respiratory therapist had competencies for all job duties performed. Review of S9RT’s personnel record did not reveal a competency on noninvasive ventilation which includes CPAPs and BiPAPs. In an interview on 02/25/2026 at 12:05 PM, S1ADM confirmed the above mentioned findings. 50453”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48050 Based on record review and an interview, the hospital failed to ensure the patient/patient representative’s right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to document the reason the patient did not participate in the treatment plan for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed. Findings: Review of hospital’s policy titled, “Individual Program Planning, last reviewed 08/2025 revealed in part: PROCEDURE: 4. The patient has the right to be apprised of his or her treatment needs, and to give input into the planning process as a respected team member. Review of the hospital’s policy titled, “Plan of Care”, last approved 09/17/2024 revealed in part: POLICY: B. Planning: c. Care plans will be individualized and the patient will be included in negotiating his/her plan of care. d. Documentation of all patient care planning is recorded in the patient’s medical record. This will be documented on the Care Plan. Review of Patient #3’s medical record revealed Patient #3 was admitted on 07/25/2025 with Multiple Sclerosis. Patient #3’s treatment plan was initiated on admission and updated on 07/29/2025 and 08/05/2025. Further review failed to reveal a patient signature to indicate Patient #3 was involved in their treatment planning. In an interview on 09/16/2025 at 2:40 PM, S1DON verified there is no documentation Patient #3 was involved in the treatment planning.”

“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: 48050 Based on observation and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to identify potential safety risk of medication storage. Findings: During a tour of the facility on 09/15/2025 between 12:00 PM to 12:30 PM, it was observed the medication room with shelves and storage bins. The labeled storage bins revealed items in the storage bins that did not match the bin label. Bin #1 labeled Tylenol/Motrin/ASA but contained 2 unopened Bottles of D 3 125 mcg containing 110 tablets, 1 unopened bottle of Glucose containing 50 tablets, 1 opened bottle of Thera-M tablets, 2 opened bottles of Sodium Chloride 1 gram tablets, 1 unopened bottle of Aspirin 81mg containing 36 tablets, 1 open bottle of Aspirin 81mg tablets, and 1 open bottle of Vitamin B-1 100mg tablets, Bin #2 labeled Calcium/Melatonin/Benadryl but contained glucometer lancets Bin #3 labeled Vancomycin but contained Sodium Chloride inhalation solution 3% 4ml X 60 Bin #4 unlabeled but contained an open bottle of Ammonium Lactate 12% and 1 Fleets enema. Bin #5 unlabeled but contained Metamucil packets X 16, Albuterol Sulfate Inhaler 90 mcg, and Chloraseptic Lozenges X 4 Bin #6 unlabeled but contained an unopen tube of Hydrocortisone Cream 1% Further observation revealed the following packaged loose medications found on the shelves in the medication room: Lisinopril 10mg tablet X1, Renal Caps tablet X 1, Dexamethasone 4mg tablet X 1, Sodium Bicarbonate 650mg tablet X 1, and Folic Acid 1mg tablet x1. In an interview on 09/15/2025 at 12:10 PM, S1DON verified the above information.”

“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: 48050 Based on record review and interview, the hospital failed to ensure the registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by: 1)failure to administer medications and treatments per provider order in 1 (#2) of 3 (#1-#3) patient medical records reviewed; and 2)failure to report change in patient’s condition to the provider in 1 (#2) of 3 (#1-#3) patient medical records reviewed. Findings: 1)failure to administer medications and treatments per provider order 1n 1 (#2) of 3 (#1-#3) patient medical records reviewed. Review of Patient #2’s medical record revealed Patient #2 was admitted on 06/25/2025 with Left Foot Amputation with daily wound care ordered on 06/26/2025. Further review of Patient #2’s nursing notes revealed daily wound care was missed on 06/27/2025. Patient #2’s provider also ordered Tylenol 650mg PO Q 6 hour PRN Temperature > 100 degrees or pain. The following dates and time Patient #2 temperature was > 100 degrees and didn’t receive Tylenol: On 07/01/2025 At 8:14 PM temperature was 100.9 degrees; on 07/04/2025 at 8:00 PM temperature was 101.2; and on 07/05/2025 at 9:01 PM temperature was 100.4 degrees. In an interview on 09/15/2025 at 3:28 PM, S1DON verified Patient #2’s nurse didn’t follow the MD order for daily wound care or administered Tylenol as ordered. 2)failure to report change in patient’s condition to the provider in 1 (#2) of 3 (#1-#3) patient medical records reviewed. Review of the hospital’s policy titled, “Vital Sign Policy” last approved 08/2025 revealed in part: Vital Signs and Sepsis Screening: Reporting and interpretation of vital signs may be used as a screening tool for sepsis. The following vital signs with known or suspected infection should be discussed with Physician/LIP. Temperature >38 or <36 degree Celsius (100.4F or 96.8F). Review of Patient #2’s medical record revealed the following date/times that Patient #2 temperature was > 100.4 degrees that were not reported to the provider: On 07/01/2025 At 8:14 PM temperature was 100.9 degrees; on 07/04/2025 at 8:00 PM temperature was 101.2 degrees; and on 07/05/2025 at 9:01 PM temperature was 100.4 degrees. Further review revealed Patient #2 was transferred to Hospital B on 07/07/2025 and admitted with a diagnosis of Sepsis. In an interview on 09/15/2025 at 3:35 PM, S1DON verified the above information.”

“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: 48050 Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 3 (#1, #2, #3) of 3 (#1-#3) patient records reviewed. Findings: Review of the hospital’s policy titled, “Plan of Care”, last approved 09/17/2024 revealed in part: POLICY: B. Planning: 3. A written Plan of Care is initiated for each patient within 24 hours of admission. b. The Care Plan will be reviewed daily and revised as necessary and as indicated by the changing needs of the patient. c. Care plans will be individualized and the patient will be included in negotiating his/her plan of care. d. Documentation of all patient care planning is recorded in the patient’s medical record. This will be documented on the Care Plan. Review of Patient #1’s medical record revealed Patient #1 was admitted on 09/08/2025 with Type 2 Diabetes and Left Foot Ulcer. During Patient #1’s hospitalization he received multiple PRN doses of Norco for pain and was taking antibiotics for infection prevention. Further review of Patient #1’s nursing care plan failed to reveal a nursing diagnoses for infection prevention or pain management. In an interview on 09/16/2025 at 3:40 PM, S1DON verified Patient #1’s nursing care plan should have addressed infection prevention and pain management. Review of Patient #2’s medical record revealed Patient #2 was admitted on 06/25/2025 with Left Great Toe Amputation. Review of Patient #2’s nursing care plan failed to reveal an update to the actual/potential for infection related to wound nursing diagnosis when the provider ordered a wound culture on 07/07/2025 and placed Patient #2 on IV antibiotics on 07/07/2025. In an interview on 09/15/2025 at 4:00 PM, S1DON verified the above information. Review of Patient #3’s medical record revealed Patient #3 was admitted on 07/25/2025 with Multiple Sclerosis. Review of Patient #3’s nursing care plan failed to reveal any updates for diagnosis Actual/Potential for Infection related to Foley Catheter, Self-Cath when Patient #3 was diagnosed with an UTI and placed on Antibiotics. Patient #3 also received multiple PRN medications for pain during hospitalization and Pain was not addressed on the Nursing Care Plan. In an interview on 09/16/2025 at 2:35 PM, S1DON confirmed the above mentioned information.”

“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: 48050 Based on record review and interview, the hospital failed to follow its policy and procedure to ensure that medical records were completed within 30 days of discharge in 1 (#2) of 3 (#1-#3) patient medical records reviewed. Findings: Review of Patient #2’s medical record revealed admission on 06/25/2025 and discharge on 07/07/2025. Further review revealed a discharge summary initiated on 08/06/2025 at 11:09 AM, but not signed by the provider as of 09/16/2025. In an interview on 09/16/2023 at 2:50 PM, S1DON verified the discharge summary was not signed by the provider within 30 days from Patient #2’s discharge date of 07/07/2025.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by failing to lock the medication room door. Findings: During a tour of the facility on 09/15/2025 at 12:00 PM, the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included unlocked medication bins with patients’ prescription medications and the unit’s OTC medications. In an interview on 09/15/2025 at 12:10 PM, S2DON verified the medication room door should not be propped open and should be locked to secure the patient’s prescription medications and the unit’s OTC 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: 48050 Based on observation and interview, the facility failed to ensure expired and unusable drugs and supplies were not used for patient care. The deficient practice is evidenced by the presence of unlabeled bags of discontinued medications from previous patients. Findings: During a tour of the facility on 09/15/2025 at 12:00 PM, the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included a large plastic bin on the floor with overflowing plastic bags filled prescription medications. Further inspection revealed one of the plastic bags were Patient #4’s prescription home medications. Patient #4 had been discharged from the facility since 08/01/2025 and not returned or discarded. In an interview on 09/15/2025 at 12:15 PM, S1DON verified that pharmacy is supposed to pick up discontinued medications weekly. S1DON confirmed there should not be discontinued medications from patients who were discharged in August 2025.”

“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: 48051 Based on observation, record review and interview, the rehabilitation hospital failed to ensure the patient’s right to received care in a safe setting. This deficient practice was evidenced by: 1) Failure to ensure EvenCare Blood Glucose Test Strips had a documented open date on the test strip vial; and 2) Failure to ensure Room “a” sharps container was removed from the patient care area prior to the container exceeding its maximum limit. Findings: 1) Failure to ensure EvenCare Blood Glucose Test Strips had a documented open date on the test strip vial A review of the User’s Guide for the Medline EvenCare G3 Blood Glucose Monitoring System, revealed in part: “Important: For vial test strips, record the date on the bottle when you open a new bottle of test strips. Discard any unused test strips six months after opening.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed EvenCare Blood Glucose Test Strips being located on medication cart #1 and medication cart #2 without a documented “Date Opened” on the bottle. In an interview on 06/05/2025 and present while the medication carts were being observed, S5LPN confirmed the above mentioned findings on medication cart #1 and S6LPN confirmed the above mentioned findings on medication cart #2. 2) Failure to ensure Room “a” sharps container was removed from the patient care area prior to the container exceeding its maximum limit A review of hospital policy, “Disposal of Infectious Waste,” PolicyStat ID 16297283, last revised on 09/2017 and had been approved and effective as of 08/2024, revealed in part: “Policy: To ensure the handling and disposal of infectious waste is done safely as to not cause injury or exposure to patients, visitors, and employees. To outline the employee responsibility for the disposal of infectious wastes. To ensure safety from exposure to biomedical wastes. Procedure: Objects that are contaminated with potentially infectious materials shall be placed in an impervious bag. If outside contamination of the bag is likely to occur, a second bag shall be added. Needles and sharps should be disposed of in puncture-resistant containers. All Biological waste shall be identified with a “Biohazard” label.” A review of hospital policy, “Cleaning Occupied Rooms,” PolicyStat ID 13675828, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: All patient rooms will be cleaned on a daily basis. Procedure: B. Close and discard sharps containers when they are ¾ full. Sharps containers are considered biohazardous waste and will be disposed of as such.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed Room “a” sharps container overflowing with syringes and lancets. In an interview on 06/09/2025 and present during the hospital walk-through, S1ADM confirmed the above mentioned findings and further agreed the sharps container should have been changed for the safety of staff, patients and/or any visitors that may come in contact with a contaminated item not being properly disposed.”

“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: 48051 Based on observation, record review and interview, the rehabilitation hospital failed to ensure drugs and biologicals were 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 deficient practice was evidenced by a multiple-dose, 10 ml vial of Novolin R U-100 being open and available for patient use without a documented beyond-use date on or attached to the vial. Findings: A review of hospital policy, “Expiration and Beyond-Use Dates,” PolicyStat ID 13676256, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: Beyond-use dates for medication shall be assigned according to this policy. Beyond-Use Dated for Prepackaged Products: Beyond-use dates shall be assigned to all prepackaged products. Beyond-use dates shall be assigned in accordance with the Federal and State Laws and Regulations. In no case shall the assigned date exceed the Manufacturer’s expiration date.” A review of hospital policy, “Multiple-Dose Vials,” PolicyStat ID 16298091, last revised on 04/2021 and had been approved and effective as of 03/2025, revealed in part: “Policy: It is the policy of this facility to ensure proper and safe use of multi-dose vials of medication. Policy Explanation and Compliance Guidelines: 1. Multiple-dose Medications are clearly marked by the Manufacturer with an explanation date. b. if a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that open vial. 6. Unit manager will perform random checks of opened multi-dose vials for appropriate dating.” Observations of medication cart #1 during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed a multiple-dose, 10 ml vial of Novolin R U-100 being open and available for patient use without a documented beyond-use date on or attached to the vial. In an interview on 06/05/2025 at 12:10 PM, S5LPN confirmed the above mentioned findings and further confirmed an open, multiple-dose vial of medication should be labeled with a beyond-use date.”

“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: 48051 Based observation and interview, the rehabilitation hospital failed to provide a system of record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This deficient practice was evidenced by the storage of paper medical records in a storage closet and on the floor of Room “d” without protection from damage which could include fire, water damage and/or other threats. Findings: A review of hospital policy, “Safeguarding PHI,” PolicyStat ID 16298083, last revised on 03/2021 and had been approved and effective as of 03/2025, revealed in part: “Policy: To reasonable safeguard Protected Health Information from any intentional or unintentional use or disclosure that is in violation of the Health Insurance Portability and Accountability Act (HIPPA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, and any and all other Federal Regulations and interpretive guidelines promulgated hereunder regarding safeguarding of Protected Health Information. Procedure: B. Safeguards for Written PHI: All Documents containing PHI should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. Active Records on Nursing Unit: 1. Active Medical Records shall be stored in an area that allows staff providing care to patients to access the records quickly and easily as needed. 3. Active Medical Records shall not be left unattended on the Nurses’ Station desk or other areas where patients, visitors, and unauthorized individuals could easily view the records. 6. Medical Records shall be protected from loss, damage, and destruction. Thinned Records, Inactive Medical Records: 1. Thinned and inactive Medical Records will be filed in a systemic manner in a location that ensures the privacy and security of the information. The Health Information Manager or a designee shall monitor the storage and security of such Medical Records. When records are left unattended, records will be in a locked room, file cabinet, or drawer.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed a storage closet which contained boxed medical records being stored on open, metal shelving units. The boxes were identified with medical records from the years 2019 to 2024. The metal, shelving units were open, with no protection from damage such as fire or water. Other observations during the tour revealed a storage box being stored on the flooring, under a counter in Room “d” . This box was identified with medical records from 2025. In an interview on 06/05/2025 and present on the hospital walk-through, S2ADM confirmed the above mentioned findings and further confirmed the medical records need to be protected from potential destruction.”

“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: 48051 Based on record review and interview, the rehabilitation hospital failed to ensure a medical history and physical examination was completed and documented for each patient no more than 24 hours after admission or registration. This deficient practiced was evidenced by the failure to document a completed medical history and physical examination within 24 hours of admission on 1 (#1) of 3 (#1-#3) patient’s medical records reviewed. Findings: A review of hospital policy, “History and Physicals,” PolicyStat ID 13676094, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: An H&P must be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission, but prior to surgery or a procedure requiring anesthesia services. The H&P documentation must be placed in the medical record within 24 hours admission, but in all cases prior to surgery or a procedure requiring anesthesia services.” A review of Patient #1’s electronic medical record (EMR) revealed an admission date of 05/16/2025 at 3:52 PM. A review of the document, “Form: Provider History and Physical (IRF)” revealed the History and Physical date of service as 05/17/2025, with the document being signed by S7NP on 05/17/2025 at 7:31 PM. In an interview on 06/09/2025 at 9:30 AM and present for the EMR review, S2DON confirmed the above mentioned findings and further confirmed the H&P would not be available for staff to view in the EMR until the provider electronically signed the document.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 48051 Based on observation and interview, the rehabilitation hospital failed to ensure all drugs and biologicals were kept in a secure area and locked when appropriate. This deficient practice was evidenced by 2 medications carts being stored and unattended at the main entry of the hospital. Findings: A review of hospital policy, “Safeguarding PHI,” PolicyStat ID 16298222, last revised on 04/2022 and had been approved and effective as of 12/2024, revealed in part: “Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer’s recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed 2 medications carts being stored and unattended within 10 - 15 feet of the main entry of the hospital. The hospital entry door was not under controlled or secured access during this time frame. Any individual could exit the building with a rolling medication cart uninhibited. Observations of these 2 medication carts revealed their contents as being floor stock medications and the prescribed medications for Patients #3 and #R1 - R10. In an interview on 06/05/2025 and present on the hospital walk-through, S2ADM confirmed the above mentioned findings and further confirmed the carts were unattended at the time of our arrival to this area.”

“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: 48051 Based on observation and interview the rehabilitation hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by the clean linen storage room not being maintained in a climate controlled and sanitary environment. Findings: Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed the clean linen storage room having a large opening in one side wall, approximately 5 feet in width by 6 feet in height. This opening appeared to be the same size as the commercial clothing/linen dryer next to it. This opening in the wall allow access to a room which would have been enclosed and behind this opening and the existing dryer and appeared to be the location of the dryer exhaust ventilation. This dryer exhaust, ventilation room consisted of unfinished dry wall and the exterior wall had 2 vents approximately 2 feet by 2 feet which opened to the outside. These 2 vents had a wire mesh covering on the interior sides with the mesh openings being approximately 1cm by 1cm. This mesh would not hinder all pest or insects from entering this room. Further, these 2 openings prevented this room from being climate controlled. With these findings, the appropriate storage of the clean linen within this area, could impede the cleanliness and sanitary storage of the clean linen. In an interview on 06/05/2025 and present on the hospital walk through, S1ADM confirmed the above mentioned findings and the opening in the wall was the space where a prior clothing/linen dryer was located, which had been removed. Further, S1ADM confirmed the opening between the 2 rooms should not be there.”

“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 rehabilitation 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 supplies were removed from the patient care area; and 2) Failure to ensure Room “a” sharps container was removed from the patient care area prior to the container exceeding its maximum limit. Findings: 1) Failure to ensure expired supplies were removed from the patient care area A review of hospital policy, “Expiration and Beyond-Use Dates,” PolicyStat ID 13676256, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: Beyond-use dates for medication shall be assigned according to this policy. Beyond-Use Dated for Prepackaged Products: Beyond-use dates shall be assigned to all prepackaged products. Beyond-use dates shall be assigned in accordance with the Federal and State Laws and Regulations. In no case shall the assigned date exceed the Manufacturer’s expiration date. Expiration Date Monitoring: The expiration dates of all medications and devices shall be checked during the routine medication area inspections and all medications and devices scheduled to expire during the next month shall be removed from stock.” Observations of Room “b” during hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed a bottle of Gentian Violet Topical Antiseptic with an expiration of 10/2024 located in the room’s cabinet. In an interview on 06/05/2025 at 11:32 AM S3RN confirmed the above mentioned findings. 2) Failure to ensure Room “a” sharps container was removed from the patient care area prior to the container exceeding its maximum limit A review of hospital policy, “Disposal of Infectious Waste,” PolicyStat ID 16297283, last revised on 09/2017 and had been approved and effective as of 08/2024, revealed in part: “Policy: To ensure the handling and disposal of infectious waste is done safely as to not cause injury or exposure to patients, visitors, and employees. To outline the employee responsibility for the disposal of infectious wastes. To ensure safety from exposure to biomedical wastes. Procedure: Objects that are contaminated with potentially infectious materials shall be placed in an impervious bag. If outside contamination of the bag is likely to occur, a second bag shall be added. Needles and sharps should be disposed of in puncture-resistant containers. All Biological waste shall be identified with a “Biohazard” label.” A review of hospital policy, “Cleaning Occupied Rooms,” PolicyStat ID 13675828, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: All patient rooms will be cleaned on a daily basis. Procedure: B. Close and discard sharps containers when they are ¾ full. Sharps containers are considered biohazardous waste and will be disposed of as such.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed Room “a” sharps container overflowing with syringes and lancets. In an interview on 06/09/2025 and present during the hospital walk-through, S1ADM confirmed the above mentioned findings and further agreed the sharps container should have been changed for the safety of staff, patients and/or any visitors that may come in contact with a contaminated item not being properly disposed.”

“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: 48051 Based on observation, record review and interview, the rehabilitation hospital failed to ensure infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by: 1) Failure to ensure single patient use supplies were assigned and appropriately labeled to a single patient; 2) Failure to ensure food was not stored in lab specimen refrigerator; and 3) Failure to ensure cardboard shipping boxes were not used as storage containers on the shelving of the clean supply storage. Findings: 1) Failure to ensure single patient use supplies were assigned and appropriately labeled to a single patient Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed the following single patient use items open and available for patient use in the patient care area and not assigned to a patient: Room “d” patient preparation counter: 1 container of DeRoyal Algidex Ag Packing Strip Antimicrobial Packing Gauze; 2 containers of Curad Iodoform Packing Strip; and 2 containers of Curad Plain Packing Strip; and Rooms “b” and “c”: an opened 16 ounce bottle of Medline Skintegrity Wound Cleanser in each room. In an interview on 06/05/2025 at 11:32 AM, S3RN confirmed the above mentioned findings. 2) Failure to ensure food was not stored in lab specimen refrigerator A review of hospital policy, “General Refrigerator Cleaning,” PolicyStat ID 13676063, last revised on 09/2017 and had been approved and effective as of 05/2023, revealed in part: “Policy: To provide for the proper and safe storage of medications, patient nourishment and employee food. Procedure” Objective: Medications, food and nutrition products, and laboratory specimens will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security to maintain product stability.” Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed the lab specimen refrigerator in Room “d” had a black plastic bag containing unknown contents which appeared to be the size of a food storage container. In an interview on 06/05/2025 at 11:30 AM, S3RN confirmed the presence of the black plastic bag in the refrigerator and the bag contained an employee’s lunch. 3) Failure to ensure cardboard shipping boxes were not used as storage containers on the shelving Observations during a hospital walk-though on 06/05/2025 from 10:40 AM to 1:10 PM revealed the clean supply storage in the Room “d” had brown cardboard boxes being used as storage bins on the shelving units. Corrugated cardboards cannot be properly sanitized and potentially harbor contaminants which are unsuitable where infection control measures are necessary. In an interview on 06/05/2025 at 11:30 AM, S3RN confirmed the above mentioned findings.”